Recurrent branch retinal infarcts in association with migraine

Increased risks of retinal vascular occlusion in patients with migraine and the protective effects of migraine treatment: a population-based retrospective cohort study

Associations between migraine and retinal vascular occlusion have been reported, but there is no large-scale and comprehensive study. Therefore, we aimed to determine risks of retinal vascular occlusion in patients with migraine. Using the Taiwan National Health Insurance Research Database from 2009 to 2020, we enrolled 628,760 patients with migraine and 628,760 matched individuals without migraine. Study outcomes were diagnoses of retinal vascular occlusion, including retinal artery occlusion (RAO) and retinal vein occlusion (RVO). Adjusted hazard ratio (aHR) of retinal vascular occlusion related to migraine was estimated. The cumulative incidences of subsequent retinal vascular occlusion, RAO, and RVO were significantly higher in migraine patients compared with controls (0.31% vs. 0.21%; 0.09% vs. 0.05%; 0.22% vs. 0.17%; all p < 0.001). The hazards of retinal vascular occlusion, RAO, and RVO were significantly greater in the migraine group (aHR, 1.69 [95% CI, 1.57, 1.83], 2.13 [95% CI, 1.84, 2.48] and 1.53 [95% CI, 1.40, 1.68], respectively). Risks of retinal vascular occlusion were significantly higher in migraine both with aura (MA) and without aura (MO) (aHR, 1.77 [95% CI, 1.58, 1.98], and 1.92 [95% CI, 1.64, 2.25]). Among patients with migraine, nonsteroidal anti-inflammatory drugs, propranolol, and flunarizine significantly reduce their risks of retinal vascular occlusion (aHR, 0.19 [95% CI, 0.16, 0.22], 0.73 [95% CI, 0.62, 0.86], 0.84 [95% CI, 0.76, 0.93]). Migraine, MA and MO are independently associated with higher risks of retinal vascular occlusion, RAO, and RVO.

Reduction in retinal microvascular perfusion during migraine attacks

OBJECTIVE

To determine if there are changes in structure and function of the retinal vasculature during and between migraine attacks using optical coherence tomography angiography (OCTA).

BACKGROUND

Migraine attacks commonly include visual symptoms, but the potential role of the retina in these symptoms is not well understood. OCTA is a rapid, non-invasive imaging technique that is used to visualize the retinal microvasculature with high spatial resolution in a clinical setting. In this study we used OCTA to quantify different features of the retinal vasculature in patients with migraine during and between attacks, as well as in healthy controls (HCs).

METHODS

We performed a prospective cohort study of 37 patients with migraine with aura (MA) (median [interquartile range, IQR] age of 37 [14] years, 86% female) and 30 with migraine without aura (MO) (median [IQR] age of 37 [17] years, 77% female) and 20 HCs (median [IQR] age of 35 [7] years, 50% female). Macular OCTA scans were obtained for all participants for the interictal analysis. In 12 MA and eight MO, scans were captured both during and outside of migraine attacks and five HCs had initial and repeat scans. In addition to analyzing the morphology of the foveal avascular zone, we calculated the vessel flux index (VFI), which is an indicator of retinal perfusion and conventional metrics (such as vessel area density) in the foveal and parafoveal regions.

RESULTS

There was a significant difference in the parafoveal VFI in the ictal state between the groups (p = 0.009). During migraine attacks there was a significant reduction in the parafoveal region VFI in MA (-7%, 95% confidence interval [CI] -10% to -4%; p = 0.006) and MO (-7%, 95% CI -10% to -3%; p = 0.016) from their interictal baseline as compared to the change between repeat scans in HCs (2%, 95% CI -3% to 7%). Interictally, there was a mean (standard deviation [SD]) 13% (10%) (p = 0.003) lower blood perfusion in the MA group as compared to the MO group in the foveal region (mean [SD] 0.093 [0.023] vs. 0.107 [0.021], p = 0.003). Interictal analysis also revealed higher circularity in the superficial foveal avascular zone in the MA group compared with the MO group (mean [SD] 0.686 [0.088] vs. 0.629 [0.120], p = 0.004). In addition, interictal analysis of the patients with MA or MO and unilateral headache showed increased retinal vascular parameters consistent with greater perfusion in the eye ipsilateral to the side of the pain as compared with the contralateral eye.

CONCLUSIONS

These results indicate that perfusion is reduced in MA and MO in the parafoveal retina during the ictal period. Interictally, the foveal retina in MA has reduced perfusion when compared to the foveal retina in MO. Patients with unilateral headache showed interictal asymmetry of retinal perfusion between eyes. These results indicate that changes in retinal perfusion could be a part of migraine pathophysiology, and that distinct retinal vascular signatures identified with OCTA could represent biomarkers for migraine.

Retinal and peripapillary vascular density in episodic and chronic migraine cases without aura

BACKGROUND

Migraine is a neurovascular disease that can cause ocular and systemic ischemic damage. Despite from aura, a limited number of studies have considered the effect of the chronic migraine in cases without aura. Our aim was to evaluate the differences in the retinal and optic disk microvasculature among episodic and chronic migraine cases without aura using optical coherence tomography angiography (OCTA) imaging.

METHODS

45 cases with migraine, and 25 control subjects were included in this prospective, cross-sectional study. OCTA was performed at 3 × 3 mm and 6 × 6 mm of the macula and at 4.5 × 4.5 mm of the optic disk. Retinal nerve fiber layer (RNFL) thickness, ganglion cell complex thickness, and vessel densities of the optic nerve and macula were compared among the three groups: a control group, an episodic migraine without aura (EMWOA) group, and a chronic migraine without aura (CMWOA) group.

RESULTS

In EMWOA group, circumpapillary vascular density (cpVD) was not decreased significantly in any quadrants (all, p>0.05). Compared to the control group, CMWOA group had significantly lower RNFL thickness in superior-temporal quadrants (p = 0.002 and 0.006, respectively), while cpVD differed only in the temporal quadrant and temporal inferior sector (p = 0.002 and p = 0.009, respectively).

CONCLUSIONS

Temporal peripapillary perfusion is valuable in the follow-up of chronic migraine cases. Longitudinal studies are needed to determine the place of OCTA in the follow-up of migraine.

Microvascular involvement in migraine: an optical coherence tomography angiography study

OBJECTIVE

The aim of this study was to evaluate the microvasculature of the macula and the optic nerve in patients affected by migraine with aura (MA) and without aura (MO) by optical coherence tomography angiography (OCTA), comparing the findings with healthy controls (HC).

METHODS

We collected data from ocular and orthotic examinations, including eye motility, intraocular pressure measurement, best-corrected visual acuity (BCVA) measurement, objective refraction measurement, fundus examination, macular and optic disk OCTA examination. All subjects were imaged with solix fullrange OCT. The following OCTA parameters were recorded: macular vessel density (VD), inside disc VD, peripapillary VD, disc whole image VD, fovea choriocapillaris VD, fovea VD, parafovea VD, peripapillary thickness, fovea thickness, parafovea thickness, macular full retinal thickness, and foveal avascular zone (FAZ) parameters. Clinical and demographical data about migraine patients were collected by a neurologist.

RESULTS

We included 56 eyes from 28 patients with a diagnosis of MO, 32 eyes from 16 patients with a diagnosis of MA, and 32 eyes from 16 HC subjects. The FAZ area was 0.230 ± 0.099 mm² in the MO group, 0.248 ± 0.091 mm² in the MA group and 0.184 ± 0.061 mm² in the control group. The FAZ area was significantly larger in the MA group than in the HC group (p = 0.007). The foveal choriocapillaris VD was significantly lower in MA patients (63.6 ± 2.49%) when compared with MO patients (65.27 ± 3.29%) (p = 0.02).

CONCLUSION

An impairment of retinal microcirculation can be detected in patients with MA, as demonstrated by the enlargement of FAZ. Moreover, the study of choroid circulation may reveal microvascular damage in patients with migraine with aura. OCTA is a useful non-invasive screening tool for the detection of microcirculatory disturbance in patients with migraine.

MultiColor imaging in urticarial vasculitis with recurrent branch retinal artery occlusion in a case with positive toxoplasma IgG and interferon-gamma release assay - Case report

Introduction

We report a male who presented with acute visual defect and was diagnosed with urticarial vasculitis with recurrent branch retinal artery occlusion (BRAO) after systemic disease survey, fluorescein angiography (FA), and MultiColor imaging (MCI).

Case report

A 47-year-old male with a history of urticarial vasculitis presented with visual defect OD. Fundus examination showed two foci of ischemic retinal whitening beneath the inferior arcade and above the superior arcade. MCI demonstrated a greenish tinge in the corresponding area. FA revealed segmental arteriolar staining and arterial occlusive changes. BRAO with retinal arteritis was diagnosed. Toxoplasma IgG was positive. Sulfamethoxazole 400mg plus trimethoprim 80mg was given. His vision worsened after 1-week of treatment. The established lesions improved, but new lesions occurred. Interferon-gamma release assay was positive but tuberculosis DNA qualitative amplification test of sputum was negative. Sputum acid-fast stain was positive and culture revealed nontuberculous mycobacteria. Left facial itching and reactive lymphadenopathy developed. Prednisolone and cyclophosphamide were started. The initial retinal artery lesions regained perfusion.

Conclusions

Urticarial vasculitis with recurrent BRAO is an immune complex-mediated disease. Greenish-tinged occlusive lesions were noted from MCI with high resolution and contrast. MCI could be a valuable method for retinal vessel occlusive disease detection before FA and follow up.

Evaluation of migraine patients with optical coherence tomography angiography

PURPOSE

To compare optical coherence tomography angiography (OCTA) findings in cases with migraine and healthy controls.

METHODS

Thirty-eight eyes of 19 patients with migraine with aura and 38 eyes of 19 healthy subjects were enrolled in this prospective and comparative study. All patients and healthy controls were evaluated with OCTA (Triton, Topcon®, Tokyo, Japan). Central macular thickness (CMT), optic disc parameters (such as retinal nerve fibre layer [RNFL] thickness and rim and disc areas), foveal avascular zone (FAZ) and parafoveal superficial vessel density (VD) measurements were analysed.

RESULTS

The optic disc rim area was significantly larger in the migraine group compared to the control group (p = 0.009). In OCTA measurements, the FAZ area was significantly larger in migraine patients (p = 0.001). The parafoveal superficial VD measurements were found to be lower in the migraine patients in all quadrants, but not statistically significant. Weak negative correlations were found between superior parafoveal VD and disease duration in migraine patients.

CONCLUSION

Migraine with aura was associated with optic disc rim changes, but without any remarkable foveal vascular decrements. It is possible for migraine to cause structural changes due to its chronic nature.

Retinal vascular density evaluation of migraine patients with and without aura and association with white matter hyperintensities

Underlying pathophysiological mechanism of migraine is not all clear; however, recent reports suggested that neurovascular system is involved. We aimed to evaluate the retinal vessel densities of migraine patients with and without aura and the associations with white matter hyperintensities (WMH), using optical coherence tomography angiography (OCTA). We recruited 28 migraine with aura (MWA) patients, 26 migraine without aura (MWO) and age and sex-matched 34 healthy controls in our study. All participants were evaluated with optical coherence tomography (OCT) and OCTA for optic nerve parameters and retinal vessel densities with RTVue XR AVANTI. On macular OCTA, superficial and deeper retinal foveal vessel density (VD) were significantly lesser in MWA and MWO than controls. On optic nerve OCTA, whole optic disc, peripapillary, superior hemisphere, superior layer and temporal layer VD were significantly lesser in MWA and MWO. In group of MWA with the WMH, deeper foveal VD and superior hemisphere VD, average RNFL, superior hemisphere and superior layer were significantly lesser and also foveal avascular zone was significantly larger than the group of without WMH. Alterations of VD in patients with migraine are showed in our study. In addition, in group of MWA these alterations have associations with WMH. Supporting these findings with further reports can be useful to understand the pathophysiology of this disease.

Evaluation of the lamina cribrosa thickness and depth in patients with migraine

PURPOSE

The aim of the study was to evaluate the lamina cribrosa (LC) thickness, LC depth, and retinal nerve fiber layer (RNFL) thickness, in migraine patients with and without aura, by using optical coherence tomography (OCT).

METHODS

This single-center, case-control study included 27 migraine with aura (Group I), 35 migraine patients without aura (Group II), and 35 healthy controls (Group III). In only the right eyes of participants, RNFL thickness in all quadrants was analyzed via OCT, whereas LC thickness and depth were measured by enhanced depth imaging OCT.

RESULTS

The mean age and sex distributions did not differ significantly across the groups (p = 0.460 and p = 0.941). The RNFL thickness was significantly lower in Group I (average and superotemporal, superonasal, and inferotemporal quadrants) and Group II (average and superotemporal and superonasal quadrants) when compared with Group III. Disease duration was significantly correlated with RNFL thickness on average and in all quadrants except in the superonasal quadrant in Groups I and II. Patients in Groups I and II had significantly thinner LC thicknesses and deeper LC depth than healthy participants in Group III.

CONCLUSIONS

The LC and RNFL thicknesses were thinner and the LC depth was deeper in migraine patients with or without aura than in healthy individuals, and disease duration correlated significantly with RNFL thickness. Both results suggest that migraine patients are at risk of developing glaucoma.

Optical Coherence Tomography in Patients with Chronic Migraine: Literature Review and Update

Migraine is a chronic disease characterized by unilateral, pulsating, and often moderate-to-severe recurrent episodes of headache with nausea and vomiting. It affects approximately 15% of the general population, yet the underlying pathophysiological mechanisms are not fully understood. Optical coherence tomography (OCT) is a safe and reproducible diagnostic technique that utilizes infrared wavelengths and has a sensitivity of 8–10 μm. It can be used to measure thinning of the retinal nerve fiber layer (RNFL) in some neurological disorders. Although ophthalmologists are often the first specialists to examine patients with migraine, few studies have addressed the involvement of the optic nerve and retino-choroidal structures in this group. We reviewed the literature on the etiological and pathological mechanisms of migraine and the relationship between recurrent constriction of cerebral and retrobulbar vessels and ischemic damage to the optic nerve, retina, and choroid. We also assessed the role of OCT for measuring peripapillary RNFL thickness and macular and choroidal changes in migraine patients. There is considerable evidence of cerebral and retrobulbar vascular involvement in the etiology of migraine. Transitory and recurrent constriction of the retinal and ciliary arteries may cause ischemic damage to the optic nerve, retina, and choroid in patients with migraine. OCT to assess the thickness of the peripapillary RNFL, macula, and choroid might increase our understanding of the pathophysiology of migraine and facilitate diagnosis of retino-choroidal compromise and follow-up of therapy in migraine patients. Future studies should determine the usefulness of OCT findings as a biomarker of migraine.

Foveal and Peripapillary Vascular Decrement in Migraine With Aura Demonstrated by Optical Coherence Tomography Angiography

Purpose

Migraine, particularly with aura, has been associated with ocular and systemic ischemic complications, but there are limited data on the ocular vasculature in migraine. We used optical coherence tomography angiography (OCTA) to assess perfusion of the macula and optic nerve in migraine patients, with (MA) and without (MO) aura, compared to healthy controls (HC).

Methods

We recruited 15 MA (mean age 42 years), 12 MO (mean age 46 years), and 22 HC (mean age 39 years) participants from neurology and neuro-ophthalmology clinics. Participants underwent optical coherence tomography and 3 × 3 mm OCTA of the macula and optic nerve. Foveal avascular zone area was automatically measured using AngioVue software, and vessel density was calculated as blood vessel length divided by scan area (mm-1) after skeletonization of OCTA images.

Results

On macular OCTA, MA participants had an enlarged foveal avascular zone area when compared with HC (0.300 ± 0.019 vs. 0.220 ± 0.066 mm2, P = 0.006). In addition, superficial foveal vessel density was decreased in MA participants when compared with MO participants (7.8 ± 0.31 vs. 9.3 ± 0.44, P = 0.04) and HC (7.8 ± 0.31 vs. 9.4 ± 0.21 mm-1, P = 0.002). On optic nerve OCTA, the MA participants had reduced superior peripapillary vessel density when compared with the MO participants (12.0 ± 0.45 vs. 14.0 ± 0.38 mm-1, P = 0.031) and HC (12.0 ± 0.45 vs. 14.1 ± 0.53 mm-1, P = 0.035). There were no significant differences between the MO and HC groups.

Conclusions

Migraine with, but not without, aura was associated with foveal and peripapillary vascular decrements, which may possibly mediate increased risk of ocular and systemic vascular complications in these patients. OCTA could potentially be useful as a biomarker for migraine with aura.

Evaluation of retinal nerve fibre layer, ganglion cell layer and choroidal thickness with optical coherence tomography in migraine patients: a case-control study

BACKGROUND

Evaluation of retinal nerve fibre layer (RNFL), ganglion cell layer (GCL) and choroidal thickness (CT) with optical coherence tomography (OCT) in chronic migraine patients, to compare with healthy controls.

MATERIAL AND METHOD

Ninety-four eyes of 47 chronic migraine patients (Group 1) and 68 eyes of 34 healthy individuals (Group 2) were included in this prospective case-control study. The right and left eyes were separately evaluated. Mean peripapillary RNFL thicknesses, mean GCL measured from superior and inferior quadrants, and mean CT were measured at three different regions (central, 500 μm nasal and temporal region of the fovea).

RESULTS

There was no statistically significant differences in RNFL between the two groups (p > 0.05), while CT values were significantly higher and GCL values were significantly lower in chronic migraine groups (p < 0.05). There were no statistically significant differences between migraine duration, frequency and length of attacks, presence of aura, relation to menstrual cycle, white matter lesions in cranial magnetic resonance imaging and RNFL, GCL and CT (p > 0.05).

DISCUSSION

In this study, we observed chronic migraine disease does not have any effect on peripapillary RNFL thickness; however, increases in CT and decreases in GCL thickness were observed in migraine patients.

Evaluation of retinal nerve fiber layer, ganglion cell layer and macular changes in patients with migraine

The aim of this study was to investigate retinal nerve fiber layer (RNFL), ganglion cell layer (GCL) thickness, macular changes (central subfield thickness (CST), cube average thickness (CAT), cube volume (CV) in patients with migraine using spectral-domain optical coherence tomography (OCT) and to assess if there was any correlation with white matter lesions (WML). In this prospective case-control study, RNFL, GCL thickness and macular changes of 19 migraine patients with aura (MA), 41 migraine without aura (MO) and 60 age- and gender-matched healthy subjects were measured using OCT device. OCT measurements were taken at the same time of the day to minimize the effects of diurnal variation. The average, inferior and superior quadrant RNFL thickness were significantly thinner in patients with migraine (p = 0.017, p = 0.010, p = 0.048). There was also a significant difference between patients with and without aura in the mean and superior quadrant RNFL thickness (p = 0.02, p = 0.043).While there was a significant thinning in CST and CAT in patients with migraine (p = 0.020), there were no significant difference in GCL measurements (p = 0.184). When the groups were compared to the control group, there were significant differences between MA and the control group regarding average, superior and inferior quadrant RNLF thickness (p < 0.001, p = 0.025, p < 0.001). On the other hand, there were significant differences between MO and the control group regarding average and inferior faces (p = 0.037, p = 0.04). When OCT measurements were evaluated according to the frequency of attacks, CST and GCL thickness were significantly thinner in patients who had more than four attacks a month (p = 0.024, p = 0.014). In patients with WML, only CV measurements were significantly thinner than migraine patients without WML (p = 0.014). The decreased RNFL, CST, CAT and CV of the migraine patients might be related to the vascular pathology of the disease. Because WML was not correlated with the same measurements except CV, we think that further studies are needed to evaluate the etiopathologic relationship between OCT measurements and WML in migraine patients.

Retinal Nerve Fibre Layer Thickness of Migraine Patients with or without White Matter Lesions

The aim of this study was to determine whether retinal nerve fibre layer (RNFL) thickness is correlated with cerebral white matter lesions (WML) in migraine patients. Forty migraine and 40 healthy subjects were included in this study. The difference in RNFL thickness between the control and a migraine group with WML and a migraine group without WML were investigated using analysis of variance (ANOVA). A Tukey post hoc test was conducted to determine from which group the difference originated. Lower RNFL thicknesses were observed in the migraine patient group where WML was detected using magnetic resonance imaging (MRI), compared with the control group and with the migraine group with no WML. Statistically significant difference was found between the three groups in terms of RNFL thickness. Although there was a statistically significant difference between the control and the migraine group with WML detected with MRI, no statistically significant difference was found in terms of RNFL thickness between the control and the migraine group with no WML related to Tukey post hoc test. Moreover, there was a statistically significant difference between migraine patients with WML and patients without WML in terms of retinal nerve fibre layer thickness. The results indicate that reduction in RNFL detected via optical coherence tomography may be related to cerebral WML in migraine patients. Further studies by neurologists and ophthalmologists are necessary to determine the clinical relevance of the relation between RNFL and cerebral WML.

Foveal Thickness Alterations in Patients with Migraine

AIM

To investigate the alterations in foveal retinal thickness (FT) values in patients with migraine and to reveal the correlations between FT and clinical characteristics of migraine disease.

METHODS

This study included sixty-eight eyes of 34 migraine patients [twenty-eight eyes of 14 patients with aura (group 1), and forty eyes of 20 patients without aura (group 2)] and forty eyes of 20 healthy volunteer who served as the control group (group 3). FT values were measured by optical coherence tomography (OCT) in each group.

RESULTS

Mean age of patients in group 1, 2, and 3 was 34.0± 6.82, 35.2±10.12, and 35.1± 6.85 years, respectively (p=0.84). Mean FT was 211.07±7.36, 220.0±12.01, and 221.85±12.27 in groups 1, 2, and 3, respectively. There was statistically significance among the group 1-2 and 1-3 (p=0.002 and p< 0.001). There was no statistically significance between group 2-3 (p=0.88).

CONCLUSION

This study suggests that in particular migraine with aura may lead to a reduction in FT values. This finding can be explained by the blood flow decrease theory in migraine; however larger studies seem mandatory.

The impact of migraine on posterior ocular structures

Purpose. To investigate the thickness of the retinal nerve fiber layer (RNFL) and choroid in patients who have migraines in comparison to healthy controls. Methods. This study included 76 eyes and patients in the migraine group, 36 with aura (MWA group) and 40 without (MWoA group), and 38 eyes as control subjects. The RNFL and macular thicknesses were analysed with standard OCT protocol while choroidal thickness was analysed with EDI protocol in all subjects. Choroidal thickness was measured at the fovea, 1500 µm nasal and 1500 µm temporal to the fovea in a horizontal section. Results. The mean RNFL thickness for nasal and nasal inferior sectors was significantly thinner (P ≤ 0.018) in the migraineurs' eyes than in those of the controls, as was the mean choroid thickness at the fovea and measured points (P < 0.0001). However, the mean macular thickness was not significantly different between the groups. Conclusions. This study suggests that migraine leads to a reduction in the peripapillary RNFL thickness and to thinning in choroidal structures. These findings can be explained by a chronic ischemic insult related to migraine pathogenic mechanisms and these findings are considered supportive of the relationship between glaucoma and migraine.

Retinal Nerve Fibre Layer Thickness in Migraine Patients with or without Aura

The objective of this study was to evaluate the retinal nerve fibre layer (RNFL) thickness using spectral-domain optical coherence tomography (Optos SD-OCT, UK) in migraine patients with or without aura and to search for possible structural effects of migraine on the retina. Eighty eyes of 40 migraine patients and 80 eyes of 40 healthy subjects were included in this study. All four quadrants (temporal, superior, nasal, and inferior) and average peripapillary RNFL measurements were taken with SD-OCT in both groups. The average age of the patients and the control group were 35.7 ± 9.5 and 40.9 ± 12.7 years, respectively. In the migraine group, 45% of patients were with aura, and 55% were without aura. The average frequency of attacks per month and the migraine diagnosis time was 4.6 ± 4.4 and 6.2 ± 5.6, respectively. Parameters related to RNFL thickness of right and left eyes' average, superior, inferior, nasal, and temporal quadrant values were found to be similar in migraine and control subjects (p > 0.05). Focusing on the RNFL thickness of right and left eyes and the migraine parameters, there were no statistically significant differences between migraineurs with aura and without aura (p > 0.05). The correlations between the RNFL thickness parameters and the migraine patient's MIDAS (Migraine Disability Assessment Score) score, frequency of attacks, and diagnosis time of migraine were studied and no correlation was noted (p > 0.05). These findings demonstrated that migraine disease with or without aura does not have any effect on the thickness of the RNFL.

Retinal nerve fibre layer, ganglion cell layer and choroid thinning in migraine with aura

BACKGROUND

The aim of this study was to investigate the thickness of the retinal nerve fiber layer (RNFL), the ganglion cell layer (GCL), and choroid thickness (CT) in patients who have migraines, with and without aura, using spectral optical coherence tomography (OCT).

METHODS

Forty-five patients who had migraines without aura (Group 1), 45 patients who had migraines with aura (Group 2), and 30 healthy participants (control group) were included in the study. Spectral OCT was used to measure the RNFL, GCL and CT values for all patients.

RESULTS

The mean age of Group 1, Group 2, and the control group was 34.6 ± 4.3, 32.8 ± 4.9, and 31.8 ± 4.6 years, respectively. The mean attack frequency was 3.6/month in Group 1 and 3.7/month in Group 2. The mean age among the groups (p = 0.27) and number of attacks in migraine patients (p = 0.73) were not significantly different. There was significant thinning in the RNFL and GCL in Group 2 (p < 0.05, p < 0.001 respectively), while there were no significant differences in RNFL and GCL measurements between Group 1 and the control group (p > 0.05). All groups were significantly different from one another with respect to CT, with the most thinning observed in Group 2 (p < 0.001). When all migraine patients (without grouping) were compared with the control group, there were significant differences on all parameters: RNFL thickness, GCC thickness and CT (p < 0.05).

CONCLUSIONS

RNFL and GCL were significantly thinner in the migraine patients with aura as compared with both the migraine patients without aura and the control subjects. In migraine, both with aura and without aura, patients' choroid thinning should be considered when evaluating ophthalmological findings.

Migraine and vascular diseases: a review of the evidence and potential implications for management

INTRODUCTION

The higher-than-expected incidence of vascular diseases reported in migraineurs suggests that migraine may, in some cases, be a dangerous condition rather than just a distressing but harmless disorder. We provide a systematic review of data linking migraine to vascular diseases.

MIGRAINE AND VASCULAR DISEASES

Available data indicate an increased risk of ischemic stroke in subjects suffering from migraine with aura. In addition, evidence suggests an association between migraine with aura and cardiac disease, intracerebral hemorrhage, retinal vasculopathy and mortality that needs to be further corroborated; consequently, for those conditions, migraine with aura can be only considered among the less-well-documented risk factors. As the absolute risk of ischemic stroke in the overall migraineur population is low, subjects suffering from migraine with aura should be made aware of the possible link but not unduly alarmed. It is a common notion that the vascular risk of migraineurs may be further increased by the presence of easily treatable vascular risk factors such as arterial hypertension, cigarette smoking and oral contraceptive use.

CONCLUSIONS

Forthcoming guidelines should appropriately recommend supporting migraineurs not only with measures aimed at decreasing headache frequency, thus improving quality of life, but also with general measures and preventive strategies aimed to reduce the overall vascular risk. In fact, headache specialists should take care not only of relieving pain but also of assessing and treating concurrent vascular risk factors, while gynecologists, in particular, should routinely consider the presence and type of migraine before prescribing oral contraceptives.

Reduction in retinal nerve fiber layer thickness in migraine patients

Migraine is a common disorder and its pathogenesis remains still unclear. Several hypotheses about the mechanisms involved in the pathogenesis of migraine have been proposed, but the issue is still far from being fully clarified. Neurovascular system remains one of the most important mechanisms involved in the pathogenesis of migraine and it could be possible that hypoperfusion might involve other areas besides brain, including the retina. This is, for example, of particular interest in a form of migraine, the retinal migraine, which has been associated with hypoperfusion and vasoconstriction of the retinal vasculature. Although vasoconstriction of cerebral and retinal blood vessels is a transient phenomenon, the chronic nature of the migraine might cause permanent structural abnormalities of the brain and also of the retina. On this basis, a few studies have evaluated whether retina is involved in migraine patients: Tan et al. have not found differences in retinal nerve fiber layer (RNFL) thickness between migraine patients and healthy subjects, while Martinez et al. have shown that RNFL in the temporal retinic quadrant of migraineurs is thinner than in normal people. The aim of our study was to analyze if there are differences in retinal nerve fiber layer thickness between migraine patients and normal subjects by studying 24 consecutive migraine patients who presented at the Headache Center of our Neurological Department. Migraine diagnosis has been made according to the International Classification of Headache disorder (ICHD-II). Patients have been recruited according to strict inclusion criteria; then patients have undergone a complete ophthalmological examination at the Ophthalmological Department. All patients and controls who met the ophthalmological criteria have been examined with ocular coherence tomography spectral domain (OCT-SD) after pupillary dilation. OCT-SD is an optical system designed to acquire the retinal layer images simultaneously with fundus confocal images. The statistical analysis has been performed using the Statistical Package for Social Sciences program. The Student's t test has been used to compare numeric variables between migraine and control groups. p value >0.05 has been considered not significant. We have analyzed 40 female subjects, 24 included in the study group and 16 included in the control group. Two migraine patients have been excluded. No differences have been found in the visual acuity between the two groups. Comparing RNFLs of a single eye per person in the two groups, we have found that migraine patients showed significant reduction in the superior quadrants (p < 0.005). Also evaluating both eyes per person there was a significant difference in the same quadrant between the two groups (p < 0.05). The result of this present study show that migraine patients have RNFL thickness reduction in the superior retinal quadrant compared with normal subjects. It is important to underline that RNFL thickness measurement could be a new interesting technique to evaluate the evolution of migraine and perhaps to study if prophylactic treatment could reduce retinal abnormalities seen in migraine patients. OCT-SD is a simple exam that could be repeated and then used for evaluation of headache progression during the time. Our study shows that RNFLs thickness does not depend on illness duration and frequency.

Acute retinal arterial occlusive disorders

The initial section deals with basic sciences; among the various topics briefly discussed are the anatomical features of ophthalmic, central retinal and cilioretinal arteries which may play a role in acute retinal arterial ischemic disorders. Crucial information required in the management of central retinal artery occlusion (CRAO) is the length of time the retina can survive following that. An experimental study shows that CRAO for 97min produces no detectable permanent retinal damage but there is a progressive ischemic damage thereafter, and by 4h the retina has suffered irreversible damage. In the clinical section, I discuss at length various controversies on acute retinal arterial ischemic disorders. Classification of acute retinal arterial ischemic disorders: These are of 4 types: CRAO, branch retinal artery occlusion (BRAO), cotton wool spots and amaurosis fugax. Both CRAO and BRAO further comprise multiple clinical entities. Contrary to the universal belief, pathogenetically, clinically and for management, CRAO is not one clinical entity but 4 distinct clinical entities - non-arteritic CRAO, non-arteritic CRAO with cilioretinal artery sparing, arteritic CRAO associated with giant cell arteritis (GCA) and transient non-arteritic CRAO. Similarly, BRAO comprises permanent BRAO, transient BRAO and cilioretinal artery occlusion (CLRAO), and the latter further consists of 3 distinct clinical entities - non-arteritic CLRAO alone, non-arteritic CLRAO associated with central retinal vein occlusion and arteritic CLRAO associated with GCA. Understanding these classifications is essential to comprehend fully various aspects of these disorders. Central retinal artery occlusion: The pathogeneses, clinical features and management of the various types of CRAO are discussed in detail. Contrary to the prevalent belief, spontaneous improvement in both visual acuity and visual fields does occur, mainly during the first 7 days. The incidence of spontaneous visual acuity improvement during the first 7 days differs significantly (p<0.001) among the 4 types of CRAO; among them, in eyes with initial visual acuity of counting finger or worse, visual acuity improved, remained stable or deteriorated in non-arteritic CRAO in 22%, 66% and 12% respectively; in non-arteritic CRAO with cilioretinal artery sparing in 67%, 33% and none respectively; and in transient non-arteritic CRAO in 82%, 18% and none respectively. Arteritic CRAO shows no change. Recent studies have shown that administration of local intra-arterial thrombolytic agent not only has no beneficial effect but also can be harmful. Prevalent multiple misconceptions on CRAO are discussed. Branch retinal artery occlusion: Pathogeneses, clinical features and management of various types of BRAO are discussed at length. The natural history of visual acuity outcome shows a final visual acuity of 20/40 or better in 89% of permanent BRAO cases, 100% of transient BRAO and 100% of non-arteritic CLRAO alone. Cotton wools spots: These are common, non-specific acute focal retinal ischemic lesions, seen in many retinopathies. Their pathogenesis and clinical features are discussed in detail. Amaurosis fugax: Its pathogenesis, clinical features and management are described.

Comorbid neuropathologies in migraine: an update on cerebrovascular and cardiovascular aspects

Several conditions are comorbid with migraine; our review is focused on the relation between migraine, and cerebrovascular and cardiovascular diseases. Despite many studies showed an association between migraine and patent foramen ovale, it is still not known whether its presence might be causal for the migraine pathogenesis and currently its closure cannot be recommended for migraine prevention. On the contrary, conflicting epidemiological data link migraine to arterial hypertension and the use of antihypertensive agents acting on the renin-angiotensin system sounds promising in migraine prevention. A complex bidirectional relation exists between migraine and stroke, and new evidences show a clear association between migraine and coronary heart disease. In both conditions, migraine represents a defined risk factor although the magnitude of the risk varies across the different studies. However, since the risk is low in the general population, it is not possible to identify which migraineurs will develop a cardiovascular or a cerebrovascular event making difficult to apply preventive measures.

Branch retinal artery occlusion during a migraine attack

A 60-year-old male with a history of migraine presented with evidence of branch retinal arterial occlusion that developed at the time of an attack of retinal migraine. The diagnosis of branch arterial occlusion secondary to migraine was made after exclusion of numerous possible medical conditions. The possible role of vasospasm in this condition is discussed.

Most Cases Labeled as “Retinal Migraine” Are Not Migraine

BACKGROUND

Monocular visual loss has often been labeled "retinal migraine." Yet there is reason to believe that many such cases do not meet the criteria set out by the International Headache Society (IHS), which defines "retinal migraine" as attacks of fully reversible monocular visual disturbance associated with migraine headache and a normal neuro-ophthalmic examination between attacks.

METHODS

We performed a literature search of articles mentioning "retinal migraine," "anterior visual pathway migraine," "monocular migraine," "ocular migraine," "retinal vasospasm," "transient monocular visual loss," and "retinal spreading depression" using Medline and older textbooks. We applied the IHS criteria for retinal migraine to all cases so labeled. To be included as definite retinal migraine, patients were required to have had at least two episodes of transient monocular visual loss associated with, or followed by, a headache with migrainous features.

RESULTS

Only 16 patients with transient monocular visual loss had clinical manifestations consistent with retinal migraine. Only 5 of these patients met the IHS criteria for definite retinal migraine. No patient with permanent visual loss met the IHS criteria for retinal migraine.

CONCLUSIONS

Definite retinal migraine, as defined by the IHS criteria, is an exceedingly rare cause of transient monocular visual loss. There are no convincing reports of permanent monocular visual loss associated with migraine. Most cases of transient monocular visual loss diagnosed as retinal migraine would more properly be diagnosed as "presumed retinal vasospasm."

Retinal migraine

Retinal migraine is a primary headache disorder, clinically manifested by attacks of transient monocular visual loss associated with migraine headache. Although isolated reports suggest that retinal migraine is rare, it likely is under-recognized. Retinal migraine usually is reported in women of childbearing age who have a history of migraine with aura. It typically is characterized by negative monocular visual phenomena lasting less than 1 hour. More than half of reported cases with recurrent transient monocular visual loss subsequently experienced permanent monocular visual loss. Although the International Headache Society diagnostic criteria for retinal migraine require reversible visual loss, our findings suggest that irreversible visual loss is part of the retinal migraine spectrum, likely representing an ocular form of migrainous infarction.

Retinal nerve fiber layer thickness is unaffected in migraine patients

OBJECTIVES

To search for possible structural effects of migraine on the retina.

MATERIALS AND METHODS

The study group included 39 consecutive migraine patients, 15 with visual aura and 24 without aura, and 25 healthy subjects as the control group. Scanning laser polarimetry was used to measure and compare retinal nerve fiber layer (RNFL) thickness between migraine and control groups.

RESULTS

The mean age of the patients and the control group were 35.64 +/- 8.3 and 35.96 +/- 9.14 years, respectively (P = 0.92) and the mean duration of migraine in patients with aura and without aura as 4.4 +/- 2.9 and 5.3 +/- 4.3 years, respectively (P = 0.68). Parameters related to RNFL thickness were found to be similar (P > 0.001) in migraine and control subjects. After examining the whole patient group migraine patients with and without aura were compared to each other and the control group individually for RNFL thickness parameters. Briefly no statistical difference was found for any of the test parameters between migraine patients with aura, without aura and controls (P > 0.001).

CONCLUSION

Retinal nerve fiber layer thickness was found to be unaffected in migraine patients.

Retinal, ophthalmic, or ocular migraine

Ocular migraine, an uncommon cause of transient monocular visual loss, is an entity physicians should be able to recognize in order to provide appropriate treatment and to avoid unnecessary testing. The following text provides an overview of ocular migraine, including discussion of accepted terminology, clinical presentation, and pathophysiology. An ocular and systemic differential diagnosis, appropriate evaluation, therapy, and prognosis are also discussed.

Migraine-associated dizziness: patient characteristics and management options

OBJECTIVE

To determine patient characteristics and effectiveness of therapy for migraine-associated dizziness.

STUDY DESIGN

Retrospective chart review.

SETTING

Tertiary referral center.

PATIENTS

Patients were identified through a code query of billing records for the diagnosis of migraine-associated vertigo or disequilibrium, based on the International Headache Society criteria. There were 81 patients (61 women, 20 men) with an average age of 36.6 years (range, 8-71 yr); all except four patients were evaluated between 1995 and 1999. Follow-up was obtained from chart review. Mean follow-up time was 54.5 weeks, with a range of 4 to 456 weeks.

INTERVENTION

One or more treatment methods, including dietary manipulation, medication (tricyclic antidepressants, beta-blockers or calcium-channel blockers), and neurology consultation, were applied sequentially as necessary.

MAIN OUTCOME MEASURE

Response to therapy was defined as greater than 75% reduction in symptom recurrence rate.

RESULTS

Overall, 72% of patients experienced resolution or dramatic reduction of their attacks of vertigo or disequilibrium. Of the 13 patients treated with the introduction of dietary manipulation alone, 100% received significant relief. Of the 31 patients treated with dietary manipulation and the addition of a medication, 77% of these patients had significant relief. Of the final group of 37 patients treated with another medication or a neurology consultation, 57% received substantial relief. Of the responders, the majority (>95%) experienced an equal reduction in both vertigo or disequilibrium and headache symptoms. Interestingly, 100% of the patients in the migraine without active headache group received substantial relief of their vertigo or disequilibrium symptoms with migraine therapy.

CONCLUSION

We conclude that there is effective therapy for the common problem of migraine-associated dizziness.