What are the treatment options for a patient experiencing ocular migraines?

Treatment of Ocular Migraine

Ocular migraine should be treated with the same acute and preventive strategies used for typical migraine, with NSAIDs as first-line acute therapy and triptans as second-line, while preventive therapy should be initiated if attacks occur ≥2 times per month with significant disability. 1

Understanding Ocular Migraine

Ocular migraine (also called retinal migraine) presents as transient monocular visual loss and is an uncommon but recognized migraine variant that requires appropriate recognition to provide treatment and avoid unnecessary testing 2. The treatment approach mirrors standard migraine management, as the underlying pathophysiology is similar 2.

Acute Treatment Strategy

First-Line: NSAIDs

• Use NSAIDs (aspirin, ibuprofen, or naproxen sodium) as initial acute treatment for mild to moderate attacks 1
• The acetaminophen-aspirin-caffeine combination is also effective 1
• Acetaminophen alone is ineffective and should not be used 1
• Administer early in the attack phase, as effectiveness depends on timely use with correct dosing 3

Second-Line: Triptans

• Sumatriptan (50-100 mg orally) should be used when NSAIDs fail to provide adequate relief 1, 4
• Triptans demonstrate 52-62% headache response at 2 hours and 65-79% response at 4 hours across all doses 4
• The 50 mg dose is optimal, as doses above 50 mg do not provide greater effect 4
• Consider non-oral routes (nasal spray) if nausea or vomiting are prominent 1

Critical contraindications for triptans include: 1, 4

• Uncontrolled hypertension
• Coronary artery disease or Prinzmetal's angina
• History of stroke or TIA
• Basilar or hemiplegic migraine
• Wolff-Parkinson-White syndrome

Combination Therapy

• Combine a triptan with an NSAID for patients with insufficient relief from either medication alone 1
• This combination may be more effective than monotherapy 3, 1

Adjunctive Treatment

• Add antiemetic medications (domperidone or metoclopramide) when nausea is present 3, 1

Medication Overuse Prevention

• Limit acute treatments to no more than twice weekly to prevent medication overuse headache 1, 4
• Overuse is defined as using triptans ≥10 days/month or NSAIDs ≥15 days/month 5
• Medication overuse headache can present as daily migraine-like headaches or marked increase in attack frequency 4

Preventive Treatment Strategy

Indications for Prophylaxis

Initiate preventive therapy when: 5, 1

• Attacks occur ≥2 times per month with disability lasting ≥3 days per month
• Acute medications are used more than twice weekly
• Contraindications exist to acute treatments
• Patient experiences prolonged aura or other complicated features

First-Line Preventive Medications

Beta-blockers: 5, 1

• Propranolol 80-240 mg/day (FDA-approved, strong evidence)
• Timolol 20-30 mg/day
• Alternative beta-blockers: atenolol, bisoprolol, or metoprolol

Topiramate: 5

• 100 mg/day (typically 50 mg twice daily)
• Only agent proven efficacious in randomized controlled trials for chronic migraine 3
• Particularly useful in patients with comorbid obesity due to weight loss effects 5

Candesartan: 5

• First-line agent, especially useful with comorbid hypertension

Second-Line Preventive Medications

Amitriptyline: 5, 1

• 30-150 mg/day
• Optimal choice for patients with comorbid depression, anxiety, or mixed migraine/tension-type headache 3, 5

Valproate/Divalproex sodium: 5, 1

• 800-1500 mg/day (valproate) or 500-1500 mg/day (divalproex)
• Strictly contraindicated in women of childbearing potential due to teratogenic effects 5

Flunarizine: 5

• 5-10 mg once daily at night (where available)
• Effective second-line option with efficacy comparable to propranolol and topiramate
• Screen for depression and Parkinson's disease before initiating, as it may exacerbate these conditions 5
• Avoid in elderly due to increased risk of extrapyramidal symptoms 5

Third-Line: CGRP Monoclonal Antibodies

Consider when 2-3 oral preventive medications have failed: 5

• Erenumab, fremanezumab, galcanezumab (monthly subcutaneous injection)
• Eptinezumab (intravenous)
• Assess efficacy only after 3-6 months of treatment 3, 5
• Significantly more expensive ($5,000-$6,000 annually) than oral agents 5

Implementation Strategy

• Start with low dose and titrate slowly until clinical benefits achieved or side effects limit increases 5, 1
• Allow adequate trial period of 2-3 months before determining efficacy 3, 5, 1
• For CGRP antibodies, wait 3-6 months before assessing response 3, 5
• Consider pausing preventive therapy after 6-12 months of successful treatment to determine if it can be discontinued 3, 5

Non-Pharmacological Approaches

Behavioral interventions should be offered alongside medication: 3, 5

• Cognitive-behavioral therapy
• Biofeedback and relaxation training
• Progressive muscle relaxation
• Meditation and abdominal breathing exercises
• Regular exercise (40 minutes three times weekly is as effective as topiramate or relaxation therapy) 3

Monitoring and Follow-Up

Maintain a headache diary to track: 3, 1, 6

• Attack frequency, severity, and duration
• Disability and quality of life impact
• Treatment response and adverse effects
• Potential triggers (foods, stress, sleep patterns, hormonal changes)
• Medication use to identify overuse patterns

Critical Pitfalls to Avoid

• Failing to recognize medication overuse headache from frequent acute medication use (≥10 days/month for triptans, ≥15 days/month for NSAIDs) 5
• Inadequate duration of preventive trial (less than 2-3 months) before declaring treatment failure 5
• Starting preventive medications at too high a dose, leading to poor tolerability and discontinuation 5
• Using valproate in women of childbearing potential without addressing teratogenic risks 5
• Prescribing triptans without screening for cardiovascular contraindications, particularly in patients with multiple risk factors 4
• Failing to rule out secondary causes of visual symptoms before attributing them to ocular migraine, especially with atypical features or prolonged visual loss 2, 7