Migraine with Aura Management in Stroke Survivors

Acute Migraine Treatment

The American College of Neurology recommends using NSAIDs (ibuprofen, naproxen) or acetaminophen for acute headache management in patients with migraine with aura and a history of stroke 1
Consider antiemetics (metoclopramide, prochlorperazine) for nausea without vascular risk in patients with migraine with aura and a history of stroke 1
Employ non-pharmacologic measures including dark room, cold compress, and rest for acute migraine management in patients with migraine with aura and a history of stroke 1

The American Academy of Neurology recommends initiating migraine prophylaxis with propranolol 80-160 mg daily or topiramate 50-100 mg daily to reduce attack frequency and future stroke risk in patients with migraine with aura and a history of stroke 1, 2
Propranolol has a dual benefit of migraine prevention and cardiovascular protection in patients with migraine with aura and a history of stroke 1, 2
Topiramate is effective for reducing aura frequency in patients with migraine with aura and a history of stroke 1, 2

The American Heart Association recommends ensuring the patient is on antiplatelet therapy (typically aspirin or clopidogrel) as standard secondary stroke prevention in patients with migraine with aura and a history of stroke 1
Low-dose aspirin serves a dual purpose for stroke prevention and may provide additional benefit given the migraine-related lesion burden in patients with migraine with aura and a history of stroke 1

The American College of Cardiology recommends smoking cessation as absolutely mandatory in patients with migraine with aura and a history of stroke, as smoking combined with migraine with aura creates catastrophic stroke risk (RR 9.03; 95% CI 4.22-19.34) 1, 2, 3
Estrogen-containing contraceptives are absolutely contraindicated in women with migraine with aura, as they increase stroke risk 7-fold (RR 7.02; 95% CI 1.51-32.68) 1, 2, 3
Aggressively manage hypertension, diabetes, and hyperlipidemia in patients with migraine with aura and a history of stroke 2
Screen for hypercoagulable states, as migraine with aura associates with thrombophilia (OR 6.81; 95% CI 1.01-45.79) in patients with migraine with aura and a history of stroke 1

Monitor for any change in aura characteristics - new or prolonged symptoms (>60 minutes) require immediate stroke evaluation in patients with migraine with aura and a history of stroke 4
Track migraine frequency monthly to assess prophylaxis effectiveness in patients with migraine with aura and a history of stroke 2
Any objective neurological deficit persisting beyond typical aura duration warrants urgent imaging in patients with migraine with aura and a history of stroke 4

Patients with migraine with aura and prior stroke have elevated risk of accumulating additional infarct-like lesions (OR 1.4; 95% CI 1.1-1.8) 1, 3
Consider baseline MRI to document lesion burden, particularly cerebellar lesions which are common in women with migraine with aura (OR 1.9; 95% CI 1.4-2.6) 1, 3