Visual dysfunction in migraine

Acute monocular oligemia in a patient with migraine with aura demonstrated using OCT-angiography: A case report

Introduction:

Migraine is one of the most common causes of transient visual loss. Optical coherence tomography angiography (OCTA) provides fast and non-invasive imaging of the retinal vessels. We report one case of monocular retinal oligemia demonstrated using OCTA during a migraine attack with aura.

Case description:

A 27-year-old man with a previous history of migraine with visual aura was seen in the emergency room due to acute left hemicranial pain with positive visual symptoms in his right eye. The patient reported a blue stain in his right eye. Optical coherence tomography angiography (OCT-A) showed an extensive area of hypoperfusion in the macular region of his right eye. Forty-eight hours later visual symptoms had improved and the OCT-A showed a significant reduction in the area of hypoperfusion. Seven days later the patient was asymptomatic and retinal perfusion had returned to normal values.

Conclusion:

Monocular involvement suggests that these retinal vascular changes are independent from cerebral vascular changes, supporting the hypothesis of selective retinal ganglion cell layer spreading depression as the possible cause of some cases of retinal migraine.

Symptoms in cervical vertigo

Objective

To use a unique, 41‐question survey to identify patient features distinguishing cervical vertigo from vestibular causes of vertigo and vestibular migraine.

Methods

In this study, a unique, 41‐question survey was administered to 48 patients diagnosed with cervical vertigo (n = 16), migraine (n = 16), and vestibular vertigo (eg, unilateral vestibular paresis, Meniere's disease) (n = 16) to test the hypothesis that a set of distinct symptoms can characterize cervical vertigo. Responses between the three diagnostic groups were compared to identify questions which differentiated patients based on their symptoms.

Results

Eight questions were successful in differentiating vestibular vertigo from migraine and cervical vertigo. Symptoms endorsed by subjects with cervical vertigo overlapped substantially with subjects with well‐established vestibular disturbances as well as symptoms of subjects with migraine. Twenty‐seven percent of cervical vertigo subjects reported having true vertigo, 50% having headache, and 94% having neck pain.

Conclusion

Lacking knowledge of neck disturbance, the symptoms we elicited in our questionnaire suggest that cervical vertigo subjects may resemble migraine subjects who also have evidence of neck injury. Whether or not subjects with “cervical vertigo” also overlap with other diagnoses defined by a combination of symptoms and exclusion of objective findings such as chronic subjective dizziness and other variants of psychogenic dizziness remain to be established.

Level of Evidence

IV

The role of visual system in migraine

The visual system is involved in different ways in migraine. Visual auras are the most common form of migraine aura. It may consist of positive or negative visual symptoms and cortical spreading depression is felt to be the phenomenon that underlies it. Even in migraine without aura, vision it is not totally excluded given that one of the major criteria for the diagnosis of migraine is photophobia. In persistent visual aura, patients refer symptoms defined as visual snow and television static. In retinal migraine unilateral decreased vision or complete visual loss occurs. Ophthalmoplegic migraine is characterized by palsy of one among the three ocular motor nerves. Migraine visual aura, particularly when occurring without headache, is a diagnosis of exclusion. Imaging studies and laboratory tests should exclude neurologic disease, included seizures and central nervous system tumor, ocular pathologies, carotid or cardiac disease, thrombosis and connective tissue disease.

Headache in the Emergency Department: Avoiding Misdiagnosis of Dangerous Secondary Causes

There are a number of dangerous secondary causes of headaches that are life, limb, brain, or vision threatening that emergency physicians must consider in patients presenting with acute headache. Careful history and physical examination targeted at these important secondary causes of headache will help to avoid misdiagnosis in these patients. Patients with acute thunderclap headache have a differential diagnosis beyond subarachnoid hemorrhage. Considering the "context" of headache "PLUS" some other symptom or sign is one strategy to help focus the differential diagnosis.

Persistent migraine aura in an adolescent girl

A 14-year-old girl presented with a prolonged migraine visual aura of several weeks' duration. Symptoms gradually resolved over a 6-week period, with no recurrence of visual aura over a 20-month follow-up period. Although there is significant overlap between the features of stereotypical and persistent migraine auras, or "visual snow," the latter tend to be unformed and can occupy the entire visual field of both eyes. To our knowledge, this phenomenon has been reported only twice before in children. Recognition of its features will allow the pediatric ophthalmologist to differentiate persistent visual aura from visual hallucinations.

Transient monocular visual loss

Transient monocular visual loss is an important clinical complaint and has a number of causes, of which the most common is retinal ischemia. A practical approach is to perform a careful examination to determine whether there are any eye abnormalities that can explain the visual loss. Despite the transient nature of the symptom, there may be clues to the diagnosis on the examination even after the visual loss has recovered.