What is Treatment of the Aura part of Migraine with Aura? 2023
There are a number of acute and chronic preventive treatment drugs for the headache part of migraine with and without aura. There is not much written about treatment of just the aura part of migraine because the headache part of the syndrome is usually the worst part and the headache may usually be treated at onset with a Triptan.
The aura relates to cortical spreading depression (CSD) of electrical energy over the occipital portion of the brain. To the patient with migraine with aura the experience is usually one of seeing zigzag lines, flashing lights, blind spots in the center of vision, or half of things.
About 25-30% of patients with Migraine have aura symptoms which for most is a visual type aura lasting 20-30 minutes. Sometimes the aura lasts as long as 60 minutes.
Research using functional MRI for persons with Migraine aura has shown cortical spreading depression (CSD) events in the occipital cortex. Transient spreading excitation or depolarization followed by cortical depression are thought to be the pathophysiologic representation of Migraine aura.
Spreading depression, starting in the occiptal lobe and moving forward.
When discussing migraine with aura, most patients have only a visual aura, but they may also have tingling on one side of the body or trouble talking which are rare aura type symptoms during the migraine attack.
Tingling moving from fingers-arm-cheek.
Also, some patients do not have the headache part with their visual migraine experience, and this is called Migraine aura without headache, or in Latin “Migraine sine hemicrania.” Many patients have this type of migraine aura experience and there is a great need for medical intervention and treatment for this type of migraine symptom. Migraine patients ask about this.
This is an article by Britt Talley Daniel MD, member of the American Academy of Neurology, the American Headache Society, migraine textbook author, podcaster, YouTube video producer, and blogger.
Consider my small eBook on Migraine here.
What is treatment of the aura part of migraine with aura? The migraine aura may be treated acutely with inhaled isoproterenol. Triptans may be given for acute therapy of the headache. For prevention of Migraine, the usual drugs for general Migraine prevention may be used long-term.
Acute therapy for the Migraine aura.
Isuprel (isoproterenol) is inhaled once at onset of the aura symptoms. Isoproterenol comes in an inhaler which is usually used for treating asthma.
Inhaler
Nitroglycerin and NSAIDS have been suggested for treating the Migraine aura but have little documentation of efficacy.
Triptans do not work for the aura part of the syndrome.
Preventive therapy for Migraine aura.
The American Academy of Neurology and American Headache Society recommendations for preventive drugs are:
Level A drugs, that is those which have been established as effective, are:
Divalproex sodium, sodium valproate 400-1000 mg/day (for non-fertile women only).
Topamax (topiramate), short acting ,or Trokendia XR, Qudexy XR, long acting 25-200 mg/day.
Frovatriptan (long acting triptan--26 hours) for menstrually related migraine short term 2.5 mg/day’
Onabotulinumtoxin A (Botox)--physician injects onabotulinumtoxin A into the muscles of the forehead and neck. When effective, the treatment is repeated every 3 months. Indicated by the FDA for persons with Chronic Migraine (15 headache days/month, 8 of which are like migraine).
Botox has been found to be only modestly effective for preventing migraines in the most frequent suffers. Botox prevented 1.8 headaches a month more than placebo.
Betablockers
Metoprolol 47.5-200 mg/day
propranolol 120-240 mg/day
Timolol 10-15 mg bid
Level B drugs, those which are “probably effective.”
Amitriptyline 25-150 mg/day
nortriptyline 25-50 mg/day
venlafaxine 150 mg extended release/day
Level C drugs, thought to be “possibly effective.”
ACE inhibitors (lisinopril) 10-20 mg/day
angiotensin receptor blockers (candesartan) 16 mg/day
alpha-agonists (clonidine) 0.75-0.15 mg/day; patch formulations also studied
carbamazepine 600 mg/day
Cyproheptadine 4 mg/day
Atenolol 100 mg/day
Guanfacine 0.5-1 mg/day
Lomotrigine may be given orally as 25 mg/day for a week and increasing the dose by 25 mg per day on a 2X/day schedule till a dose of 50/50 mg or 100 mg is given. The drug is then used long-term for aura prevention. Lomotrigine is the only drug that comes up after searching the internet for a preventive drug just for Migraine with aura.
CGRP drugs. Currently one of the four injectable CGRP drugs would be preferred for Migraine prevention over the older durgs—Aimovig, Emgality, Ajovy, or Vyepti.
Special considerations
All of the listed drugs above for prevention may reduce headache significantly. However, there are special considerations for patients with multiple medical problems using these drugs
Patients who are anxious and can’t sleep or have depression may be given amitriptyline or nortriptyline. Amitriptyline is also the go to drug for patients who have limited funds or no insurance drug coverage since it is so cheap, often just 3-4 dollars a month.
Persons who have epilepsy and migraine and overweight should be offered topiramate, but this drug shouldn’t be given to patients with a history of kidney stones.
Patients with tremor, hypertension, or migraine may be given a beta blocker which may treat all three conditions.
Thinking this way, the doctor and the patient may get a double treatment effect from a single preventive medication.
Also there is no endorsement by the American Academy of Neurology or the American Headache Society on the new CGRP drugs—Aimovig, Ajovy, or Emgality--for migraine prevention, but it’s well known that these new drugs work better than the old time preventive drugs listed above.
Stay tuned for new data on these CGRP drugs for preventing migraine. For now, see my articles on these three drugs at www.doctormigraine.com.
What is the literature supporting use of isoproterenol to treat the migraine aura?
Kupersmith MJ, Hass W K, Chase NE wrote on “Isoproterenol treatment of visual symptoms in migraine in Stroke. 1979;10 (3): 299-305.”
Abstract
Six patients with transient or permanent visual loss associated with migraine are presented. In 3 patients with monocular and one patient with binocular episodes of transient visual loss subsequent visual episodes were relieved by prompt inhalation of isoproterenol.
The authors review the possible mechanisms of action of isoproterenol in migraine and present evidence to support the prophylactic use of isoproterenol to prevent transient and possible persistent visual loss in patients with migraine.
What is the literature supporting use of Triptans to treat the migraine aura?
D Bates 1, E Ashford, R Dawson, F B Ensink, N E Gilhus, J Olesen, A J Pilgrim, P Shevlin wrote in Neurology in 1994 Sep;44(9):1587-92 on “Subcutaneous sumatriptan during the migraine aura. Sumatriptan Aura Study Group.”
Abstract
This double-blind, placebo-controlled, multicenter, parallel-group study assessed whether subcutaneous sumatriptan administered during the migraine aura would prolong or modify the aura and prevent or delay development of the headache.
One hundred seventy-one patients (88 receiving 6 mg sumatriptan, 83 receiving placebo) treated a single attack of migraine with typical aura at home, by self-injection. The median duration of aura following the first injection was 25 minutes for the sumatriptan group and 30 minutes for the placebo group (NS).
The aura symptom profile was similar for the two treatment groups. The proportion of patients who developed a moderate or severe headache within 6 hours after dose administration was similar in the two groups--68% among those receiving sumatriptan and 75% among those receiving placebo (NS).
Sumatriptan given during the aura did not prolong or alter the nature of the migraine aura and did not prevent or significantly delay headache development.
Author tip: Triptans don’t work.
What is the literature supporting use of Lamotrigine to prevent migraine aura?
Dan Buch, Hugues Chabriat wrote in Headache in 2019 Sep;59(8):1187-1197 on “Lamotrigine in the Prevention of Migraine with Aura: A Narrative Review.”
Abstract Background: Lamotrigine is not recommended in the prevention of migraine in general, but some reports suggest that it might be effective for treating specifically migraine with aura (MA).
This review aims to summarize the related data from the literature and to better understand this discrepancy.
Methods: All reports from the literature related to the use of lamotrigine in migraine with or without aura published prior to February 2019 found using PUBMED and the 2 keywords "migraine" AND "lamotrigine" were reviewed.
Original studies, published in full, systematic reviews, and all case reports were synthetized. We also examined the risk profile, pharmacokinetics, and mode of action of lamotrigine in view of the presumed mechanism of MA.
Results: Lamotrigine was tested in different populations of migraineurs, but previous studies had small sample sizes (n < 35) and might not have been powered enough for detecting a potential benefit of lamotrigine in MA.
Accumulating data suggest that the drug can reduce both the frequency and severity of aura symptoms in multiple conditions and is well tolerated.
Conclusion: Lamotrigine appears promising for treating attacks of MA and related clinical manifestations because of its high potential of efficacy, low-risk profile, and cost.
Additional studies are needed for testing lamotrigine in patients with MA.
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C Lampl, Z Katsarava, H-C Diener, V Limmroth wrote in J Neurol Neurosurg Psychiatry in 2005 Dec; 76(12): 1730–1732 on “Lamotrigine reduces migraine aura and migraine attacks in patients with migraine with aura.”
Abstract: This study examined the efficacy of lamotrigine in the prevention of migraine aura. Fifty-nine patients suffering from migraine with aura received lamotrigine in a controlled three-year prospective open study.
Treatment response was defined as a reduction of aura frequency each month by at least 50%. Primary endpoint was reached by three quarters of the patients. Lamotrigine significantly reduced both frequency of migraine aura (mean, 1.5 (SD, 0.6) each month before v 0.4 (0.7) after treatment; p < 0.001) and aura duration (mean, 27 (SD, 11) minutes before v 8 (14) after treatment; p < 0.001).
Furthermore, more than three quarters of those patients with a reduction of aura symptoms experienced a significant reduction of frequency of migraine attacks (mean, 2.1 (SD, 1.0) each month before v 1.2 (1.1) after treatment; p < 0.001). Lamotrigine was highly effective in reducing migraine aura and migraine attacks.
The strong correlation between reduction of aura symptoms and migraine attacks stresses the potential role of aura-like events and possibly cortical spreading depression as a trigger for trigeminal vascular activation, and subsequently the development of migraine headaches.
The Bottom Line: Use isoproternol inhalation acutely for the Migraine aura, and typical Migraine preventive drugs or Lamotrigine daily long term to reduce the number of Migraine with Aura attacks.
Check out my Big Book on Migraine here.
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All the best.
Britt Talley Daniel MD
