Urgent Neuroimaging for Prolonged Visual Aura

Diagnostic Approach

The American Academy of Neurology recommends immediate neuroimaging, such as MRI brain with diffusion-weighted imaging, to rule out stroke or other serious pathology in patients with persistent visual aura beyond 72 hours 1
Normal migraine aura lasts 5-60 minutes maximum, and visual aura symptoms that persist beyond 1 hour are abnormal and warrant investigation 1, 2

The American Headache Society suggests that NSAIDs, such as ibuprofen 400-800mg every 6 hours or naproxen sodium 275-550mg, should be started during the aura phase to prevent or diminish the subsequent headache phase 3
Triptans are contraindicated during aura and ineffective for aura symptoms, and should only be used when headache begins, not during the aura phase 4, 3
First-line treatment for migraine headache includes NSAIDs, such as ibuprofen, naproxen, or diclofenac potassium, if not already given 4, 3
Second-line treatment for migraine headache includes triptans, such as sumatriptan 50-100mg, with a maximum of 200mg/24 hours, separated by at least 2 hours between doses 4

The American Academy of Neurology recommends initiating daily preventive therapy, with first-line options including propranolol 80-160mg daily, metoprolol 50-100mg twice daily, topiramate 50-100mg daily, or candesartan 16-32mg daily 5, 3
Response to preventive therapy should be evaluated within 2-3 months 5, 3

The American Headache Society advises against dismissing persistent visual symptoms as "just migraine" without imaging, as this requires exclusion of structural or vascular pathology 4, 3
Triptans should not be given during ongoing aura, as they are ineffective for aura and contraindicated in basilar or hemiplegic migraine 4, 3
Patients should be monitored for medication overuse headache and educated about rebound risk, with limited triptan use 4, 3