Migraine with Aura

DIAGNOSIS: Migraine with Aura ICD-10: G43.109 (Migraine with aura, not intractable, without status migrainosus), G43.101 (with status migrainosus), G43.119 (intractable, without status migrainosus), G43.111 (intractable, with status migrainosus), G43.409 (Hemiplegic migraine, not intractable), G43.419 (Hemiplegic migraine, intractable)

CPT CODES: 85025 (CBC), 80048 (BMP), 82947 (Glucose), 85610 (PT/INR), 83036 (HbA1c), 80061 (Lipid panel), 85652 (ESR), 84443 (TSH), 83735 (Magnesium, RBC), 83090 (Homocysteine), 82607 (Vitamin B12), 82306 (Vitamin D, 25-OH), 81241 (Factor V Leiden), 86038 (ANA), 81291 (MTHFR mutation), 81406 (Genetic testing: CACNA1A, ATP1A2, SCN1A), 70551 (MRI Brain without contrast), 70450 (CT Head non-contrast), 70544 (MRA Head), 70553 (MRI Brain with contrast), 70547 (MRA Neck), 93306 (TTE with bubble study), 93312 (TEE), 93886 (Transcranial Doppler with bubble), 95816 (EEG) SYNONYMS: Classic migraine, migraine with typical aura, hemiplegic migraine, familial hemiplegic migraine (FHM), sporadic hemiplegic migraine, visual migraine, ophthalmic migraine, acephalgic migraine, migraine aura without headache, scintillating scotoma, fortification spectra SCOPE: Diagnosis and management of migraine with typical aura (visual, sensory, language) and hemiplegic migraine. Focuses on outpatient management with acute care considerations. Covers differentiation from TIA/stroke, contraceptive counseling, and preventive therapy. Excludes migraine with brainstem aura (separate protocol) and retinal migraine.

VERSION: 1.1 CREATED: January 27, 2026 REVISED: January 30, 2026

STATUS: Approved

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PRIORITY KEY: STAT = Immediate | URGENT = Within hours | ROUTINE = Standard | EXT = Extended/atypical cases | - = Not applicable to this setting

CLINICAL NOTES: - Aura typically precedes headache by 5-60 minutes but can occur during or without headache - Triptans ARE safe in typical migraine with aura (visual, sensory, language) - Triptans/ergots CONTRAINDICATED in hemiplegic migraine (motor aura) - Estrogen-containing contraceptives contraindicated - elevated ischemic stroke risk - Always differentiate from TIA/stroke on first presentation

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SECTION A: ACTION ITEMS

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1. LABORATORY WORKUP

1A. Essential/Core Labs

Test (CPT)	ED	HOSP	OPD	ICU	Rationale	Target Finding
CBC (CPT 85025)	STAT	ROUTINE	ROUTINE	-	Rule out anemia, infection; baseline before treatment	Normal
BMP (CPT 80048)	STAT	ROUTINE	ROUTINE	-	Electrolyte abnormalities; renal function for medication dosing	Normal
Glucose (CPT 82947)	STAT	ROUTINE	ROUTINE	-	Hypoglycemia can mimic aura; hyperglycemia raises stroke risk	70-180 mg/dL
PT/INR (CPT 85610), PTT (CPT 85730)	STAT	ROUTINE	-	-	Coagulation screen if stroke consideration; before LP	Normal
HbA1c (CPT 83036)	-	ROUTINE	ROUTINE	-	Vascular risk assessment	<7% optimal
Lipid panel (CPT 80061)	-	ROUTINE	ROUTINE	-	Vascular risk stratification	LDL <100 mg/dL

1B. Extended Workup (Second-line)

Test (CPT)	ED	HOSP	OPD	ICU	Rationale	Target Finding
ESR (CPT 85652), CRP (CPT 86140)	URGENT	ROUTINE	ROUTINE	-	Rule out GCA if age >50 with new visual symptoms	Normal
TSH (CPT 84443)	-	ROUTINE	ROUTINE	-	Thyroid dysfunction can trigger headache/aura-like symptoms	Normal (0.4-4.0 mIU/L)
Magnesium, RBC (CPT 83735)	-	ROUTINE	ROUTINE	-	Deficiency linked to migraine with aura specifically	>4.2 mg/dL
Homocysteine (CPT 83090)	-	ROUTINE	ROUTINE	-	Elevated levels associated with migraine with aura and stroke	<15 μmol/L
Vitamin B12 (CPT 82607), Folate (CPT 82746)	-	ROUTINE	ROUTINE	-	Deficiency can elevate homocysteine; sensory symptoms	Normal
Vitamin D, 25-OH (CPT 82306)	-	ROUTINE	ROUTINE	-	Deficiency associated with increased migraine frequency	>30 ng/mL

1C. Rare/Specialized (Refractory or Atypical)

Test (CPT)	ED	HOSP	OPD	ICU	Rationale	Target Finding
Antiphospholipid antibodies (CPT 86235, 86147, 86146)	-	EXT	EXT	-	Thrombophilia workup if young stroke or recurrent prolonged aura	Negative
Factor V Leiden (CPT 81241), Prothrombin G20210A (CPT 81240)	-	-	EXT	-	Hereditary thrombophilia if recurrent aura or stroke-like events	Negative
ANA (CPT 86038), Anti-dsDNA (CPT 86225)	-	EXT	EXT	-	CNS lupus in atypical presentations	Negative
MTHFR mutation (CPT 81291)	-	-	EXT	-	Elevated homocysteine with aura	Wild type or heterozygous
Genetic testing: CACNA1A, ATP1A2, SCN1A (CPT 81406)	-	-	EXT	-	Hemiplegic migraine suspected; family history	Variant identified
CSF analysis (CPT 89050, 89051)	URGENT	ROUTINE	-	-	Rule out meningitis, SAH if atypical presentation	Normal; no xanthochromia

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2. DIAGNOSTIC IMAGING & STUDIES

2A. Essential/First-line

Study (CPT)	ED	HOSP	OPD	ICU	Timing	Target Finding	Contraindications
MRI Brain without contrast (CPT 70551)	URGENT	ROUTINE	ROUTINE	-	First presentation with aura; rule out stroke/structural lesion	Normal; no acute infarct; no WMH concerning for vasculopathy	MRI-incompatible devices
CT Head non-contrast (CPT 70450)	STAT	STAT	-	-	Acute presentation if MRI unavailable; rule out hemorrhage	No hemorrhage or mass	Pregnancy (relative)
MRA Head (CPT 70544)	URGENT	ROUTINE	ROUTINE	-	First aura or prolonged aura to assess intracranial vessels	No stenosis, aneurysm, or dissection	MRI contraindications

2B. Extended

Study (CPT)	ED	HOSP	OPD	ICU	Timing	Target Finding	Contraindications
MRI Brain with contrast (CPT 70553)	URGENT	ROUTINE	ROUTINE	-	Atypical features; persistent deficits; concern for mass	No enhancement; no mass	Gadolinium allergy; severe renal impairment
MRA Neck (CPT 70547)	URGENT	ROUTINE	ROUTINE	-	Suspected cervical dissection (neck pain, Horner syndrome)	No dissection	MRI contraindications
CTA Head/Neck (CPT 70496, 70498)	STAT	URGENT	-	-	Acute vascular imaging if MRI unavailable	No aneurysm, dissection, occlusion	Contrast allergy; CKD (eGFR <30)
TTE with bubble study (CPT 93306)	-	ROUTINE	ROUTINE	-	Evaluate for PFO if recurrent aura or cryptogenic stroke history	No PFO; if present, assess shunt size	None

2C. Rare/Specialized

Study (CPT)	ED	HOSP	OPD	ICU	Timing	Target Finding	Contraindications
TEE (CPT 93312)	-	EXT	EXT	-	Detailed cardiac source evaluation if TTE positive or high suspicion	No cardiac thrombus; characterize PFO	Esophageal pathology
MRI with perfusion/DWI (CPT 70553)	URGENT	ROUTINE	EXT	-	Prolonged aura to differentiate migrainous infarct from stroke	No DWI restriction	MRI contraindications
Transcranial Doppler with bubble (CPT 93886)	-	ROUTINE	ROUTINE	-	PFO screening; noninvasive alternative to TTE bubble	No right-to-left shunt	Inadequate acoustic windows
EEG (CPT 95816)	URGENT	ROUTINE	EXT	-	Aura with altered consciousness; differentiate from seizure	No epileptiform activity	None

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3. TREATMENT

3A. Acute/Emergent

Treatment	Route	Indication	Dosing	Contraindications	Monitoring	ED	HOSP	OPD	ICU
Ketorolac	IV/IM	First-line acute migraine with aura in ED	30 mg :: IV :: once :: 30 mg IV (15 mg if >65y, renal impairment, or <50 kg); max 5 days NSAIDs	Renal impairment (CrCl <30); active GI bleed; aspirin/NSAID allergy; third trimester	Renal function if repeated dosing	STAT	STAT	-	-
Metoclopramide	IV	Antiemetic with anti-migraine properties	10 mg :: IV :: once :: 10-20 mg IV over 15 min; pretreat with diphenhydramine 25 mg IV to prevent akathisia	Parkinson's disease; tardive dyskinesia history; bowel obstruction; pheochromocytoma	Akathisia, dystonia; discontinue if EPS	STAT	STAT	-	-
Prochlorperazine	IV	Dopamine antagonist for acute migraine with prominent nausea	10 mg :: IV :: once :: 10 mg IV slowly over 2 min; pretreat with diphenhydramine 25 mg IV	QT prolongation (QTc >500ms); Parkinson's disease; neuroleptic malignant syndrome history	QTc if baseline prolonged; EPS	STAT	STAT	-	-
Diphenhydramine	IV	Prevent akathisia from dopamine antagonists; sedation	25 mg :: IV :: once :: 25-50 mg IV given concurrently with dopamine antagonist	Narrow-angle glaucoma; urinary retention; severe prostatic hypertrophy	Sedation; anticholinergic effects	STAT	STAT	-	-
Magnesium sulfate	IV	Migraine with aura - particularly effective; refractory migraine	2 g :: IV :: once :: 2 g IV in 50 mL NS over 20-30 min; may repeat x1 after 2 hr	Heart block; severe hypermagnesemia; myasthenia gravis; severe renal impairment	BP, HR during infusion; flushing is common and benign	STAT	URGENT	-	-
Sumatriptan	SC/PO	Acute migraine with TYPICAL aura (visual, sensory, language) - SAFE	6 mg :: SC :: once :: 6 mg SC (may repeat after 1 hr, max 12 mg/24hr) OR 50-100 mg PO (may repeat after 2 hr, max 200 mg/24hr); take AFTER aura resolves or at headache onset	HEMIPLEGIC MIGRAINE (motor aura); uncontrolled HTN; CAD; prior stroke/TIA; MAOIs within 14 days; ergots within 24 hr	Chest tightness (triptan sensation vs cardiac); assess cardiovascular risk	URGENT	URGENT	ROUTINE	-
Valproate sodium	IV	Status migrainosus with aura; refractory to first-line	500 mg :: IV :: once :: 500-1000 mg IV over 5-10 min; may repeat 500 mg in 8 hr	Hepatic disease; pregnancy (teratogenic); urea cycle disorders; pancreatitis history	LFTs; ammonia if altered mental status	URGENT	URGENT	-	-
Dexamethasone	IV	Prevent headache recurrence after acute treatment	10 mg :: IV :: once :: 10 mg IV x1 at time of discharge or admission; single dose	Active untreated infection; known hypersensitivity	Glucose if diabetic	URGENT	URGENT	-	-

3B. Symptomatic Treatments

Treatment	Route	Indication	Dosing	Contraindications	Monitoring	ED	HOSP	OPD	ICU
Rizatriptan	PO	Acute typical migraine with aura; fast onset	10 mg :: PO :: once :: 5-10 mg PO (use 5 mg if on propranolol); may repeat after 2 hr; max 30 mg/24hr	HEMIPLEGIC MIGRAINE (motor aura); uncontrolled HTN; CAD; prior stroke/TIA; MAOIs within 14 days; ergots within 24 hr; use 5 mg max if on propranolol	Triptan sensation	-	ROUTINE	ROUTINE	-
Eletriptan	PO	Acute typical migraine with aura; good for recurrence	40 mg :: PO :: once :: 40 mg PO; may repeat 40 mg after 2 hr if partial response; max 80 mg/24hr	HEMIPLEGIC MIGRAINE (motor aura); uncontrolled HTN; CAD; prior stroke/TIA; MAOIs within 14 days; ergots within 24 hr; potent CYP3A4 inhibitors (ketoconazole, clarithromycin)	Triptan sensation	-	ROUTINE	ROUTINE	-
Naratriptan	PO	Migraine with aura; longer duration; menstrual migraine	2.5 mg :: PO :: once :: 2.5 mg PO; may repeat after 4 hr; max 5 mg/24hr; slower onset but longer lasting	HEMIPLEGIC MIGRAINE (motor aura); uncontrolled HTN; CAD; prior stroke/TIA; MAOIs within 14 days; ergots within 24 hr; moderate-severe renal/hepatic impairment	Triptan sensation	-	ROUTINE	ROUTINE	-
Ubrogepant	PO	CGRP antagonist; use if triptan contraindicated or cardiovascular risk	50 mg :: PO :: once :: 50-100 mg PO; may repeat after 2 hr; max 200 mg/24hr	Strong CYP3A4 inhibitors; severe hepatic impairment	None routine; no cardiovascular contraindications	-	ROUTINE	ROUTINE	-
Rimegepant	PO/ODT	CGRP antagonist; can use for acute and prevention	75 mg :: PO :: once :: 75 mg ODT at onset; max 75 mg/24hr for acute; also approved 75 mg every other day for prevention	Strong CYP3A4 inhibitors/inducers; severe hepatic impairment	None routine	-	ROUTINE	ROUTINE	-
Lasmiditan	PO	5-HT1F agonist; safe in cardiovascular disease; ditan class	100 mg :: PO :: once :: 50-200 mg PO x1; max 200 mg/24hr; DO NOT DRIVE for 8 hours after dose	Concurrent alcohol; CYP3A4 substrates with narrow TI	CNS depression; dizziness; NO driving for 8 hr	-	ROUTINE	ROUTINE	-
Ibuprofen	PO	Mild-moderate aura migraine	400 mg :: PO :: once :: 400-800 mg PO at onset; max 2400 mg/day	Renal impairment; active GI bleed; aspirin/NSAID allergy; third trimester	GI symptoms; renal function if prolonged use	URGENT	ROUTINE	ROUTINE	-
Naproxen sodium	PO	Mild-moderate aura migraine; menstrual migraine prevention	550 mg :: PO :: once :: 550 mg PO at onset; may add 275 mg in 12 hr; max 1375 mg day 1, then 1100 mg/day	Renal impairment; active GI bleed; aspirin/NSAID allergy	GI symptoms	URGENT	ROUTINE	ROUTINE	-
Acetaminophen-Aspirin-Caffeine	PO	Mild-moderate migraine with aura (OTC option)	2 tablets :: PO :: once :: 2 tablets (250/250/65 mg each) at onset; max 2 doses/24hr	Aspirin allergy; hepatic impairment; avoid if using other acetaminophen sources	Limit total acetaminophen <3 g/day	URGENT	ROUTINE	ROUTINE	-
Ondansetron	IV/PO	Nausea/vomiting with migraine	4 mg :: IV :: PRN :: 4 mg IV or 8 mg PO/ODT; may repeat q8h as needed	QT prolongation (QTc >500ms); severe hepatic impairment	QTc if multiple doses or baseline prolongation	STAT	STAT	ROUTINE	-

3C. Second-line/Refractory

Treatment	Route	Indication	Dosing	Contraindications	Monitoring	ED	HOSP	OPD	ICU
Dihydroergotamine (DHE)	IV/SC/Nasal	Refractory migraine; status migrainosus; NOT for hemiplegic	0.5 mg :: IV :: q8h :: IV: 0.5-1 mg q8h for up to 3 days (pretreat with antiemetic); SC: 1 mg, may repeat in 1 hr; Nasal: 1 spray each nostril, repeat in 15 min	Pregnancy; CAD; uncontrolled HTN; peripheral vascular disease; HEMIPLEGIC MIGRAINE; triptan use within 24hr; severe hepatic/renal impairment	BP; nausea; chest pain; continuous cardiac monitoring for IV	-	URGENT	EXT	-
Occipital nerve block	SC	Refractory migraine; occipital-predominant pain	2.5 mL :: SC :: once :: Inject bupivacaine 0.5% 2-3 mL + triamcinolone 40 mg at greater occipital nerve bilaterally; may add lesser occipital, supraorbital	Local anesthetic allergy; infection at injection site; anticoagulation (relative)	Vasovagal reaction; immediate pain assessment	-	EXT	ROUTINE	-
Ketamine	IV	Status migrainosus refractory to DHE	0.1 mg/kg/hr :: IV :: continuous :: 0.1-0.3 mg/kg/hr continuous infusion for 24-48 hr; subanesthetic dosing only	Uncontrolled HTN; psychosis history; elevated ICP; pregnancy	Dissociation; BP; HR; requires continuous cardiac monitoring	-	EXT	-	-
Verapamil	IV	Hemiplegic migraine acute (if severe); status migrainosus	5 mg :: IV :: once :: 5 mg IV over 2-3 min; may repeat in 30 min (max 20 mg)	Heart block (2nd/3rd degree); severe LV dysfunction; hypotension	Continuous ECG; BP; for hemiplegic migraine when triptans contraindicated	-	EXT	-	-
Intranasal lidocaine	Intranasal	Acute migraine with aura; rapid onset option	0.5 mL :: Intranasal :: once :: 4% lidocaine 0.5 mL per nostril directed at sphenopalatine fossa; may repeat x1 in 15 min	Local anesthetic allergy	Local numbness; cardiac arrhythmia (rare with low dose)	URGENT	URGENT	ROUTINE	-

3D. Disease-Modifying or Chronic Therapies (Preventive Medications)

Treatment	Route	Indication	Dosing	Pre-Treatment Requirements	Contraindications	Monitoring	ED	HOSP	OPD	ICU
Magnesium oxide	PO	First-line supplement for migraine with aura prevention	400 mg :: PO :: daily :: Start 400 mg daily; may increase to 400 mg BID; take with food to reduce GI upset	None	Renal impairment (CrCl <30) - dose reduce	Diarrhea; check Mg level if symptomatic or renal disease	-	ROUTINE	ROUTINE	-
Topiramate	PO	First-line oral prevention; reduces aura frequency; weight loss	25 mg :: PO :: qHS :: Start 25 mg qHS; increase by 25 mg/wk; target 50-100 mg BID	None	PREGNANCY (teratogenic); glaucoma; kidney stones; metabolic acidosis	Cognitive effects; paresthesias; weight; serum bicarbonate; kidney stones	-	ROUTINE	ROUTINE	-
Propranolol	PO	First-line prevention; comorbid HTN, anxiety, tremor	40 mg :: PO :: BID :: Start 40 mg BID or 80 mg LA daily; titrate q2wk; target 80-240 mg/day	None	Asthma; COPD with bronchospasm; bradycardia <50; 2nd/3rd degree heart block; decompensated HF	HR (goal >50); BP; fatigue; depression; exercise intolerance	-	ROUTINE	ROUTINE	-
Amitriptyline	PO	Prevention with comorbid insomnia, depression, tension-type headache	10 mg :: PO :: qHS :: Start 10 mg qHS; titrate by 10-25 mg q1-2wk; target 25-75 mg qHS	ECG if >50 y/o or cardiac history	Cardiac conduction disease; recent MI; glaucoma; urinary retention; elderly (anticholinergic burden)	Sedation; weight; dry mouth; ECG if dose >100 mg or cardiac history	-	ROUTINE	ROUTINE	-
Venlafaxine XR	PO	Prevention with comorbid depression, anxiety	37.5 mg :: PO :: daily :: Start 37.5 mg daily; increase by 37.5-75 mg q1wk; target 75-150 mg daily	None	Uncontrolled HTN; MAOIs within 14 days; abrupt discontinuation risk	BP at doses >150 mg; serotonin syndrome signs; taper to discontinue	-	ROUTINE	ROUTINE	-
Candesartan	PO	Prevention; comorbid HTN; beta-blocker intolerant	8 mg :: PO :: daily :: Start 8 mg daily; may increase to 16 mg daily after 4 wk	None	Pregnancy; bilateral renal artery stenosis; hyperkalemia	BP; potassium; creatinine	-	ROUTINE	ROUTINE	-
Valproate/Divalproex	PO	Prevention with comorbid bipolar or epilepsy	250 mg :: PO :: BID :: Start 250 mg BID or 500 mg ER daily; titrate to 500-1000 mg/day	LFTs; CBC	Pregnancy (teratogenic - neural tube defects); hepatic disease; urea cycle disorders; pancreatitis history	LFTs q6mo; weight; hair loss; tremor; CBC	-	ROUTINE	ROUTINE	-
Riboflavin (Vitamin B2)	PO	Supplement for prevention; well-tolerated; may reduce aura	400 mg :: PO :: daily :: 400 mg daily	None	None	Fluorescent yellow urine (reassure patient); benign	-	ROUTINE	ROUTINE	-
Coenzyme Q10	PO	Supplement; mitochondrial support	100 mg :: PO :: TID :: 100-300 mg daily	None	None	None	-	ROUTINE	ROUTINE	-
Erenumab (Aimovig)	SC	CGRP mAb; failed 2+ oral preventives or intolerance	70 mg :: SC :: monthly :: 70 mg SC monthly; may increase to 140 mg monthly after 3 months if suboptimal response	None	Hypersensitivity to erenumab	Constipation (can be severe - may need laxatives); injection site reactions; HTN monitoring	-	-	ROUTINE	-
Fremanezumab (Ajovy)	SC	CGRP mAb; flexible dosing options	225 mg :: SC :: monthly :: 225 mg SC monthly OR 675 mg SC quarterly (three 225 mg injections)	None	Hypersensitivity	Injection site reactions	-	-	ROUTINE	-
Galcanezumab (Emgality)	SC	CGRP mAb; requires loading dose	240 mg :: SC :: once :: 240 mg SC loading dose (2 x 120 mg injections), then 120 mg SC monthly	None	Hypersensitivity	Injection site reactions; vertigo	-	-	ROUTINE	-
Onabotulinumtoxin A (Botox)	IM	Chronic migraine with aura (≥15 days/month); failed oral preventives	155 units :: IM :: q12wk :: 155-195 units across 31-39 injection sites per PREEMPT protocol; repeat q12 weeks; effect may take 2-3 cycles	None	Infection at injection sites; myasthenia gravis; neuromuscular disorder	Neck weakness; ptosis; antibody formation if loss of effect	-	-	ROUTINE	-
Flunarizine	PO	Calcium channel blocker for prevention; especially hemiplegic migraine	5 mg :: PO :: qHS :: Start 5 mg qHS; may increase to 10 mg qHS; especially useful for hemiplegic migraine (not available in US)	None	Depression; Parkinson's disease; extrapyramidal disorders	Weight gain; depression; parkinsonism with prolonged use	-	ROUTINE	ROUTINE	-
Lamotrigine	PO	May reduce aura frequency specifically; hemiplegic migraine	25 mg :: PO :: daily :: Start 25 mg daily; increase by 25 mg q2wk to 50-100 mg BID; SLOW titration to prevent rash	None	History of lamotrigine-related rash; interacting drugs (valproate halves dose)	RASH (stop immediately if rash develops - SJS risk); monitor closely during titration	-	ROUTINE	ROUTINE	-
Acetazolamide	PO	Hemiplegic migraine prevention; familial hemiplegic migraine	250 mg :: PO :: BID :: Start 250 mg BID; may increase to 500 mg BID	None	Sulfa allergy; severe hepatic/renal disease; hypokalemia; acidosis	Paresthesias; metabolic acidosis; K+; bicarbonate	-	ROUTINE	ROUTINE	-

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4. OTHER RECOMMENDATIONS

4A. Referrals & Consults

Recommendation	ED	HOSP	OPD	ICU
Neurology/Headache specialist referral for aura characterization, preventive optimization, and differentiation from other neurological conditions	URGENT	ROUTINE	ROUTINE	-
OB/GYN consultation for contraceptive counseling - estrogen-containing contraceptives contraindicated in migraine with aura due to elevated ischemic stroke risk	-	-	ROUTINE	-
Cardiology referral if TTE shows PFO for discussion of closure in select cases (recurrent cryptogenic stroke or debilitating aura despite medical therapy)	-	ROUTINE	ROUTINE	-
Genetics consultation if hemiplegic migraine suspected for CACNA1A, ATP1A2, SCN1A testing and family counseling	-	-	ROUTINE	-
Physical therapy for cervicogenic component and trigger point management	-	-	ROUTINE	-
Psychology/Behavioral medicine for CBT addressing aura anxiety, attack anticipation, and comorbid mood disorders	-	-	ROUTINE	-
Ophthalmology if visual aura atypical or concern for retinal pathology	-	ROUTINE	ROUTINE	-
Sleep medicine if sleep disorder contributing to migraine frequency (OSA, insomnia)	-	-	ROUTINE	-

4B. Patient Instructions

Recommendation	ED	HOSP	OPD
Return immediately for new/different headache, "worst headache of life," or thunderclap onset which may indicate subarachnoid hemorrhage	STAT	-	ROUTINE
Return immediately if aura persists >60 minutes or if new weakness on one side of body develops (need to rule out stroke)	STAT	-	ROUTINE
Return immediately for headache with fever, stiff neck, or altered mental status which may indicate CNS infection	STAT	-	ROUTINE
AVOID estrogen-containing contraceptives (combined birth control pills, patch, ring) - use progestin-only methods (mini-pill, Depo-Provera, Mirena IUD, Nexplanon) or non-hormonal methods	-	ROUTINE	ROUTINE
Triptans ARE safe for your typical visual/sensory aura - take at headache onset or when aura ends; do NOT take if you experience weakness (motor aura)	-	ROUTINE	ROUTINE
Maintain headache/aura diary tracking aura type, duration, triggers, and medication use to guide treatment optimization	-	ROUTINE	ROUTINE
Limit acute medication use to ≤10 days/month to prevent medication overuse headache which worsens both headache and aura	URGENT	ROUTINE	ROUTINE
Learn your personal aura warning signs and take acute medication promptly when headache begins	-	ROUTINE	ROUTINE
Do not drive or operate machinery during visual or motor aura as vision and coordination may be impaired	URGENT	ROUTINE	ROUTINE

4C. Lifestyle & Prevention

Recommendation	ED	HOSP	OPD
Regular sleep schedule (7-8 hours, consistent bedtime) as sleep changes are a major aura trigger	-	ROUTINE	ROUTINE
Avoid known aura triggers (bright/flashing lights, high altitude, significant sleep deprivation, extreme stress)	-	ROUTINE	ROUTINE
Regular aerobic exercise (30 min moderate activity 5x/week) reduces migraine frequency; avoid if currently in aura	-	ROUTINE	ROUTINE
Magnesium-rich diet (leafy greens, nuts, whole grains) or supplementation as magnesium specifically helps aura	-	ROUTINE	ROUTINE
Stress management techniques (mindfulness, biofeedback, relaxation training) as stress is a major trigger	-	ROUTINE	ROUTINE
Adequate hydration (at least 64 oz water daily) as dehydration can trigger attacks	-	ROUTINE	ROUTINE
Smoking cessation to reduce vascular risk, particularly important given aura-associated stroke risk	-	ROUTINE	ROUTINE
Caffeine moderation (≤200 mg/day) and consistent daily intake to avoid withdrawal triggers	-	ROUTINE	ROUTINE
Blood pressure control (target <130/80) given elevated vascular risk with aura	-	ROUTINE	ROUTINE
Avoid high altitude or rapid altitude changes if altitude is a known aura trigger	-	-	ROUTINE

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SECTION B: REFERENCE

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5. DIFFERENTIAL DIAGNOSIS

Alternative Diagnosis	Key Distinguishing Features	Tests to Differentiate
Transient ischemic attack (TIA)	Sudden onset (maximal at onset vs gradual aura spread); negative symptoms (vision loss vs positive scintillations); vascular risk factors; older age; duration usually <1 hr	MRI DWI (no restriction in aura); MRA/CTA (no vessel occlusion); aura has visual "march"
Ischemic stroke	Fixed deficit; sudden onset; vascular territory distribution; risk factors	MRI DWI (shows restriction); CT may be normal early
Migraine with brainstem aura	Aura includes brainstem symptoms (vertigo, tinnitus, decreased hearing, diplopia, ataxia, dysarthria, decreased LOC)	Clinical criteria; MRI to exclude posterior fossa lesion
Retinal migraine	Monocular visual symptoms (vs binocular in typical aura); complete vision loss in one eye	Ophthalmology exam; cover/uncover test during symptoms
Focal seizure with visual phenomena	Shorter duration (seconds to minutes); positive phenomena; may have automatisms; post-ictal confusion	EEG may show epileptiform activity; MRI for structural lesion
Transient global amnesia	Anterograde amnesia; repetitive questioning; no visual or motor symptoms; resolves <24 hr	Clinical diagnosis; MRI may show hippocampal DWI changes
Giant cell arteritis	Age >50; scalp tenderness; jaw claudication; visual loss (not scintillations); elevated ESR/CRP	ESR, CRP (elevated); temporal artery biopsy
Carotid/vertebral dissection	Neck pain; Horner syndrome; pulsatile tinnitus; stroke symptoms	MRA/CTA neck showing dissection
CADASIL	Migraine with aura often first symptom; subcortical strokes; family history; cognitive decline	MRI shows characteristic WMH (anterior temporal, external capsule); NOTCH3 mutation
Mitochondrial encephalopathy (MELAS)	Stroke-like episodes not following vascular territory; seizures; elevated lactate; short stature	MRI (non-vascular stroke pattern); genetic testing; muscle biopsy

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6. MONITORING PARAMETERS

Parameter	Frequency	Target/Threshold	Action if Abnormal	ED	HOSP	OPD	ICU
Aura characteristics (type, duration, frequency)	Each visit; diary	Aura duration <60 min; stable pattern	Prolonged aura needs stroke rule-out; increasing frequency reassess prevention	-	ROUTINE	ROUTINE	-
Headache days/month	Monthly	<4 headache days/month; 50% reduction on preventive	Escalate therapy if not meeting target; consider CGRP mAb or Botox	-	ROUTINE	ROUTINE	-
Acute medication use days	Monthly	≤10 days/month	MOH education; consider preventive escalation; may need withdrawal	-	ROUTINE	ROUTINE	-
Blood pressure	Each visit	<130/80 mmHg	Optimize BP control given elevated vascular risk with aura	STAT	ROUTINE	ROUTINE	-
HIT-6 or MIDAS disability score	Every 3 months	50% improvement or score <50	Escalate preventive therapy if severely disabled	-	-	ROUTINE	-
Topiramate: serum bicarbonate	Baseline, 3 months	>18 mEq/L	Consider dose reduction or switch if metabolic acidosis	-	ROUTINE	ROUTINE	-
Valproate: LFTs	Baseline, 3 months, then q6mo	AST/ALT <3x ULN	Discontinue if significant elevation	-	ROUTINE	ROUTINE	-
CGRP mAb: constipation assessment	Each visit	No severe constipation	Add fiber/laxatives; reduce dose or discontinue if severe	-	-	ROUTINE	-
Lamotrigine: rash monitoring	Weekly during titration	No rash	STOP IMMEDIATELY if rash develops - SJS risk	-	ROUTINE	ROUTINE	-
Contraceptive status	Each visit (women of reproductive age)	Progestin-only or non-hormonal	Remove estrogen-containing contraceptives; counsel on alternatives	-	ROUTINE	ROUTINE	-

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7. DISPOSITION CRITERIA

Disposition	Criteria
Discharge home	Typical aura pattern confirmed; no stroke symptoms; pain controlled; able to tolerate PO; follow-up arranged; contraceptive counseling if needed
Admit to floor	Prolonged aura (>60 min) requiring observation; status migrainosus requiring IV therapy; first aura with abnormal imaging requiring further workup; hemiplegic migraine with prolonged weakness
Admit to ICU	Migrainous infarction (stroke occurring during typical aura); hemodynamic instability; severe refractory status migrainosus requiring ketamine infusion
Transfer to higher level	Stroke mimicking aura requiring thrombectomy evaluation; complex hemiplegic migraine requiring tertiary headache center
Outpatient follow-up	New diagnosis: 2-4 weeks; Stable on prevention: 3-6 months; After preventive change: 4-8 weeks

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8. EVIDENCE & REFERENCES

Recommendation	Evidence Level	Source
Migraine with aura increases ischemic stroke risk, especially in women using combined oral contraceptives	Class II, Level B	Etminan et al. BMJ 2005
ACOG: Combined hormonal contraceptives contraindicated in migraine with aura	Class I (Guideline)	ACOG Practice Bulletin 2019
Triptans safe and effective in migraine with typical aura	Class I, Level A	Marmura et al. Headache 2015
Triptans contraindicated in hemiplegic migraine (expert consensus)	Class III, Level C	Expert consensus; IHS Classification ICHD-3 2018
Magnesium particularly effective for migraine with aura prevention	Class II, Level B	Peikert et al. Cephalalgia 1996
Lamotrigine may reduce aura frequency specifically	Class II, Level C	Lampl et al. Neurology 2005
Topiramate effective for migraine prevention	Class I, Level A	Silberstein et al. Arch Neurol 2004
Propranolol effective for migraine prevention	Class I, Level A	Linde et al. Cochrane 2004
CGRP monoclonal antibodies effective for prevention	Class I, Level A	Goadsby et al. NEJM 2017 (erenumab STRIVE)
Gepants safe in patients with cardiovascular contraindications to triptans	Class I, Level B	Dodick et al. JAMA 2019 (ubrogepant ACHIEVE I)
Lasmiditan (ditan) does not have cardiovascular contraindications	Class I, Level A	Kuca et al. Headache 2018
IV magnesium effective for acute migraine with aura	Class II, Level B	Bigal et al. Headache 2002
Aura duration >60 minutes warrants stroke evaluation	Class III, Level C	Expert consensus; Lipton et al. Headache 2004
PFO closure may benefit select patients with migraine with aura	Class II, Level B	Tobis et al. JACC 2017 (RESPECT trial long-term)
Acetazolamide effective for familial hemiplegic migraine	Class III, Level C	Battistini et al. Neurology 1999
Verapamil may be used acutely in hemiplegic migraine	Class III, Level C	Expert consensus; Mathew et al. Headache 2005
OnabotulinumtoxinA effective for chronic migraine	Class I, Level A	Dodick et al. Headache 2010 (PREEMPT pooled)
Exercise as effective as topiramate for migraine prevention	Class II, Level B	Varkey et al. Cephalalgia 2011

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CHANGE LOG

v1.1 (January 30, 2026) - Standardized lab tables (1A/1B/1C) to Test (CPT) | ED | HOSP | OPD | ICU | Rationale | Target Finding format - Standardized imaging tables (2A/2B/2C) to Study (CPT) | ED | HOSP | OPD | ICU | Timing | Target Finding | Contraindications format - Added inline CPT codes to all laboratory and imaging studies - Fixed structured dosing first fields across all treatment sections (3A/3B/3C/3D) - Expanded "Same as sumatriptan" cross-references in 3B (Rizatriptan, Eletriptan, Naratriptan) - Added additional ICD-10 codes (G43.101, G43.119, G43.111, G43.409, G43.419) - Added clinical synonyms - Added VERSION/CREATED/REVISED header block

v1.0 (January 27, 2026) - Initial template creation - Comprehensive coverage of migraine with aura including typical and hemiplegic subtypes - Strong emphasis on aura vs TIA/stroke differentiation - Contraceptive counseling guidance (estrogen contraindicated) - Hemiplegic migraine-specific treatment considerations (no triptans/ergots) - CGRP antagonists and ditans for cardiovascular-safe options - PubMed-linked citations throughout - Structured dosing format for order sentence generation

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APPENDIX A: Aura Types and Characteristics

Typical Aura Features (ICHD-3 Criteria)

Aura Type	Characteristics	Duration	Positive/Negative Symptoms
Visual (most common ~90%)	Scintillating scotoma, fortification spectra (zigzag lines), photopsia (flashes), spreading across visual field	5-60 min	Positive (flashes, lines) then negative (scotoma)
Sensory (~30%)	Paresthesias (pins/needles) typically starting in hand, spreading up arm, then to face/tongue	5-60 min	Positive (tingling) may be followed by numbness
Language/Speech (~10%)	Dysphasia, word-finding difficulty, paraphasic errors	5-60 min	Negative (difficulty speaking)
Motor (hemiplegic migraine)	Unilateral weakness involving arm and/or leg	Minutes to days	Negative (weakness); TRIPTANS CONTRAINDICATED

Visual Aura "March" Pattern

The classic visual aura demonstrates a characteristic march: 1. Starts as small flickering spot near center of vision 2. Expands outward with scintillating (zigzag, fortress-like) border 3. Leaves scotoma (blind spot) in its wake 4. Duration typically 20-30 minutes 5. Followed by headache within 60 minutes (usually)

Key Differentiator from Stroke: Aura symptoms SPREAD gradually over 5+ minutes; stroke symptoms are maximal at onset.

Hemiplegic Migraine Special Considerations

Feature	Management Implication
Motor weakness present	NO TRIPTANS, NO ERGOTS - potential vasoconstriction risk
Weakness may last hours to days	Requires stroke rule-out; observation may be needed
Familial form (FHM)	Genetic counseling; CACNA1A, ATP1A2, SCN1A testing
May have brainstem symptoms	Consider migraine with brainstem aura overlap
Prevention	Verapamil, flunarizine, acetazolamide preferred; avoid beta-blockers in FHM type 1

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APPENDIX B: Contraceptive Guidance for Migraine with Aura

Why Estrogen is Contraindicated

• Migraine with aura increases ischemic stroke risk 2-4x baseline
• Estrogen-containing contraceptives increase stroke risk 2-4x
• Combined risk: 6-8x increased stroke risk (multiplicative)
• Risk highest in women who smoke or have other vascular risk factors

Safe Contraceptive Options

Method	Type	Notes
Copper IUD (Paragard)	Non-hormonal	Highly effective; no hormone exposure
Levonorgestrel IUD (Mirena, Liletta)	Progestin-only	Minimal systemic absorption; highly effective
Progestin-only pill (mini-pill)	Progestin-only	Must take at same time daily; less effective than combined
Depo-Provera	Progestin-only	IM injection q3 months
Nexplanon (etonogestrel implant)	Progestin-only	3-year subdermal implant; highly effective
Condoms, diaphragm	Barrier	No hormones; less effective

Contraceptives to AVOID

Method	Why Contraindicated
Combined oral contraceptives (COCs)	Contains estrogen - elevated stroke risk
Contraceptive patch (Xulane)	Contains estrogen
Vaginal ring (NuvaRing)	Contains estrogen

Counseling Points

1. Document contraceptive method and provide alternatives
2. If patient is on estrogen, counsel on immediate discontinuation
3. Refer to OB/GYN for contraceptive transition
4. Discuss emergency contraception options (progestin-only preferred)
5. Address pregnancy planning if relevant