What is the recommended treatment approach for a patient with migraine with aura?

Treatment of Migraine with Aura

For acute treatment of migraine with aura, start NSAIDs (ibuprofen 400-800mg or naproxen sodium 275-550mg) immediately during the aura phase to prevent or diminish the subsequent headache, and if NSAIDs fail, use triptans (sumatriptan 50-100mg, rizatriptan 10mg, or zolmitriptan) only when the headache begins—never during the aura itself. 1, 2

Acute Treatment Algorithm

First-Line: NSAIDs During Aura Phase

• Administer NSAIDs as soon as the aura begins, not to treat the aura itself, but to prevent or reduce the intensity of the impending headache phase 2
• Ibuprofen 400-800mg every 6 hours is the preferred first-line agent 1, 3
• Naproxen sodium 275-550mg every 2-6 hours is an equally effective alternative 3
• Diclofenac potassium is another validated option for mild-to-moderate attacks 1
• Acetaminophen alone is ineffective and should only be used if the patient cannot tolerate NSAIDs 4, 1

Second-Line: Triptans for Headache Phase

• Critical timing: Never use triptans during the aura phase—they are ineffective and should only be administered when the headache begins 3, 5, 2
• Sumatriptan 50-100mg orally is the most extensively studied triptan, with 50mg being as effective as 100mg in most patients 6
• Rizatriptan 10mg or zolmitriptan (oral or nasal spray) are equally effective alternatives 4, 1
• Combination sumatriptan 85mg/naproxen 500mg may provide superior efficacy 3
• Triptans are contraindicated in patients with uncontrolled hypertension, coronary artery disease, basilar or hemiplegic migraine, or stroke history 4, 6

Antiemetic Adjunct

• Metoclopramide or domperidone should be used for associated nausea and vomiting 3, 5
• Administer antiemetics early, as oral medications are unlikely to prevent vomiting once it begins 5

Medications to Avoid

• Avoid opioids and butalbital-containing compounds due to dependency risk, rebound headaches, and poor efficacy 4, 1, 3
• Avoid ergot alkaloids orally due to poor efficacy and potential toxicity 3

Preventive Treatment Indications

Consider preventive therapy if the patient experiences ≥2 migraine attacks per month causing significant disability despite optimized acute treatment, or if acute medications are being used more than twice weekly. 4, 1

First-Line Preventive Agents

• Beta-blockers are the preferred first-line preventive treatment:

  • Propranolol 80-240mg daily has the strongest evidence 4, 1, 5
  • Metoprolol, atenolol, or bisoprolol are alternatives with moderate evidence 4, 1
  • Beta-blockers with intrinsic sympathomimetic activity (acebutolol, pindolol) are ineffective 4

• Topiramate 50-100mg daily is an alternative first-line option, particularly useful for patients with prolonged or atypical aura 4, 1

  • May cause weight loss but carries risk of cognitive adverse effects 7

• Candesartan is another first-line choice, especially in hypertensive patients 1, 7

Second-Line Preventive Agents

• Amitriptyline 30-150mg daily has consistent evidence for efficacy, particularly useful in patients with comorbid tension-type headache or sleep disturbances 4, 1, 5

  • Drowsiness, weight gain, and anticholinergic effects are common 4

• Divalproex sodium or sodium valproate have good evidence for efficacy, especially in prolonged or atypical aura 4, 7

  • Absolutely contraindicated in women of childbearing age due to teratogenic effects (neural tube defects) 1, 5

Third-Line Options

• OnabotulinumtoxinA and CGRP monoclonal antibodies (erenumab, fremanezumab) are reserved for chronic migraine that has failed first- and second-line preventives 1

Special Considerations for Migraine with Aura

Prolonged Aura (>1 hour)

• If aura symptoms last longer than one hour, consider lamotrigine or greater occipital nerve blocks based on open-label evidence 8, 9
• Amiloride showed promise in a small pilot study for prolonged aura 8
• Prolonged aura warrants evaluation to exclude stroke or other serious pathology 2

Stroke Risk and Contraception

• The relative risk of ischemic stroke is significantly increased in migraine with aura 2
• Combined hormonal contraceptives containing estrogen are absolutely contraindicated in women with migraine with aura due to substantially increased stroke risk 1, 3, 2

Red Flags Requiring Emergency Evaluation

• First-time aura with sudden (not gradual) onset of symptoms 2
• Simultaneous neurological symptoms or symptoms corresponding to a vascular territory (suggests TIA) 2
• Late-onset aura (new aura symptoms beginning later in life) 2
• Dramatic increase in aura attack frequency 2

Medication Overuse Prevention

Limit acute medication use to prevent medication-overuse headache: triptans to <10 days/month and NSAIDs to <15 days/month. 4, 1, 5

• If medication overuse is suspected, preventive therapy should be initiated and detoxification may be necessary 4, 6
• Rebound headaches are associated with withdrawal of analgesics, triptans, ergotamine, and compounds containing caffeine, isometheptene, or butalbital 4

Monitoring and Follow-Up

• Evaluate treatment response within 2-3 months of initiating or changing therapy 1, 3, 5
• Use headache calendars to track attack frequency, severity, duration, disability, medication use, and adverse effects 4, 1, 3
• The efficacy of treatment is unaffected by presence of aura, duration of headache prior to treatment, gender, age, or concomitant use of prophylactic drugs 6