Neuro-ophthalmologist says there is “no such thing” as ocular migraine

The Internet is littered with the term “ocular migraine,” and Dr. Deborah Friedman, a neuro-ophthalmologist with expert credentials said, “We have an international criteria for headache disorders that defines the terms and there is no such term as ocular migraine.”

Simply put, Friedman said migraines “have their origin in the brain – not in the eye. It is aura. It comes from the brain.”

“This is analogous to the terms ‘common migraine’ and ‘classic migraine,’” said Friedman. The most common type of migraine in the population is “common migraine.” Migraine with aura is “classic migraine.” The names changed decades ago, but some people continue to use the older terminology.

The International Headache Society now defines “common migraine” as “migraine without aura,” which is a “recurrent headache disorder manifesting in attacks lasting from 4 to 72 hours.”

Characteristics of migraine without aura attacks include headaches that are “pulsating quality, moderate or severe intensity, aggravation by routine physical activity and association with nausea and/or photophobia and phonophobia.”

Phonophobia suggests a person has a lower threshold for sound tolerance. Photophobia is sensitivity of the eyes to light.

The International Headache Society defines as “recurrent attacks, lasting minutes, of unilateral fully reversible visual, sensory or other central nervous system symptoms that usually develop gradually and are usually followed by headache and associated migraine symptoms.”

So for those that only have the aura and the migraine doesn’t progress into the painful headache, there are a lot of unknowns.

“We don’t really know what is going on in the brain for those people,” said Friedman. “There are some people that experience both [types] at different times (some migraine with aura or some auras without headache).”

It is assumed “that this process called cortical spreading depression (CSD) is the abnormality or the process that is behind the aura.” Generally CSD is said to be a wave of sustained neuronal activation followed by a wave of decreased neuronal activity moving through intact brain tissue.

“Why the process sometimes stops at aura is uncertain,” Friedman said.

As a migraine patient who regularly experiences pain in or around the eye during an attack, I was curious what is physiologically occurring to the eye or the optic nerve to cause the eye pain. “Migraine usually does not affect the optic nerve at all,” Friedman said.

She noted that in patients she sees, “Having pain located in the front of the head is the most common place for migraine. Involvement in the eye area is very common because the sensation to the eye is provided by the ophthalmic nerve which is the first division of the trigeminal nerve,” Friedman added.

Let’s go behind the scenes and learn what “aura” is.

“Positive symptoms of aura [can include] seeing shapes that aren’t really there, such as flashing lights or zig zag lines – they may appear more prominent in one eye or the other.”  But Friedman further clarified, “They are not coming from the eye – they are coming from the brain.”

Another fascinating thing about migraine with aura “people still see the positive visual disturbances with their eyes closed,” Friedman said.

A commonality when treating patients Friedman said is, “People have difficulty differentiating if [the aura] is coming from one eye or one side of their visual field.”

Many individuals with migraine will say “they lost their vision in the left eye when they really lost vision on the left side of their world,” she said.

There are ways to clarify what the patient is experiencing. The first being, “pay attention to what [you] see when [you] look straight ahead with both eyes. If you lose vision in one eye, the world doesn’t split in half,” Friedman noted.

The second, “is to cover one eye and then cover the other eye and see if there is a difference between [the two], and usually there is not,” she further explained. “I often say [to my patients] what would you see if you looked at the clock?” And, “if they only see half – it’s coming from the brain.”

Treatment wise, Friedman usually advises patients “to take their triptan (triptans act on serotonin receptors in the brain and on blood vessels) or other acute medication.”

“We don’t have anything that reliably stops aura more quickly, so if people are having auras that are distressing to them, we would recommend preventive treatment,” said Friedman. Being proactive and taking action to keep migraines at bay is important.

There is a very uncommon type of migraine called a “retinal migraine” and “it is very, very rare and it does cause symptoms in one eye only,” Friedman said. This is a very controversial migraine diagnosis because there is discussion as to “if it really exists in the neuro-ophthalmology world.” This type of migraine is “the only exception to the rule and it’s very, very rare to have retinal migraine.”

“There have been isolated reports of people having a retinal migraine and having permanent visual loss when they took a triptan during a retinal migraine,” she said. “It’s a rare complication of a very rare migraine.”  Friedman has also seen patients who “report of getting permanent visual field loss in an eye without taking a triptan.”

A reader of The Honest Migraine recently shared her experience as to experiencing aura and completely losing her vision. Friedman confirmed this occurrence in some patients and said, “There are some people who completely lose their vision temporarily with aura. In those circumstances we would recommend preventive treatment.”

Prevention means seeking guidance and treatment from a provider.

One key takeaway, and reassurance, Friedman said if a person is experiencing “total blindness [with aura] – the vision will come back, it’s migraine.”

As the mind can quickly wander to worst case scenario, “reassuring people they are not having a stroke is important,” she emphasized.

Seeking out medical assistance, scheduling with your primary doctor or seeing a neurologist is suggested. Simply going to the ER isn’t the solution; seeking out effective acute and preventive treatment with your doctor(s) is more ideal.

As far as treatment goes, “Some medications may work better than others for example,” said Friedman.  “For those people with prominent aura or isolated aura without headaches we may suggest verapamil, lamotrigine, even a daily aspirin for prevention, but any of the medicines that we use for migraine prevention could be tried.”

Dr. Deborah I. Friedman is a neuro-ophthalmologist and headache medicine specialist at UT Southwestern Medical Center. Dr. Friedman is the founding Director of UT Southwestern’s Headache and Facial Pain Program. She is a Fellow of the American Academy of Neurology, the American Headache Society, and the North American Neuro-Ophthalmology Society.

Watch for more from Dr. Friedman on December 23, 2021

Coming next: Communication: There’s no way around it

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