Migraine - Eye Notes

Unlock FRCOphth Part 2 Study Notes to access this content.

Characteristics

Recurrent headaches
Highly variable
Commonly
- Unilateral
- Associated nausea/vomiting ie. autonomic dysfunction
- Family history
- Visual aura (classical migraine) or without (common migraine)
- Pounding/throbbing nature to headache
- Premonitory phase: mood change, cravings, yawning, fatigue, neck stiffness
Can occur without headaches eg isolated visual aura
- Headaches follow aura
Less common
- Paraesthesia
- Dysphasia
- Weakness
- Familial hemiplegic migraine: failure of full recovery of focal neurological features

Ophthalmic features of migraine

Aura:
- Binocular but tends to affect the central field on one side
- Negative scotoma
- Positive ‘scintillating’ scotoma: fortification or ‘heat haze’ distortion
- Tunnel vision
- Progresses across visual field
- Tends to recover within 30 minutes
Retroorbital pain
Photophobia
Retinal migraine:
- Visual disturbance typical of migraine but monocular
- Controversial: possibly binocular hemifield symptoms misinterpreted as monocular?
- Young women
- Retinal embolisation should be considered/excluded
- Diagnostic criteria (International Headache Society)
  - At least 2 attacks fulfilling either
    - Fully reversible monocular visual phenomena confirmed by either visual field examination or patient drawing
    - At least 2 of: 1. Aura spreads gradually over at least 5 minutes; 2. Aura lasts 5-60 minutes; 3. Aura is followed by headache within 60 minutes
  - Alternative diagnosis not more likely eg amaurosis fugax
Ophthalmoplegic migraine: recurrent headache followed by transient (third) nerve palsy. May indicate demyelination. Typical onset under age 10

3 out of 4 from:
- One or more fully reversible aura symptoms
- At least one aura symptom developing over longer than 4 minutes or two in succession
- No aura symptom lasts longer than 60 minutes
- Headache follows the aura within 60 minutes (or may precede)