What is the best course of treatment for a patient with a history of migraines experiencing eye migraines with symptoms of temporary vision loss or blind spots?

Eye Migraines (Retinal Migraine/Migraine with Visual Aura)

For patients experiencing eye migraines with temporary vision loss or blind spots, treat acute episodes with NSAIDs (ibuprofen 400-800 mg or naproxen 500-825 mg) as first-line therapy, escalating to triptans (sumatriptan 50-100 mg) combined with an NSAID for moderate to severe attacks, and initiate preventive therapy with propranolol if attacks occur more than twice monthly. 1, 2

Acute Treatment Algorithm

First-Line for Mild to Moderate Visual Symptoms

• Start with NSAIDs immediately at symptom onset: Ibuprofen 400-800 mg, naproxen sodium 500-825 mg, or aspirin 1000 mg 1, 2
• Acetaminophen 1000 mg is less effective than NSAIDs and should be reserved for patients with NSAID contraindications 1
• Critical timing principle: Administer medication as early as possible during the attack, ideally when visual symptoms first appear, to maximize efficacy 1, 2

Escalation for Moderate to Severe Episodes

• Combination therapy is superior to monotherapy: Triptan (sumatriptan 50-100 mg, rizatriptan, or naratriptan) PLUS an NSAID provides the strongest evidence for efficacy 1, 2
• This combination achieves 130 more patients per 1000 with sustained pain relief at 48 hours compared to either agent alone 1
• For rapid-onset visual symptoms with nausea/vomiting, use subcutaneous sumatriptan 6 mg, which provides relief within 15 minutes in 70-82% of patients 2

When Nausea Accompanies Visual Symptoms

• Add metoclopramide 10 mg orally or IV, which provides both antiemetic effects and direct analgesic benefit through central dopamine receptor antagonism 1, 2
• Alternatively, use prochlorperazine 10 mg IV, which has comparable efficacy to metoclopramide 1
• Consider nonoral routes (intranasal sumatriptan 5-20 mg or subcutaneous formulations) when significant nausea is present 1, 2

Critical Frequency Limitation to Prevent Medication-Overuse Headache

Restrict all acute migraine medications to no more than 2 days per week (10 days per month maximum). 1

• NSAIDs trigger medication-overuse headache at ≥15 days/month 1
• Triptans trigger medication-overuse headache at ≥10 days/month 1
• If requiring acute treatment more frequently, immediately initiate preventive therapy rather than increasing acute medication frequency 1

Preventive Therapy Indications

Initiate preventive therapy if any of the following criteria are met: 1

• Two or more attacks per month producing disability for 3+ days 1
• Use of acute medications more than twice weekly 1
• Contraindication to or failure of acute treatments 1
• Patient preference to reduce attack frequency 1

First-Line Preventive Medications

• Propranolol 80-240 mg daily has the strongest evidence for migraine prevention, including migraine with aura 1
• Metoprolol 50-200 mg daily is an alternative beta-blocker option 1
• Topiramate 50-100 mg daily is effective but has more adverse effects (nephrolithiasis, cognitive effects, teratogenicity) 1
• Amitriptyline 10-100 mg at night is particularly useful for patients with mixed migraine and tension-type headache 1

Second-Line Options When First-Line Fails

• Flunarizine 5-10 mg daily (contraindicated in Parkinsonism, depression) 1
• Sodium valproate 600-1,500 mg daily (absolutely contraindicated in women of childbearing potential due to teratogenicity) 1

Third-Line Options for Refractory Cases

• CGRP monoclonal antibodies: Erenumab 70-140 mg subcutaneous monthly, fremanezumab 225 mg monthly or 675 mg quarterly 1
• OnabotulinumtoxinA 155-195 units to 31-39 sites every 12 weeks (approved for chronic migraine only) 1

Special Considerations for Visual Symptoms

When to Suspect Serious Pathology (Red Flags)

Obtain urgent neuroimaging if any of the following are present: 1, 3

• Visual loss lasting >60 minutes (typical migraine aura resolves within 5-60 minutes) 1
• First episode of visual symptoms in a patient >40 years old without prior migraine history 1
• Progressive worsening pattern of visual symptoms 1
• Abnormal neurologic examination findings 1
• Headache that awakens from sleep or is worsened by Valsalva maneuver 1

Distinguishing Retinal Migraine from Migraine with Visual Aura

• Retinal migraine involves monocular vision loss (one eye only) and is much rarer 3
• Migraine with visual aura typically involves binocular visual disturbances (both eyes, often homonymous hemianopia) 1
• Both require the same acute treatment approach, but retinal migraine warrants more aggressive workup to exclude vascular causes like carotid stenosis or vasospasm 3

Contraindications to Triptans (Requiring Alternative Therapy)

Triptans are absolutely contraindicated in: 2

• Ischemic heart disease or previous myocardial infarction 2
• Uncontrolled hypertension 2
• Cerebrovascular disease or previous stroke 2
• Basilar or hemiplegic migraine 2
• Peripheral vascular disease 2

Alternative Acute Treatments When Triptans Are Contraindicated

• CGRP antagonists (gepants): Rimegepant, ubrogepant 50-100 mg, or zavegepant intranasal spray have no vasoconstriction and are safe in cardiovascular disease 1
• Lasmiditan (ditan): 50-200 mg is a 5-HT1F agonist without vasoconstrictor activity, but patients cannot drive for 8 hours after use due to CNS effects 1
• Dihydroergotamine (DHE) intranasal or IV has good efficacy but shares some cardiovascular contraindications with triptans 1, 2

Medications to Absolutely Avoid

Never use opioids or butalbital-containing compounds for eye migraines. 1

• These medications have questionable efficacy for migraine 1
• They lead to dependency, rebound headaches, and eventual loss of efficacy 1, 2
• They increase the risk of progression from episodic to chronic migraine 1

Monitoring and Follow-Up

• Evaluate treatment response within 2-3 months after initiation or change in therapy 1
• Use headache calendars to track attack frequency, severity, and medication use 1
• Assess for medication-overuse headache if headaches are occurring ≥15 days/month 1
• Preventive therapy requires 2-3 months for oral agents to demonstrate full efficacy 1

Common Pitfalls to Avoid

• Do not delay treatment waiting for headache to develop: Visual aura symptoms alone warrant immediate treatment, as early intervention is more effective 1, 2
• Do not allow patients to increase acute medication frequency in response to treatment failure: This creates a vicious cycle of medication-overuse headache; instead, transition to preventive therapy 1
• Do not assume all monocular vision loss is benign retinal migraine: Aggressive workup including carotid imaging is necessary to exclude atherosclerotic disease, especially in patients >40 years 3
• Do not prescribe combined hormonal contraceptives to women with migraine with aura: This combination increases stroke risk and is absolutely contraindicated 1