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Ophthalmic migraine

You have experienced visual disturbances (bright spots, colored patches, distorted perception of objects, blurred vision, or loss of part of your field of vision) followed by throbbing headaches, often accompanied by nausea or sensitivity to noise or light. It is possible that you are suffering from ocular migraine, a benign condition provided that other, sometimes serious, diagnoses have been ruled out. Here is some information about this condition.

Symptoms of ocular migraine

  • Migraine is one of the most common neurological conditions and is characterized by attacks of headaches (cephalalgia) that are often throbbing, unilateral and alternating, of moderate to severe intensity and lasting from 4 to 72 hours.

  • It is aggravated by routine physical activity (walking), light, and noise, and improved by rest in the dark. Nausea and vomiting are common.

  • Migraines are classified into two main types: common migraines and migraines with aura (approximately 20% of attacks), which are preceded by transient neurological symptoms (auras) affecting vision, sensation, or speech. When the aura is visual (the most frequent type), it is called an ophthalmic migraine.

  • The symptoms of an ophthalmic aura, which appear gradually and last from 5 to 60 minutes, affect the vision in both eyes. These symptoms may include a gap in the visual field (scotoma) sometimes accompanied by glimmers or flashes of light, distorted perception of objects, blurred vision, black, white, or colored spots, or even blindness.

  • Headaches can start during or after the aura, rarely before. Isolated auras without headaches occur in one-third of patients, and 5% never experience headaches.

Beware of misconceptions

  • The ophthalmic symptoms of ophthalmic migraine have a neurological origin.

  • Ophthalmic migraine should not be confused with headaches due to refractive errors (myopia, hyperopia, astigmatism, presbyopia) often caused by wearing unsuitable corrective glasses, or due to convergence disorders, which occur preferentially after visual exertion (prolonged reading, screen work, etc.) and have different symptoms (band headaches, bilateral, non-pulsating).

  • It is also necessary to distinguish scintillating scotoma from phosphene, which is suggestive of retinal pathologies.

The causes of ocular migraine

  • Migraine affects approximately 12% of adults and 5 to 10% of children, and is three times more common in women than in men. It is caused by abnormal neuronal excitability, underpinned by a complex genetic predisposition and modulated by intrinsic (hormones) or extrinsic (stress, food, etc.) environmental factors.

  • Migraine triggers vary from person to person and can be: psychological (emotions, upset, anxiety, stress), dietary (chocolate, processed meats, coffee, alcohol), sensory (noise, smells, flashing lights), hormonal (menstruation, hormone treatments), or climatic. Lifestyle changes and dietary habits can also be triggers (fasting, withdrawal, job changes, vacations, lack of sleep, smoking).

Diagnosis

The diagnosis of migraine with ophthalmic aura is clinical: the presence of headaches preceded by abnormal, reversible visual symptoms. Scientifically, the diagnosis of ophthalmic migraine is based on the criteria of the International Headache Society (IHS):

Presenting with headaches preceded by visual disturbances exhibiting at least 3 of the following criteria:

  • The disorder is completely reversible.

  • Symptoms should develop gradually over a period of more than 4 minutes. If there are multiple symptoms, they must occur gradually.

  • Duration of each visual symptom less than 60 minutes.

  • Headaches appear within 60 minutes of visual symptoms.

Normally, at least two similar attacks are required to make a firm diagnosis of migraine.

Between two migraine attacks, you should not experience any neurological symptoms.

Trigeminal neuralgia – The other headache with eye involvement

  • You may experience extremely painful headache attacks, always localized to the same side of the face.

  • The sensation of pain can be like an electric shock invading half of the face or the feeling that the face is being crushed.

  • The eye and eyelid are extremely painful. This is trigeminal neuralgia, not a migraine.

  • The treatments are different and the disease is linked to damage to the trigeminal nerve (V) which innervates the face.

Why consult a doctor?

  • Migraine disease is a benign condition but can impair quality of life, with repercussions on professional activities.

  • The consultation allows, on the one hand, to confirm the diagnosis of migraine when the attacks meet the criteria of typical migraine, on the other hand to eliminate differential diagnoses in the face of atypical cases, which may lead to the prescription of brain imaging.

  • We speak of an atypical picture in particular in the presence of: headaches always affecting the same half of the skull, an aura of unusual duration (more than one hour) or of sudden or very atypical onset (diplopia, psychic disturbances, auditory or gustatory hallucinations).

  • MRI is indicated if it is a first migraine attack before age 10 or after age 40, or in case of a major and recent change in symptoms.

  • The consultation also allows for the prescription of pain medication to relieve the attack. It will also be necessary to rule out any other emergencies (particularly vascular ones).

Migraine treatment – Pain relief

  • As a first-line treatment, a non-specific analgesic treatment will be prescribed (paracetamol, aspirin or non-steroidal anti-inflammatory drugs in the absence of contraindication).

  • If ineffective, triptans (or increasingly rarely ergot derivatives) may be prescribed but should only be taken at the onset of headaches, once the aura has ended.

Course of action

Following the consultation during which the ophthalmologist confirmed the diagnosis, you will be prescribed pain medication to best relieve your headaches. In addition, the following precautions should be taken:

To rest in peace and quiet, away from light and noise.

  • Physical exertion worsens the symptoms of a migraine attack, during which light and noise can be particularly bothersome.

  • It is therefore recommended to rest in the dark and in a quiet place.

Avoid the identified risk factors

  • Risk factors vary from person to person. Identifying these factors helps reduce exposure to them and thus decrease the frequency of seizures.

To consult

  • A consultation and follow-up with your general practitioner, who can refer you to a specialist (neurologist) if necessary in case of migraines that are resistant to well-conducted acute treatment, is required.

  • If an ophthalmological origin is suspected (migraine triggered by visual fatigue at the end of the day) or if there is doubt between a migraine aura and accommodative spasms, your doctor may request an ophthalmological examination.

  • In cases of persistent migraines, self-medication is not the solution. Regular checkups with your general practitioner are important to find the right treatment for your attacks. A specialist may need to reassess the treatment if it proves insufficient, or even prescribe preventative medication.

Non-urgent brain imaging may also be prescribed following the first episode of ocular migraine.

Treatment

Treatment for ophthalmic migraine is based on acute treatment and preventive treatment.

Crisis management

  • In addition to avoiding triggers, treatment for an acute attack relies on analgesics. Nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen or aspirin should be used as first-line treatment because they are more effective than paracetamol (Doliprane). NSAIDs can be started as soon as the migraine aura begins.

  • If NSAIDs fail, triptans may be used. This class of drugs is contraindicated in patients with a history of stroke, myocardial infarction, or renal or hepatic insufficiency.

  • The medications are usually prescribed by a neurologist and should be taken at the end of the aura, BEFORE the onset of headaches.

background treatment

  • A preventative treatment should be introduced if you experience more than 4 debilitating migraine attacks per month.

  • These prescriptions fall within the scope of practice of a neurologist. Medications that may be prescribed for migraine with ophthalmic aura include: amitriptyline (Laroxyl®), oxerotone, or flunarizine.

  • Their goal is to reduce the number and intensity of seizures in order to restore a decent quality of life.

When should you worry?

In cases of typical migraines, there is no cause for concern and no unnecessary further testing is required. In cases of atypical migraines, a brain MRI, or failing that, a CT scan, is advisable. The criteria that should prompt caution are:

  • To experience sudden, severe headaches, described as “thunderclap headaches”.

  • To experience headaches that are unusual in intensity, duration, or associated symptoms.

  • Presenting signs of neurological localization: numb or paralyzed limb, pupils of different sizes,…

  • Having migraines that are always located in the same area of the skull.

  • Starting migraine attacks after age 40.

Complication – Status Migraine

  • Ocular migraine is a common, painful, debilitating but rarely serious condition.

  • Its most serious complication is status migraine. This is an intense migraine attack lasting more than 24 hours, or repeated attacks with less than 1 hour of rest between each attack.

  • In this case, emergency hospitalization in neurology with the implementation of intravenous treatments is necessary.

Sources:
https://eyewiki.org/Category:Articles
https://www.cahiers-ophtalmologie.fr/
https://snof.org/
https://couf.fr/

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