The eye and headache

Ophthalmologists are often the first physicians to evaluate patients with headaches, eye pain, and headache-associated visual disturbances. Although ophthalmic causes are sometimes diagnosed, most eye pain and many types of visual disturbances are neurologic in origin. Afferent and efferent symptoms and signs are associated with headache disorders. This article reviews the primary headache disorders and focuses on their ophthalmic manifestations. The major divisions are migraine and the trigeminal autonomic cephalgias.     

Clinical description and review of migraine aura without headache.

BACKGROUND: Migraine aura without headache (MAWOH) is a type of migraine that seems to be reported more frequently in ophthalmic than neurologic or general medical practice. The clinical characteristics of this condition are described relative to its relationship with other forms of migraine, patient age, gender distribution, laterality, personal or family history, visual aura, and precipitating factors. As a result of its prevalence, it is a condition with which every optometrist and ophthalmologist should be familiar. Since MAWOH is a common cause of photopsia and transient vision loss, it is also important to consider it in the differential diagnosis of these conditions-especially in older patients. METHODS: The clinical investigations of MAWOH by prospective and retrospective case series are reviewed. This review includes an analysis by study of the number of patients, migraine history, and type of visual symptom. Comparison of clinical characteristics is used to distinguish MAWOH from other types of migraine. CONCLUSION: Migraine aura without headache is a type of migraine that is reported frequently in ophthalmic practice. Because it is related to photopsia and/or transient vision loss, specific clinical procedures should be performed to assist in the differential diagnosis of these conditions.     

Visual field examination during transient migrainous visual loss.

A transient episode of bilateral amaurosis fugax, or transient visual loss, occurred in a patient with ophthalmic migraine associated with mitral valve prolapse while computerized visual field testing was performed. This fortunate finding illustrated characteristic defects which are compared with the patient's visual field tested 24 hours later. Statistical analysis of both examinations is stressed here.     

Ocular migraine and antiphospholipid antibodies--where we stand?

There is no doubt that ocular migraine also known as retinal migraine or ophthalmic migraine should not to be confused with ophthalmoplegic migraine. The hallmark of ocular migraine is the unilateral visual loss or "monocular transient loss of vision" associated or followed by the headache. Better safe than sorry, therefore an ophthalmologic examination during the migraine attack is the most diagnostic method. age with typical history for ocular migraine. Importantly supportive data sustain that different neuro-ophthalmologic manifestations as amaurosis fugax, retinal vascular thrombosis and optic neuropathy, may be considered as the ocular hallmarks of the Hughes's syndrome. Clues for the evaluating of antiphospholipid antibodies include recurrent thrombosis especially in young people, recurrent fetal loss, and thrombocytopenia. There are no studies that focus exclusively on the prophylaxis of ocular migraine. Ocular features due to antiphospholipid antibodies - induced thrombosis or Hughes's syndrome should be treated with anticoagulant therapy.     

眼底成像揭示视觉偏头痛的相关神经血管病变

偏头痛是一种常见的慢性神经血管疾病,其病理生理机制尚不明确。偏头痛有多种临床表型,其中视觉偏头痛可表现为视觉先兆。视网膜偏头痛和眼麻痹性偏头痛也属于视觉偏头痛的范畴。光学相干断层扫描(OCT)及血管成像(OCTA)可以定性及定量地检测视网膜神经纤维层、神经节细胞层、视神经乳头、视网膜和脉络膜的循环状况。基于上述两种影像学的研究发现,在视觉偏头痛发病过程中,偏头痛患者的视网膜和睫状动脉短暂反复收缩,可能导致视神经、视网膜和脉络膜的缺血性损伤,随后视网膜神经纤维层及神经节细胞层变薄、视网膜微血管减少。眼底影像学检查有助于提高对视觉偏头痛相关病理生理学机制的认知,而基于OCT及OCTA检查所见可作为评估视觉偏头痛病程及病情严重程度的指标。     

Visual field loss in migraine

Ocular symptoms are a common, though transient, initial component of migraine. Although permanent visual loss has been reported in a limited number of patients, detailed evaluations of the visual field using current techniques have not been conducted. This study examined the prevalence of visual field loss in patients with migraine, using an automated static perimeter. All patients had at least a 2-year history of migraine (as diagnosed by a neurologist) and no ocular problems (by history or as determined by a visual screening examination consisting of acuity, intraocular pressure [IOP], and evaluation of the disc). The authors' results for 60 migraine patients showed that 21 (35%) had some form of visual field abnormality (P less than 0.05). The prevalence of visual field loss was greater with increasing age and duration of disease. These results suggest that visual field loss from migraine may be more common than previously considered. This information also may be useful in elucidating the relationship between migraine and certain vascular conditions of the eye.     

Perspectives on migraine: prevalence and visual symptoms

About 20 per cent of women and 10 per cent of men experience migraine at some time in their lives, of whom about one half to two thirds will have had a migraine attack in the previous 12 months. Prevalences of this order have been found in a survey of patients in an Australian optometric practice. Between one third and one half of migraineurs experience sensory or motor aura. Visual aura are by far the most common of the aura. A high proportion (more than 40 per cent) of migraineurs presenting for routine optometric examination will not have had their headache or aura formally diagnosed. Optometrists can give reassurance by providing a formal diagnosis and, when appropriate, they can refer their migraine patients to sources of advice on how the frequency and severity of their attacks might be ameliorated. The diagnosis of migraine is straightforward when the migrainous episode and any associated aura follow a classical pattern. However, diagnosis is often challenging, especially for aura occurring without headache, when the aura are atypical, when the first attack of migraine occurs after the age of 50 years, when there are persistent visual field losses or when there are pupillary anomalies or extra‐ocular muscle palsy and diplopia associated with the migraine. Unusual presentations must be approached with care, using a good knowledge of the diversity of migraine, careful history taking and a thorough ocular and visual examination. As visual field losses can be associated with migraine and migraine may be a risk factor for low‐tension glaucoma, visual field examination is often indicated for patients with a history of migraine. In some cases of migraine, referral for neurological work‐up will be necessary before concluding that the headache and visual symptoms can be attributed to migraine.     

Topical beta-blocker treatment for migraine

Beta-blockers are a well-known prophylactic treatment for migraine; however, treatment by the ocular route has not been widely considered. This case illustrates the resolution of a visual field defect associated with migraine and improvement of symptoms possibly due to administration of a topical beta-blocker. This novel method of treatment especially when visual field defects are present may have a place in the management of migraine.     

Visual search in migraine and visual discomfort groups.

Two experiments that investigate automatic and conscious attention among migraine and visual discomfort groups are reported. The prediction of a heightened sensory sensitivity producing a processing speed advantage in migraine was tested. In Experiment 1, an automatic attention task was conducted. There was no effect of migraine group, but the high visual discomfort group responded significantly more slowly than the low visual discomfort group when 16 distractors were presented. In Experiment 2, a conscious visual attention task was conducted. No processing-speed advantage was found for migraine groups. In all conditions, the high visual discomfort group performed significantly more slowly than other groups. It was concluded that heightened sensory sensitivity could not explain the processing speed advantage found previously in migraine but may explain the processing speed disadvantage found for the high visual discomfort group. Results are discussed in terms of disordered sustained attention in the high visual discomfort group.     

Migraine-like visual aura due to focal cerebral lesions: case series and review

Visual aura is a common presenting symptom of migraine to both neurologists and ophthalmologists. Features such as photopsia, fortification spectra, and the slow propagation of a scintillating scotoma across the visual field are usually considered diagnostic features of the visual aura of migraine. In the vast majority of cases, the diagnosis can be made without the need for further investigations. We present 9 patients and a further 31 cases from the literature who experienced visual aura fulfilling the diagnostic criteria for migraines but caused by focal occipital pathology. Key clinical features that could help to differentiate between the visual aura of migraine and those suggestive of a structural lesion are outlined. We review current scientific theories into the pathophysiology of visual aura, drawing on clinical and basic science research, including human functional imaging studies of migraine aura and advances in the genetic characterization of familial channelopathies, in order to explain the overlap which occurs in the clinical features of visual aura associated with migraine, cortical lesions, and epilepsy. We conclude that any disease process that is able to create a state of neuronal hyperexcitability can therefore increase an individual’s susceptibility to the development of cortical spreading depression, the electrophysiological correlate of the visual aura.     

Clinical impact of migraine for the management of glaucoma patients

Migraine is a common and debilitating primary headache disorder that affects 10–15% of the general population, particularly people of working age. Migraine is relevant to providers of clinical eye-care because migraine attacks are associated with a range of visual sensory symptoms, and because of growing evidence that the results of standard tests of visual function necessary for the diagnosis and monitoring of glaucoma (visual fields, electrophysiology, ocular imaging) can be abnormal due to migraine. These abnormalities are measureable in-between migraine events (the interictal period), despite patients being asymptomatic and otherwise healthy. This picture is further complicated by epidemiological data that suggests an increased prevalence of migraine in patients with glaucoma, particularly in patients with normal tension glaucoma. We discuss how migraine, as a co-morbidity, can confound the results and interpretation of clinical tests that form part of contemporary glaucoma evaluation, and provide practical evidence-based recommendations for the clinical testing and management of patients with migraine who attend eye-care settings.     

Frequency Doubling Technology perimetry and standard automated perimetry in migraine

The literature suggests that visual field defects may be more common in people who experience migraine. The Humphrey frequency doubling (FDT) visual field instrument selectively examines the magnocellular visual pathway, but has not previously been used to investigate visual function in migraine. In a masked controlled study we compared Humphrey FDT and Humphrey Swedish Interactive Threshold Algorithm fields of 25 migraine sufferers with 25 age- and gender-matched controls. Although both mean deviation and pattern standard deviation were a little worse in the migraine group, these differences did not reach statistical significance. There were no inter-eye visual field differences in the migraine group compared with controls. Comparing the mean of all the contrast thresholds in each hemisphere, there were no more inter-hemifield visual field differences in the migraine group compared with controls. There was no significant difference between the migraine and control groups in intra-ocular pressures. The visual field parameters were not correlated with the interval since the last migraine headache, the severity of migraine headache, the duration of migraine headache or the number of migraine headaches per annum. In our data, there was no evidence of visual field deficits, a magnocellular deficit, or indications of glaucomatous pathology.     

Headache for ophthalmologists: current advances in headache understanding and management

Patients with headache and head pain are often referred to ophthalmologists. These symptoms can either be associated with underlying ophthalmic conditions, or more often are headache disorders unrelated to the eyes. Understanding the phenotype of the headache is critical for advice, safe discharge or onward referral. This review will provide an update on the criteria for common headache disorders that are often seen by ophthalmology and embrace disorders associated with ophthalmic diseases. It will also describe the changing management of migraine and outline recent therapies that are currently available.Subject terms: Diseases of the nervous system, Visual system, Pain     

Migraine with and without headache

Transient visual and neurological episodes are relatively common and can occur for the first time in middle and old age. In many cases these transient events are migraine auras. An aura is a transient, stereotypical, visual or neurological episode usually lasting 4 to 60 minutes in duration. Migraine is usually, but not always, associated with headache and can be accompanied by systemic and autonomic symptoms. Diagnosis is dependent on International Headache Society criteria. The pathophysiology is believed to involve neurovascular mechanisms. There is a hereditary component to migraine. When migraine auras occur in the absence of headache they are termed acephalgic migraines. Late onset migraine accompaniment is an acephalgic migraine that presents in middle-aged and older adults. It is usually benign. Migraines can be mimicked by other more serious conditions. Most patients with a stable migraine pattern and normal neurological evaluation do not require further testing. Some patients with atypical presentation, older age, or suspected secondary causes need further investigation.     

Migraine with and without headache

Transient visual and neurological episodes are relatively common and can occur for the first time in middle and old age. In many cases these transient events are migraine auras. An aura is a transient, stereotypical, visual or neurological episode usually lasting 4 to 60 minutes in duration. Migraine is usually, but not always, associated with headache and can be accompanied by systemic and autonomic symptoms. Diagnosis is dependent on International Headache Society criteria. The pathophysiology is believed to involve neurovascular mechanisms. There is a hereditary component to migraine. When migraine auras occur in the absence of headache they are termed acephalgic migraines. Late onset migraine accompaniment is an acephalgic migraine that presents in middle-aged and older adults. It is usually benign. Migraines can be mimicked by other more serious conditions. Most patients with a stable migraine pattern and normal neurological evaluation do not require further testing. Some patients with atypical presentation, older age, or suspected secondary causes need further investigation.     

Contrast-processing dysfunction in both magnocellular and parvocellular pathways in migraineurs with or without aura

PURPOSE: To assess contrast-discrimination thresholds in patients with migraine who have manifest visual field loss. This study was undertaken to determine whether contrast processing abnormalities in migraineurs are more readily identified by using stimuli that elicit a response from the subject that depends, at least in part, on adaptation mechanisms, and if so, whether deficits appear more pronounced in magnocellular (M) or parvocellular (P) visual pathways. METHODS: Ten patients with migraine who had abnormal visual fields measured with flicker perimetry but had normal standard automated perimetry (SAP) thresholds participated, along with 15 age-matched control subjects. Contrast-discrimination performance was assessed with the steady-pedestal (magnocellular) and pulsed-pedestal (parvocellular) stimuli of Pokorny and Smith for seven pedestal luminances between 15 and 60 cd/m(2) on a background of 30 cd/m(2). Subjects were tested foveally and midperipherally at 12.5 degrees. Migraineurs were tested in the quadrant of worst visual field performance. Control subjects were assessed in locations matched to those of the migraine group. RESULTS: Foveal performance was not significantly different between the migraine and control groups for either task. At 12.5 degrees the migraine group had significantly raised thresholds for both conditions. Effect size statistics revealed similar deficit magnitudes for each test (steady pedestal, -1.06; pulsed pedestal, -1.04). CONCLUSIONS: Dysfunction in both the M and P pathways was identified in the midperipheral visual field of the migraine group. The P pathway dysfunction was not identified by SAP. These findings support the possibility of nonselective neural adaptation abnormalities in some subjects with migraine.     

Decreased visual field sensitivity measured 1 day, then 1 week, after migraine

PURPOSE: To determine whether perimetric performance is worse the day after a migraine than prior interictal measurements, and if so, to determine whether differences have resolved by 1 week after migraine. METHODS: Twenty-two nonheadache control subjects (aged 18-45 years) and 22 migraineurs (aged 18-45 years: 10 migraine with visual aura, 12 migraine without aura) participated. Standard automated perimetry (SAP) and temporal modulation perimetry (TMP) were measured by perimeter (model M-700; Medmont, Pty Ltd., Camberwell, Victoria, Australia). Control subjects attended two test visits: baseline and retest. Migraineurs attended three times: baseline (>or=4 days after migraine), the day after the offset of the next migraine, and 7 days later. Groups were compared using the global indices of the perimeter: Average Defect (AD) and Pattern Defect (PD), in addition to point-wise comparisons. RESULTS: Group migraineur TMP performance was significantly worse the day after a migraine, showing decreased general sensitivity and increased localized loss. Performance measured 7 days later was not significantly different from that measured the day after a migraine. Group migraineur SAP performance was not significantly worse after migraine; however, a subgroup of six eyes from five patients had 10 or more visual field locations with decreases in sensitivity greater than control test-retest 95% confidence limits. CONCLUSIONS: Decreased visual field performance was present after migraine, as well as greater test-retest variability in the migraine group compared with control subjects. As migraineurs constitute 10% to 15% of the general population, the presence of this subgroup of patients with periodic prolonged decreased visual field sensitivity after migraine has implications for differential clinical diagnosis, and for clinical research using perimetry.     

经眼动脉超选插管溶栓治疗视网膜中央动脉阻塞

目的探讨超选择性眼动脉溶栓治疗视膜中央动脉栓塞治疗方法和疗效。方法采用Seldinger技术，对9例患者经超选择性眼动脉插管，用尿激酶18~75万U直接灌注溶栓治疗。结果其中8例患者视力有不同程度的提高，1例患者视力与治疗前相比没有变化；各例患者在治疗过程中均未出现任何并发症。结论视网膜中央动脉阻塞介入溶栓治疗可使大部分患者视力不同程度的提高。临床疗效与发病时间、尿激酶用量及治疗前视力不呈正相关。超选择性眼动脉溶栓治疗视网膜中央动脉阻塞是安全、可靠的。(中华眼底病杂志,2005,21:22-24)     

The optometric correlates of migraine

Migraine is a common, chronic, multi-factorial, neuro-vascular disorder typically characterised by recurrent attacks of unilateral, pulsating headache and autonomic nervous system dysfunction. Migraine may additionally be associated with aura; those focal neurological symptoms that may precede or sometimes accompany the headache. This review describes the optometric aspects of migraine headache. There have been claims of a relationship between migraine headaches and errors of refraction, binocular vision anomalies, pupil anomalies, visual field changes and pattern glare. The quality of the evidence for a relationship between errors of refraction and binocular vision and migraine is poor. The quality of the evidence to suggest a relationship between migraine headache and pupil anomalies, visual field defects and pattern glare is stronger. In particular the link between migraine headache and pattern glare is striking. The therapeutic use of precision-tinted spectacles to reduce pattern glare (visual stress) and to help some migraine sufferers is described.     

Intraretinal gray lesions as a sign of reversible visual loss following prolonged ophthalmic artery hypoperfusion.

A 49-year-old woman developed severe unilateral visual loss following carotid artery ligation for a carotid-cavernous fistula. The pathophysiology was presumed to be an ophthalmic artery steal caused by the fistula. This was confirmed when visual acuity was restored by a subsequent ligation of the ophthalmic artery, despite 2 weeks of profound visual loss and ocular ischemia. Superficial cotton-wool spots and deep gray intraretinal lesions developed in the retina during the period of ocular ischemia. We postulate that the deep intraretinal lesions are clinical manifestations of a zone of retinal microvascular watershed ischemia, and that their presence may be an important diagnostic guide to the presence of reversible ocular ischemia.