The patient should discontinue taking the combined oral contraceptive. She has a history of migraine with typical aura. Aura is considered typical if it involves any combination of visual, hemisensory, or language dysfunction, with sensory auras most typically affecting the face and upper extremities. Each neurologic feature of a typical aura typically lasts between 5 and 60 minutes before completely resolving and can occur before, during, or independent of a headache. Migraine with typical or other aura is a strong contributor to stroke risk in women. Data suggest that migraine with aura represents the second greatest risk factor for stroke in women (after hypertension), surpassing even diabetes mellitus. Estrogen-containing contraceptives, which further increase stroke risk, should be avoided by women with this diagnosis. Progesterone-only oral contraceptives, injections, implants, and intrauterine devices do not appear to increase the risk of stroke in these patients and are preferred means of contraception in this population.

Findings from physical examination and neuroimaging studies showed no evidence of a stroke in this patient. Therefore, aspirin therapy is unnecessary.

Topiramate is approved for use as migraine prophylaxis. Because this patient typically has a migraine only at onset of menses that is successfully treated with rizatriptan, she has no need for migraine preventive therapies.

Although basilar migraine and hemiplegic migraine are contraindications for triptan therapy, this patient has no symptoms indicating the presence of either subtype. Discontinuation of rizatriptan is thus unnecessary.