What other medications can be used to treat migraine with aura?

Medications for Migraine with Aura

For acute treatment of migraine with aura, start NSAIDs (ibuprofen 400–800 mg, naproxen 500–825 mg, or aspirin 1000 mg) as soon as possible during the aura phase to prevent or diminish the subsequent headache; if NSAIDs fail after 2–3 episodes, escalate to a triptan (sumatriptan 50–100 mg, rizatriptan 10 mg, or zolmitriptan 2.5–5 mg) when the headache begins. 1, 2, 3

Acute Treatment Algorithm

First-Line: NSAIDs During Aura Phase

• Initiate NSAIDs or aspirin immediately when aura symptoms begin—not to treat the aura itself, but to abort or reduce the intensity of the impending headache phase. 3
• Recommended doses: ibuprofen 400–800 mg, naproxen sodium 500–825 mg, or aspirin 1000 mg. 1, 2
• NSAIDs demonstrate Level A evidence for mild-to-moderate migraine attacks. 2

Second-Line: Triptans for Headache Phase

• If NSAIDs fail after 2–3 migraine episodes, switch to a triptan when the headache begins (not during aura). 1, 2, 3
• Oral triptans with strong evidence include sumatriptan 50–100 mg, rizatriptan 10 mg, zolmitriptan 2.5–5 mg, and naratriptan. 1, 2
• Combination therapy (triptan + NSAID) is superior to either agent alone for moderate-to-severe attacks, with 130 additional patients per 1,000 achieving sustained pain relief at 48 hours. 2
• Subcutaneous sumatriptan 6 mg provides the highest efficacy (59% pain-free at 2 hours) with onset within 15 minutes, particularly useful when nausea or rapid progression occurs. 2

Third-Line: CGRP Antagonists (Gepants)

• Rimegepant 75 mg or ubrogepant 50–100 mg are recommended when triptans are contraindicated (cardiovascular disease, uncontrolled hypertension) or after triptan failure. 2, 4
• Rimegepant achieved 21.2% pain freedom at 2 hours versus 10.9% with placebo (p<0.001) in pivotal trials. 4
• Gepants have no vasoconstriction, making them safe in patients with cardiovascular contraindications to triptans. 2

Alternative: Dihydroergotamine (DHE)

• Intranasal or IV dihydroergotamine has good evidence for efficacy when NSAIDs and triptans are insufficient or contraindicated. 1, 2
• DHE is contraindicated with concurrent triptan use (within 24 hours), beta-blockers, uncontrolled hypertension, coronary artery disease, and pregnancy. 2

Critical Medication Frequency Limits

• Limit all acute medications to ≤2 days per week (≤10 days per month) to prevent medication-overuse headache, which paradoxically increases headache frequency and can lead to daily headaches. 1, 2, 5
• Triptans trigger medication-overuse headache at ≥10 days/month; NSAIDs at ≥15 days/month. 1, 2
• If acute medication use exceeds twice weekly, immediately initiate preventive therapy. 1, 2, 6

Preventive Therapy for Migraine with Aura

The prophylactic treatments for migraine with aura are identical to those used for migraine without aura, as very few randomized trials specifically target migraine with aura. 3, 7

First-Line Preventive Medications

• Propranolol 80–240 mg/day or timolol 20–30 mg/day (beta-blockers without intrinsic sympathomimetic activity) have strong evidence for migraine prevention. 1, 6
• Topiramate 50–100 mg/day has Level A evidence for both episodic and chronic migraine prevention. 6
• Candesartan is effective as first-line prevention, particularly useful for patients with comorbid hypertension. 6

Second-Line Preventive Medications

• Amitriptyline 30–150 mg/day is preferred when comorbid depression, anxiety, or sleep disturbances are present. 1, 6
• Flunarizine 5–10 mg/day (where available) is an effective second-line agent with efficacy comparable to propranolol and topiramate. 6, 8, 9
• Sodium valproate 800–1500 mg/day or divalproex sodium 500–1500 mg/day are effective but strictly contraindicated in women of childbearing potential due to teratogenic risk. 1, 6, 8

Third-Line: CGRP Monoclonal Antibodies

• Erenumab, fremanezumab, or galcanezumab (monthly subcutaneous injection) should be considered when 2–3 oral preventives have failed or are contraindicated. 6
• Efficacy requires 3–6 months for assessment. 6

Indications for Preventive Therapy

• ≥2 migraine attacks per month causing disability lasting ≥3 days. 1, 6
• Acute medication use >2 days per week. 6
• Contraindication to or failure of acute treatments. 6
• Special circumstances such as hemiplegic migraine or very frequent attacks (>2 per week). 6, 10

Medications to Absolutely Avoid

• Opioids (codeine, hydromorphone, morphine, tramadol) are absolutely contraindicated for migraine treatment due to questionable efficacy, high risk of dependence, medication-overuse headache, and worsening long-term outcomes. 2
• Butalbital-containing compounds should be avoided due to high risk of medication-overuse headache and dependency. 2
• Conventional cerebral angiography is contraindicated in hemiplegic migraine as it may provoke an attack. 8

Special Considerations for Migraine with Aura

• Visual aura occurs in >90% of patients with migraine with aura, typically lasting 5–60 minutes with gradual development. 1, 3
• Aura symptoms that are atypical, prolonged (>1 hour), or have sudden onset require urgent neuroimaging to exclude transient ischemic attack or stroke. 3
• Combined hormonal contraception with estrogens significantly increases stroke risk in women with migraine with aura and should be avoided. 3
• Migraine with aura carries an increased relative risk of ischemic stroke, particularly in women who smoke or use estrogen-containing contraceptives. 3, 7

Common Pitfalls to Avoid

• Do not delay triptan administration until aura resolves—triptans should be taken when the headache begins, not during the aura phase. 3
• Do not use triptans during aura symptoms, as they are ineffective for aura and should be reserved for the headache phase. 3
• Do not continue ineffective acute medications beyond 2–3 episodes—escalate therapy promptly to avoid prolonged disability. 1, 2
• Do not allow patients to increase acute medication frequency in response to treatment failure—this creates medication-overuse headache; instead, transition to preventive therapy. 2