Think outside the pill box
Once you have settled on a diagnosis, treatment also can pose challenges.
“There are limited studies on aura without headache, so treatment choices are difficult,” says Robbins. “The experience is limited in time, so it would be over before the medicines kicked in.” However, he adds that if the patient experiences these symptoms often, you might want to consider preventive migraine medications.
You also might consider medications you don’t typically associate with migraine. “You can use medications not generally useful for migraine with headache, for example the antiseizure drug lamotrigine,” advises Robbins. “There is no good evidence that it is useful for migraine overall, but there is some evidence that it’s useful for aura only.”
Another important consideration is stroke risk. Migraine with aura has been associated with a small but significant risk of stroke in women aged younger than 45years. “Though the absolute risk is still small,” says Robbins, “with these patients it still might be a good idea to provide stroke education and be vigilant about cardiovascular health.”
Didion said of her migraine that she had, “learned now to live with it, learned when to expect it, how to outwit it."
With a little attention, physicians treating patients with this especially perplexing form of migraine can, too, learn how to outwit it.