Treatment of Migraine Aura

Acute Treatment Algorithm

• The American College of Cardiology recommends initiating NSAIDs or aspirin as soon as aura symptoms appear to abort or diminish the headache that typically follows within 60 minutes 1
• Do NOT use triptans during the aura phase due to theoretical concerns about vasoconstriction during a period of potential cortical hypoperfusion 1

Critical Safety Considerations

• All combined hormonal contraceptives containing estrogen are absolutely contraindicated in women with migraine with aura due to compounded stroke risk 1
• Women with migraine with aura have significantly elevated baseline risk of ischemic stroke, and estrogen-containing contraceptives further increase this risk 1
• Progestin-only contraceptives are safe alternatives 1

Preventive Treatment

• First-line preventive medications include propranolol, metoprolol, or topiramate for patients with frequent migraine with aura 1
• Evaluate treatment response within 2-3 months using headache calendars to track attack frequency, severity, and medication use 1

Diagnostic Pitfalls to Avoid

• Each aura symptom lasts 5-60 minutes with gradual development 2
• At least one symptom is unilateral and at least one is positive (e.g., visual scintillations, not just scotoma) 2
• Aura is accompanied by or followed by headache within 60 minutes 2

Medication Overuse Warning

• Watch for medication overuse headache, which develops from using acute medications more than twice weekly 1
• Regular overuse for >3 months of non-opioid analgesics on ≥15 days/month or triptans/combination medications on ≥10 days/month meets criteria for medication-overuse headache 2