Neuro-ophthalmology: Migraine

Question 1

What can migraine be associated with?

Answer 1

“do you notice if it associated with anything?”
o Certain foods – cheese, chocolate, coffee, red wine, shell fish
o Nausea or vomiting
o Photophobia

Question 2

What are the typical stages of a migraine?

Answer 2

1. Prodrome – feeling of being unwell – some people describe it as they know the migraine is about to happen
2. Aura – visual disturbance, motor or sensory disturbance
3. Headache
4. Resolution
    Many types, variations of above – some just have 2 stages
   * Relieved by sleeping or going into a dark room

Question 3

List the types of migraine from most to least common and describe them?

Answer 3

• Common migraine:
  o Migraine w/o aura – px may get prodrome
  o Headaches & ANS dysfunction – pallor, nausea
  o Prodrome: changes in mood, yawning, poor concentration
  o Headache: pounding or throbbing, can start anywhere & spreads to half or whole head, photophobic & sensitive to sound
  o Lasts from hours to a day
• Classical:
  o Visual aura for ~20mins
  o Paracentral scotoma: bright, positive (they cannot see in an area of VF, but that area looks bright)
   Ask what visual aura looks like & how long it lasts
   If they describe it as a blind spot in one eye – get them to check this by covering one eye & seeing if it is on one half of VF or is indeed just one eye
  o Fortification spectrum (px may describe jaggy lines) enlarges after a few mins, lined on inner edge with negative scotoma – often moves towards temporal periphery
  o Scotoma expands & moves towards temporal periphery before breaking up
   May be on edge of the jaggy lines
  o Full visual recovery within 30min, if lasts more than an hour think of other causes
  o Headaches follows, location is usually opposite the hemianopia, associated w/ nausea & photophobia, can vary in severity – absent, trivial, severe
  o Visual aura w/o headache not uncommon in >40s but it will always be a hx of classical migraine in early 20s
• Cluster headache:
  o Typically affects men in 30s & 40s
  o They will describe quite a few headaches over a short period of time
   Could happen almost every day for a period of weeks, can go years between clusters
  o Headache severe, starts suddenly, lasts 10min-2hrs
  o Associated with ocular features & can be misdiagnosed as another ocular problem – lacrimation, conjunctival injection & rhinorrhoea (runny nose – thin, mostly clear discharge)
• Focal migraine:
  o Sx of migraine as well as transient dysphasia (problems talking), hemisensory sx (other sensory loss on one side of their body), focal weakness (just one arm for e.g.)
• Migraine sine migraine:
  o Episodic visual disturbances w/o headache
  o Typically elderly pxs w/ hx of classical migraine
• Retinal migraine:
  o Unilateral visual loss, differential diagnosis retinal embolism – check for retinal emboli – make sure to determine if affecting one eye or both eyes

Question 4

Describe the 3 more rare types of migraine?

Answer 4

• Ophthalmoplegic migraine:
  o Rare
  o Usually starts before age 10
  o Recurrent 3rd nerve palsy after headache – ask about double vision, ask parents if they’ve noticed a turn in the eye etc
• Familial hemiplegic migraine:
  o Neurological features continue after migraine attack subsides – can get residual sensory loss etc
• Basilar migraine:
  o Affects children
  o Bilateral numbness/tingling of extremities & lips
  o Ataxia of gait (balance) & speech can occur
  o Sometimes loss of consciousness
   This type would not typically present to optom in practice – more like to present to GP due to the other symptoms

Question 5

What is the differential diagnosis of migraine & other visual phenomena?

Answer 5

• Acute posterior vitreous detachment (flashes)
  o Monocular flashes of light – most migraines are bilateral
• Retinal detachment – as retina comes away, can be associated with flashing lights
  o These can be monocular
• Transient ischaemic attack – shade/cloud that spreads centrally (blood takes longest to get hear so this part will be the last bit to lose the supply), last several mins (short period of time), clears from centre  IMPORTANT TO ASK ABOUT THIS
  o Mini stroke in px – v important to get them checked
• Transient visual obsurcations – greying/darkening, papilloedema, changes in posture (if px bends over pressure can increase), may precede AION in GCA (ask exact occurrence of events & sometimes they’ll describe transient visual loss before the complete loss of vision)
• Occipital epilepsy – coloured circles during epileptic attack – ask pxs in history