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Suryavanshi P, Sawant-Pokam P, Clair S, Brennan KC. Increased presynaptic excitability in a migraine with aura mutation. Brain 2024; 147:680-697. [PMID: 37831655 PMCID: PMC10834252 DOI: 10.1093/brain/awad326] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Revised: 08/24/2023] [Accepted: 09/04/2023] [Indexed: 10/15/2023] Open
Abstract
Migraine is a common and disabling neurological disorder. The headache and sensory amplifications of migraine are attributed to hyperexcitable sensory circuits, but a detailed understanding remains elusive. A mutation in casein kinase 1 delta (CK1δ) was identified in non-hemiplegic familial migraine with aura and advanced sleep phase syndrome. Mice carrying the CK1δT44A mutation were more susceptible to spreading depolarization (the phenomenon that underlies migraine aura), but mechanisms underlying this migraine-relevant phenotype were not known. We used a combination of whole-cell electrophysiology and multiphoton imaging, in vivo and in brain slices, to compare CK1δT44A mice (adult males) to their wild-type littermates. We found that despite comparable synaptic activity at rest, CK1δT44A neurons were more excitable upon repetitive stimulation than wild-type, with a reduction in presynaptic adaptation at excitatory but not inhibitory synapses. The mechanism of this adaptation deficit was a calcium-dependent enhancement of the size of the readily releasable pool of synaptic vesicles, and a resultant increase in glutamate release, in CK1δT44A compared to wild-type synapses. Consistent with this mechanism, CK1δT44A neurons showed an increase in the cumulative amplitude of excitatory post-synaptic currents, and a higher excitation-to-inhibition ratio during sustained activity compared to wild-type. At a local circuit level, action potential bursts elicited in CK1δT44A neurons triggered an increase in recurrent excitation compared to wild-type, and at a network level, CK1δT44A mice showed a longer duration of 'up state' activity, which is dependent on recurrent excitation. Finally, we demonstrated that the spreading depolarization susceptibility of CK1δT44A mice could be returned to wild-type levels with the same intervention (reduced extracellular calcium) that normalized presynaptic adaptation. Taken together, these findings show a stimulus-dependent presynaptic gain of function at glutamatergic synapses in a genetic model of migraine, that accounts for the increased spreading depolarization susceptibility and may also explain the sensory amplifications that are associated with the disease.
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Affiliation(s)
- Pratyush Suryavanshi
- Department of Neurology, University of Utah School of Medicine, Salt Lake City, UT 84132, USA
- Interdepartmental Neuroscience Program, University of Utah School of Medicine, Salt Lake City, UT 84132, USA
- Department of Pediatrics, University of Iowa, Iowa City, IA 52242, USA
| | - Punam Sawant-Pokam
- Department of Neurology, University of Utah School of Medicine, Salt Lake City, UT 84132, USA
| | - Sarah Clair
- Department of Neurology, University of Utah School of Medicine, Salt Lake City, UT 84132, USA
| | - K C Brennan
- Department of Neurology, University of Utah School of Medicine, Salt Lake City, UT 84132, USA
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2
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Cortez MM, Martindale C, Brennan KC, Kean J, Millar MM, Knudson A, Katz BJ, Digre KB, Presson AP, Zhang C. Validation of the Utah Photophobia Symptom Impact Scale (version 2) as a headache-specific photophobia assessment tool. Headache 2023; 63:672-682. [PMID: 37140215 PMCID: PMC10368178 DOI: 10.1111/head.14516] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Revised: 03/01/2023] [Accepted: 03/03/2023] [Indexed: 05/05/2023]
Abstract
OBJECTIVE To present an updated version of the Utah Photophobia Symptom Impact Scale version 2 (UPSIS2), providing robust clinical and psychometric validation, to improve headache-specific evaluation of light sensitivity and headache-related photophobia. BACKGROUND The original UPSIS filled a gap in available tools for assessment of headache-associated light sensitivity by providing patient-reported evaluation of the impact of light sensitivity on activities of daily living (ADLs). We have since revised the original questionnaire to provide a more robust item construct and refined validation approach. METHODS We conducted a psychometric validation of the UPSIS2 through a primary analysis of an online survey of volunteers with recurrent headaches recruited from the University of Utah clinics and surrounding community. Volunteers completed the original UPSIS and UPSIS2 questionnaire versions in addition to measures of headache impact, disability, and frequency. The UPSIS2 now includes a pre-defined recall period and a 1-4 Likert scale with standardized response anchors to improve clarity. Internal construct validity, external construct validity, and test-retest reliability, were evaluated. RESULTS Responses were obtained from 163 volunteers, with UPSIS2 scores ranging from 15 to 57 (out of a possible 15-60) with a mean (standard deviation) of 32.4 (8.80). Construct validity was satisfactory, as evidenced by sufficient unidimensionality, monotonicity, and local independence. Reliability was excellent, with Rasch test reliability = 0.90 and Cronbach's alpha = 0.92, and an intraclass correlation of 0.79 (95% confidence interval 0.65-0.88) for participants who took the test twice. UPSIS2 correlates well with other headache measures (Spearman's correlations >0.50), as well as the original UPSIS (Spearman's correlation = 0.87), indicating good convergent validity. UPSIS2 scores differ significantly across International Classification of Headache Disorders (third edition) groups, indicating good known group validity. CONCLUSION The UPSIS2 provides a well-validated headache-specific outcome measure for the assessment of photophobia impact on ADLs.
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Affiliation(s)
- Melissa M. Cortez
- Department of Neurology, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Cecilia Martindale
- Department of Neurology, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - KC Brennan
- Department of Neurology, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Jacob Kean
- Department of Population Health Sciences, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Morgan M. Millar
- Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Alexander Knudson
- School of Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Bradley J. Katz
- Department of Neurology, University of Utah School of Medicine, Salt Lake City, UT, USA
- Department of Ophthalmology and Visual Sciences, John Moran Eye Center, University of Utah, Salt Lake City UT USA
| | - Kathleen B. Digre
- Department of Neurology, University of Utah School of Medicine, Salt Lake City, UT, USA
- Department of Ophthalmology and Visual Sciences, John Moran Eye Center, University of Utah, Salt Lake City UT USA
| | - Angela P. Presson
- Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Chong Zhang
- Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
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Iser C, Arca K. Headache and Autonomic Dysfunction: a Review. Curr Neurol Neurosci Rep 2022; 22:625-634. [PMID: 35994191 DOI: 10.1007/s11910-022-01225-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/14/2022] [Indexed: 01/27/2023]
Abstract
PURPOSE OF REVIEW We explore the anatomy of the central and peripheral autonomic pathways involved in primary headache as well as the mechanisms for secondary headache associated with disorders of the autonomic nervous system. The prevalence and clinical presentation of cranial and systemic autonomic symptoms in these conditions will be discussed, with a focus on recent studies. RECENT FINDINGS Several small studies have utilized the relationship between headache and the autonomic nervous system to identify potential biomarkers to aid in diagnosis of migraine and cluster headache. Headache in postural orthostatic tachycardia syndrome (POTS) has also been further characterized, particularly in its association with orthostatic headache and spontaneous intracranial hypotension (SIH). This review examines the pathophysiology of primary and secondary headache disorders in the context of the autonomic nervous system. Mechanisms of headache associated with systemic autonomic disorders are also reviewed.
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Affiliation(s)
- Courtney Iser
- Department of Neurology, Mayo Clinic Scottsdale, Scottsdale, AZ, USA
| | - Karissa Arca
- Department of Neurology, Mayo Clinic Scottsdale, Scottsdale, AZ, USA.
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McDonald MA, Holdsworth SJ, Danesh-Meyer HV. Eye Movements in Mild Traumatic Brain Injury: Ocular Biomarkers. J Eye Mov Res 2022; 15:10.16910/jemr.15.2.4. [PMID: 36439911 PMCID: PMC9682364 DOI: 10.16910/jemr.15.2.4] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/10/2023] Open
Abstract
Mild traumatic brain injury (mTBI, or concussion), results from direct and indirect trauma to the head (i.e. a closed injury of transmitted forces), with or without loss of consciousness. The current method of diagnosis is largely based on symptom assessment and clinical history. There is an urgent need to identify an objective biomarker which can not only detect injury, but inform prognosis and recovery. Ocular motor impairment is argued to be ubiquitous across mTBI subtypes and may serve as a valuable clinical biomarker with the recent advent of more affordable and portable eye tracking technology. Many groups have positively correlated the degree of ocular motor impairment to symptom severity with a minority attempting to validate these findings with diffusion tract imaging and functional MRI. However, numerous methodological issues limit the interpretation of results, preventing any singular ocular biomarker from prevailing. This review will comprehensively describe the anatomical susceptibility, clinical measurement, and current eye tracking literature surrounding saccades, smooth pursuit, vestibulo-ocular reflex, vergence, pupillary light reflex, and accommodation in mTBI.
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Affiliation(s)
- Matthew A McDonald
- Department of Ophthalmology, University of Auckland, New Zealand
- Mātai Medical Research Institute, Gisborne, New Zealand
| | - Samantha J Holdsworth
- Department of Anatomy and Medical Imaging, University of Auckland, New Zealand
- Mātai Medical Research Institute, Gisborne, New Zealand
| | - Helen V Danesh-Meyer
- Department of Ophthalmology, University of Auckland, New Zealand
- Eye Institute, Auckland, New Zealand
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Starling AJ, Cortez MM, Jarvis NR, Zhang N, Porreca F, Chong CD, Schwedt TJ. Cutaneous heat and light‐induced pain thresholds in post‐traumatic headache attributed to mild traumatic brain injury. Headache 2022; 62:726-736. [DOI: 10.1111/head.14318] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Revised: 04/13/2022] [Accepted: 04/14/2022] [Indexed: 11/29/2022]
Affiliation(s)
| | | | - Nicholas R. Jarvis
- Mayo Clinic Alix School of Medicine Mayo Clinic Arizona Scottsdale Arizona USA
| | - Nan Zhang
- Department of Neurology Mayo Clinic Arizona Scottsdale Arizona USA
| | - Frank Porreca
- Department of Neurology Mayo Clinic Arizona Scottsdale Arizona USA
| | | | - Todd J. Schwedt
- Department of Neurology Mayo Clinic Arizona Scottsdale Arizona USA
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Wang Y, Wang S, Qiu T, Xiao Z. Photophobia in headache disorders: characteristics and potential mechanisms. J Neurol 2022; 269:4055-4067. [PMID: 35322292 DOI: 10.1007/s00415-022-11080-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Revised: 03/10/2022] [Accepted: 03/10/2022] [Indexed: 01/23/2023]
Abstract
Photophobia is present in multiple types of headache disorders. The coexistence of photophobia and headache suggested the potential reciprocal interactions between visual and pain pathways. In this review, we summarized the photophobic characteristics in different types of headache disorders in the context of the three diagnostic categories of headache disorders: (1) primary headaches: migraine, tension-type headache, and trigeminal autonomic cephalalgias; (2) secondary headaches: headaches attributed to traumatic brain injury, meningitis, non-traumatic subarachnoid hemorrhage and disorder of the eyes; (3) painful cranial neuropathies: trigeminal neuralgia and painful optic neuritis. We then discussed potential mechanisms for the coexistence of photophobia and headache. In conclusion, the characteristics of photophobia are different among these headache disorders. The coexistence of photophobia and headache is associated with the interactions between visual and pain pathway at retina, midbrain, thalamus, hypothalamus and visual cortex. The communication between these pathways may depend on calcitonin gene-related peptide and pituitary cyclase-activating polypeptide transmission. Moreover, cortical spreading depression, an upstream trigger of headache, also plays an important role in photophobia by increased nociceptive input to the thalamus.
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Affiliation(s)
- Yajuan Wang
- Department of Neurology, Renmin Hospital of Wuhan University, Wuhan, 430060, Hubei, China
| | - Shaoyang Wang
- Department of Emergency, Rizhao People's Hospital, Rizhao, 276800, Shandong, China
| | - Tao Qiu
- Department of Neurology, Renmin Hospital of Wuhan University, Wuhan, 430060, Hubei, China
| | - Zheman Xiao
- Department of Neurology, Renmin Hospital of Wuhan University, Wuhan, 430060, Hubei, China.
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7
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Durgam SS, Bagari S, Nandyala S, Mohamed A, Konda N, Chaurasia S, Vaddavalli PK, Parel JM. Visual photosensitivity threshold and objective photosensitivity luminance in healthy human eyes assessed using an automated ocular photosensitivity analyser: a step towards translation of a clinical tool for assessing photophobia. Ophthalmic Physiol Opt 2022; 42:311-318. [PMID: 34846070 PMCID: PMC9739816 DOI: 10.1111/opo.12923] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2021] [Revised: 10/13/2021] [Accepted: 11/01/2021] [Indexed: 12/14/2022]
Abstract
PURPOSE To evaluate the visual photosensitivity threshold and objective photosensitivity luminance in healthy eyes, thereby providing a normative dataset that will lead to a better understanding of diseases causing photophobia. METHODS This was a prospective cross-sectional study. Emmetropes whose visual acuity was better than 0.18 logMAR (6/9) with no other ocular abnormality were included. Headache Impact Test-6 and visual light sensitivity questionnaires were administered. Visual photosensitivity threshold was measured subjectively using the ocular photosensitivity analyser. Objective photosensitivity luminance was assessed manually by evaluating videos recorded using an infrared camera and noting the intensity of light at the first squeezing reflex. RESULTS Seventy five normal subjects (age range, 7-71 years) were included. Median age was 32.7 years (inter-quartile range, 20.3-47.9 years). Forty (53.3%) were males. Median Headache Impact Test score was 38 (inter-quartile range, 36-42) and visual light sensitivity questionnaire score was 11 (inter-quartile range, 8-15). Mean (standard deviation) right eye, left eye and binocular visual photosensitivity threshold was 3.34 (0.78), 3.33 (0.81) and 3.37 (0.78) loglux, respectively. There was a significant negative correlation of visual light sensitivity questionnaire scores with right eye, left eye and binocular visual photosensitivity thresholds, and positive correlation of age with binocular visual photosensitivity thresholds. Mean (standard deviation) right eye, left eye and binocular objective photosensitivity luminance was 3.25 (0.55), 3.35 (0.47) and 3.15 (0.52) loglux, respectively. Age was only positively correlated with binocular objective photosensitivity luminance, and there was no correlation between age and right eye or left eye objective photosensitivity luminance. CONCLUSIONS The study characterised, for the first time, objective photosensitivity luminance and established normative data for both visual photosensitivity threshold and objective photosensitivity luminance. The data will help in understanding the pathophysiology of diseases causing photophobia, monitoring the disease progression and evaluating treatment modalities.
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Affiliation(s)
| | - Sowjanya Bagari
- Ophthalmic Biophysics, L V Prasad Eye Institute, Hyderabad, India,School of Medical Sciences, University of Hyderabad, Hyderabad, India
| | - Sushma Nandyala
- Ophthalmic Biophysics, L V Prasad Eye Institute, Hyderabad, India
| | - Ashik Mohamed
- Ophthalmic Biophysics, L V Prasad Eye Institute, Hyderabad, India
| | - Nagaraju Konda
- School of Medical Sciences, University of Hyderabad, Hyderabad, India
| | - Sunita Chaurasia
- The Cornea Institute, L V Prasad Eye Institute, Hyderabad, India
| | | | - Jean-Marie Parel
- Ophthalmic Biophysics Center, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, Florida, USA
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Villar-Martinez MD, Goadsby PJ. Dim the Lights: A Narrative Review of Photophobia in Migraine. Neurology 2022. [DOI: 10.17925/usn.2022.18.1.14] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
A preference for darkness is one of the main associated features in people with migraine, the cause remaining a mystery until some decades ago. In this article, we describe the epidemiology of photophobia in migraine and explain the pathophysiological mechanisms following an anatomical structure. In addition, we review the current management of migraine and photophobia. Ongoing characterization of patients with photophobia and its different manifestations continues to increase our understanding of the intricate pathophysiology of migraine and vice versa. Detailed phenotyping of the patient with photophobia is encouraged.
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9
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Artemenko AR, Filatova E, Vorobyeva YD, Do TP, Ashina M, Danilov AB. Migraine and light: A narrative review. Headache 2022; 62:4-10. [PMID: 35041220 DOI: 10.1111/head.14250] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Revised: 12/06/2021] [Accepted: 12/08/2021] [Indexed: 12/14/2022]
Abstract
OBJECTIVE In this narrative review, we summarize clinical and experimental data on the effect of light in migraine and discuss future prospects. BACKGROUND Effective nonpharmacological treatment of hypersensitivity to light in migraine is an unmet clinical need. Current management strategies primarily consist of seeking a dark room and avoiding light exposure. Advances in the past 2 decades have improved our understanding of the underlying pathophysiology of how migraine is influenced by light. This may provide promising avenues for novel approaches in clinical management. METHODS We searched MEDLINE for articles published from database inception up to September 1, 2021. We used the search term "migraine" with the search terms "light," "photophobia," "treatment," "trigger," "circadian rhythm," "environment," and/or "pathophysiology." RESULTS Light is commonly reported as a trigger factor of migraine attacks, however, early manifestation of photophobia and false attribution is likely the actual cause based on data deriving from retrospective, prospective, and experimental studies. The most common photophobia symptoms in migraine are exacerbation of headache by light and abnormal sensitivity to light with the underlying neural pathways likely being dependent on ongoing activity in the trigeminovascular system. Clinical studies and experimental models have identified mediators of photophobia and uncovered narrow wavebands of the light spectrum that may reduce pain intensity during a migraine attack. Consequently, novel devices have undergone exploratory clinical trials with promising results. CONCLUSION False attribution is likely the reason why light is commonly reported as a trigger factor of migraine attacks, and a prospective confirmation is required to prevent unnecessary avoidance. The observation that individuals with migraine are not equally photophobic to all wavebands of the light spectrum opens the potential for innovative pain management strategies. In this context, using human-centric lighting (also called integrative lighting) to mimic the natural daylight cycle and avoid harmful wavebands through modern technology may prove beneficial. Future research should identify direct and indirect consequences of light and other environmental factors in migraine to fill out knowledge gaps and enable evidence-based care strategies within institutions, work environments, and other settings.
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Affiliation(s)
- Ada R Artemenko
- I.M. Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
| | - Elena Filatova
- I.M. Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
| | - Yulia D Vorobyeva
- I.M. Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
| | - Thien Phu Do
- Danish Headache Center, Department of Neurology, Rigshospitalet Glostrup, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Messoud Ashina
- I.M. Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia.,Danish Headache Center, Department of Neurology, Rigshospitalet Glostrup, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark.,Danish Knowledge Center on Headache Disorders, Glostrup, Denmark.,Department of Neurology, Azerbaijan Medical University, Baku, Azerbaijan
| | - Alexey B Danilov
- I.M. Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
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Kaiser EA, McAdams H, Igdalova A, Haggerty EB, Cucchiara BL, Brainard DH, Aguirre GK. Reflexive Eye Closure in Response to Cone and Melanopsin Stimulation: A Study of Implicit Measures of Light Sensitivity in Migraine. Neurology 2021; 97:e1672-e1680. [PMID: 34493620 DOI: 10.1212/wnl.0000000000012734] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Accepted: 08/16/2021] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND AND OBJECTIVES To quantify interictal photophobia in migraine with and without aura using reflexive eye closure as an implicit measure of light sensitivity and to assess the contribution of melanopsin and cone signals to these responses. METHODS Participants were screened to meet criteria for 1 of 3 groups: headache-free (HF) controls, migraine without aura (MO), and migraine with visual aura (MA). MO and MA participants were included if they endorsed ictal and interictal photophobia. Exclusion criteria included impaired vision, inability to collect usable pupillometry, and history of either head trauma or seizure. Participants viewed light pulses that selectively targeted melanopsin, the cones, or their combination during recording of orbicularis oculi EMG (OO-EMG) and blinking activity. RESULTS We studied 20 participants in each group. MA and MO groups reported increased visual discomfort to light stimuli (discomfort rating, 400% contrast, MA: 4.84 [95% confidence interval 0.33, 9.35]; MO: 5.23 [0.96, 9.50]) as compared to HF controls (2.71 [0, 6.47]). Time course analysis of OO-EMG and blinking activity demonstrated that reflexive eye closure was tightly coupled to the light pulses. The MA group had greater OO-EMG and blinking activity in response to these stimuli (EMG activity, 400% contrast: 42.9%Δ [28.4, 57.4]; blink activity, 400% contrast: 11.2% [8.8, 13.6]) as compared to the MO (EMG activity, 400% contrast: 9.9%Δ [5.8, 14.0]; blink activity, 400% contrast: 4.7% [3.5, 5.9]) and HF control (EMG activity, 400% contrast: 13.2%Δ [7.1, 19.3]; blink activity, 400% contrast: 4.5% [3.1, 5.9]) groups. DISCUSSION Our findings suggest that the intrinsically photosensitive retinal ganglion cells (ipRGCs), which integrate melanopsin and cone signals, provide the afferent input for light-induced reflexive eye closure in a photophobic state. Moreover, we find a dissociation between implicit and explicit measures of interictal photophobia depending on a history of visual aura in migraine. This implies distinct pathophysiology in forms of migraine, interacting with separate neural pathways by which the amplification of ipRGC signals elicits implicit and explicit signs of visual discomfort.
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Affiliation(s)
- Eric A Kaiser
- From the Departments of Neurology (E.A.K., A.I., E.B.H., B.L.C., G.K.A.) and Neuroscience (H.M.), Perelman School of Medicine, and Department of Psychology (D.H.B.), University of Pennsylvania, Philadelphia.
| | - Harrison McAdams
- From the Departments of Neurology (E.A.K., A.I., E.B.H., B.L.C., G.K.A.) and Neuroscience (H.M.), Perelman School of Medicine, and Department of Psychology (D.H.B.), University of Pennsylvania, Philadelphia
| | - Aleksandra Igdalova
- From the Departments of Neurology (E.A.K., A.I., E.B.H., B.L.C., G.K.A.) and Neuroscience (H.M.), Perelman School of Medicine, and Department of Psychology (D.H.B.), University of Pennsylvania, Philadelphia
| | - Edda B Haggerty
- From the Departments of Neurology (E.A.K., A.I., E.B.H., B.L.C., G.K.A.) and Neuroscience (H.M.), Perelman School of Medicine, and Department of Psychology (D.H.B.), University of Pennsylvania, Philadelphia
| | - Brett L Cucchiara
- From the Departments of Neurology (E.A.K., A.I., E.B.H., B.L.C., G.K.A.) and Neuroscience (H.M.), Perelman School of Medicine, and Department of Psychology (D.H.B.), University of Pennsylvania, Philadelphia
| | - David H Brainard
- From the Departments of Neurology (E.A.K., A.I., E.B.H., B.L.C., G.K.A.) and Neuroscience (H.M.), Perelman School of Medicine, and Department of Psychology (D.H.B.), University of Pennsylvania, Philadelphia
| | - Geoffrey K Aguirre
- From the Departments of Neurology (E.A.K., A.I., E.B.H., B.L.C., G.K.A.) and Neuroscience (H.M.), Perelman School of Medicine, and Department of Psychology (D.H.B.), University of Pennsylvania, Philadelphia
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Cortez MM, Millsap L, Brennan KC, Campbell CL. Craniofacial Autonomic Dysfunction in Migraine: Implications for Treatment and Prognosis. J Neuroophthalmol 2021; 40:67-73. [PMID: 31895071 DOI: 10.1097/wno.0000000000000876] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
BACKGROUND Craniofacial autonomic signs and symptoms (CASS) are relatively underrecognized in the evaluation of migraine headache. Yet, these features provide insight into diagnostic criterion, therapeutic approaches, and overarching disease burden. EVIDENCE ACQUISITION This review aims to summarize relevant literature evaluating autonomic dysfunction, with focus on CASS, in migraine through targeted literature searches in PubMed. Full articles of original data published between 1974 and 2019 were identified using MeSH terms with no search limits. RESULTS Although CASS are typically clinically evaluated by subjective patient report, investigational measures of cranial autonomic function have identified marked distinctions between headache attack and attack-free intervals. The presence of CASS during an attack does not differ based on age, sex, or presence of aura. Unilateral CASS may be predictive of longer, more frequent, and/or severe attacks and often co-occur with sensory dysfunction such as allodynia and photophobia. Although limited research has been performed to evaluate targeted therapeutics for migraine with CASS, triptans and onabotulinumtoxinA may demonstrate greater effects in this group. CONCLUSIONS Migraine remains a debilitating disorder with significant community-wide impacts, necessitating continued evaluation of contributing features. Consideration of CASS provides important insight into potential treatment approaches and the effectiveness of novel therapeutic interventions aimed at improving overall disease burden. However, further investigation is needed to fully understand primary craniofacial features in migraine, and how these might inform individualized treatment decisions.
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Affiliation(s)
- Melissa M Cortez
- Department of Microbiology, Immunology and Pathology (CLC), Colorado State University, Fort Collins, Colorado; and Department of Neurology, University of Utah (MMC, LM, KCB, CLC), Salt Lake City, Utah
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Photophobia in complex regional pain syndrome: visual discomfort is greater on the affected than unaffected side. Pain 2021; 162:1233-1240. [PMID: 33086284 DOI: 10.1097/j.pain.0000000000002118] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Accepted: 10/15/2020] [Indexed: 01/07/2023]
Abstract
ABSTRACT In complex regional pain syndrome (CRPS), hyperalgesia encompasses uninjured sites on the ipsilateral side of the body and may also include the special senses because auditory discomfort often is greater on the CRPS-affected side. To determine whether this hemilateral hyperalgesia involves the visual system, the discomfort threshold to a light-source that increased in intensity at 100 lux/second from 500 to 3600 lux was investigated for each eye, and the nasal and temporal half of each visual field, in 33 patients with CRPS and 21 pain-free controls. Recent headache history was reviewed and, in patients with CRPS, sensitivity to mechanical and thermal stimuli was assessed in all 4 limbs and on each side of the forehead. In addition, the pupils were photographed in dim and bright light. The visual discomfort threshold was lower in patients than controls and was lower on the CRPS-affected than unaffected side (P < 0.001), indicating photophobia. Visual discomfort was unrelated to pupil diameter. Headache frequency was greater in CRPS patients than controls, and unilateral headaches were more likely to be on the CRPS-affected than contralateral side. Similarly, mechanical and thermal hyperalgesia was greater in the CRPS-affected than contralateral limb and was greater ipsilateral than contralateral to CRPS in the forehead and nonsymptomatic limbs. Ipsilateral photophobia was associated with mechanical and thermal hyperalgesia in the ipsilateral forehead but not the CRPS-affected limb. Together, these findings suggest that aberrant processing of nociceptive input in the ipsilateral trigeminal-medullary region of the brainstem contributes to visual discomfort in CRPS.
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Abstract
Photophobia is one of the most common symptoms in migraine, and the underlying mechanism is uncertain. The discovery of the intrinsically-photosensitive retinal ganglion cells which signal the intensity of light on the retina has led to discussion of their role in the pathogenesis of photophobia. In the current review, we discuss the relationship between pain and discomfort leading to light aversion (traditional photophobia) and discomfort from flicker, patterns, and colour that are also common in migraine and cannot be explained solely by the activity of intrinsically-photosensitive retinal ganglion cells. We argue that, at least in migraine, a cortical mechanism provides a parsimonious explanation for discomfort from all forms of visual stimulation, and that the traditional definition of photophobia as pain in response to light may be too restrictive. Future investigation that directly compares the retinal and cortical contributions to photophobia in migraine with that in other conditions may offer better specificity in identifying biomarkers and possible mechanisms to target for treatment.
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Affiliation(s)
| | - Sarah M Haigh
- Department of Psychology and Integrative Neuroscience, University of Nevada, Reno, USA
| | - Omar A Mahroo
- Institute of Ophthalmology, University College London, London, UK and Retinal Service, Moorfields Eye Hospital, London, UK
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14
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Cortez MM, Millsap L, Rea NA, Sciarretta C, Brennan KC. Photophobia and allodynia in persistent post-traumatic headache are associated with higher disease burden. Cephalalgia 2021; 41:1089-1099. [PMID: 33910382 DOI: 10.1177/03331024211010304] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To assess photophobia and allodynia in subjects with post-traumatic headache and examine how these sensory hypersensitivities associate with clinical measures of disease burden. BACKGROUND Post-traumatic headache is the most frequent and disabling long-term consequence of mild traumatic brain injury. There is evidence of sensory dysfunction in acute post-traumatic headache, and it is known from other headache conditions that sensory amplifications correlate with more severe disease. However, systematic studies in post-traumatic headache are surprisingly scarce. METHODS We tested light and tactile sensitivity, along with measures of disease burden, in 30 persistent post-traumatic headache subjects and 35 controls. RESULTS In all, 79% of post-traumatic headache subjects exhibited sensory hypersensitivity based on psychophysical assessment. Of those exhibiting hypersensitivity, 54% exhibited both light and tactile sensitivity. Finally, sensory thresholds were correlated across modalities, as well as with headache attack frequency. CONCLUSIONS In this study, post-traumatic headache subjects with both light and tactile sensitivity had significantly higher headache frequencies and lower sensitivity thresholds to both modalities, compared to those with single or no sensory hypersensitivity. This pattern suggests that hypersensitivity across multiple modalities may be functionally synergistic, reflect a higher disease burden, and may serve as candidate markers of disease.
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Affiliation(s)
- Melissa M Cortez
- University of Utah, Department of Neurology, Salt Lake City, UT, USA
| | - Leah Millsap
- University of Utah, Department of Neurology, Salt Lake City, UT, USA
| | - Natalie A Rea
- University of Utah, School of Medicine, Salt Lake City, UT, USA.,Mayo Clinic, Rochester, MN, USA
| | | | - K C Brennan
- University of Utah, Department of Neurology, Salt Lake City, UT, USA
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15
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Pinheiro HM, da Costa RM. Pupillary light reflex as a diagnostic aid from computational viewpoint: A systematic literature review. J Biomed Inform 2021; 117:103757. [PMID: 33826949 DOI: 10.1016/j.jbi.2021.103757] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2020] [Revised: 03/12/2021] [Accepted: 03/13/2021] [Indexed: 01/06/2023]
Abstract
This work presents a detailed and complete review of publications on pupillary light reflex (PLR) used to aid diagnoses. These are computational techniques used in the evaluation of pupillometry, as well as their application in computer-aided diagnoses (CAD) of pathologies or physiological conditions that can be studied by observing the movements of miosis and mydriasis of the human pupil. A careful survey was carried out of all studies published over the last 10 years which investigated, electronic devices, recording protocols, image treatment, computational algorithms and the pathologies related to PLR. We present the frontier of existing knowledge regarding methods and techniques used in this field of knowledge, which has been expanding due to the possibility of performing diagnoses with high precision, at a low cost and with a non-invasive method.
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16
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Quantitative Infrared Pupillometry in Nonconvulsive Status Epilepticus. Neurocrit Care 2020; 35:113-120. [PMID: 33215395 DOI: 10.1007/s12028-020-01149-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Accepted: 11/03/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND Nonconvulsive status epilepticus (NCSE) is a frequent disorder in neurocritical care and diagnosing it can be challenging. NCSE patients often show altered pupil function, but nature and extent may vary. Infrared pupillometry allows detection of subtle changes of pupil function. The neurological pupil index (NPi) is considered a surrogate marker of global pupil function which is supposed to be independent of absolute parameters such as the pupil diameter. OBJECTIVE Cross-sectional observational study to assess whether NPi is altered in NCSE. METHODS 128 consecutive adult emergency patients who had experienced a suspected seizure, have not reached their prior functional level regarding level of consciousness, mental status or focal deficits, had no obvious clinical signs of status epilepticus and had an EEG indication as determined by the treating clinician for exclusion of NCSE were examined by routine EEG and pupillometry. Exclusion criteria were ocular comorbidity (n = 21) and poor EEG quality (n = 4). Pupillometry was performed once directly before the beginning of EEG recording. NCSE diagnosis (no NCSE, possible NCSE and confirmed NCSE) was established according to Salzburg consensus criteria blinded to pupillometry results. Group comparison was performed for right NPi, left NPi, lowest NPi of both sides (minNPi) and the absolute difference of both sides (diffNPi) applying non-parametric testing. In post-hoc analysis, receiver operating characteristics (ROC) of NCSE diagnosis (combined confirmed NCSE and possible NCSE) were performed for minNPi and diffNPi. RESULTS From 103 patients included in the final analysis, 5 (4.9%) had confirmed NCSE, 7 (6.8%) had possible NCSE. Right NPi (p = 0.002), left NPi (p < 0.001) and minNPi (p < 0.001) were significantly lower in "confirmed NCSE" and "possible NCSE" compared to "no NCSE"; diffNPi was significantly higher in "confirmed NCSE" and "possible NCSE" compared to "no NCSE" (p < 0.001). There was no significant difference of minNPi and diffNPi between "confirmed NCSE" and "possible NCSE". ROC analysis showed an optimal cut-off of minNPi for NCSE diagnosis of 4.0 (AUC = 0.93, 95% CI 0.86-0.99). Optimal ROC analysis cut-off of diffNPi for NCSE diagnosis was 0.2 (AUC = 0.89, 95% CI 0.80-0.99). CONCLUSIONS NPi was significantly reduced and the difference between left and right NPi was significantly higher in confirmed NCSE. An NPi < 4.0 on either side as well as an NPi difference of both sides > 0.2 may be potential indicators of NCSE. Infrared pupillometry may be a helpful diagnostic tool in the assessment of NCSE and should be studied further in larger populations.
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17
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Cortez MM, Millsap L, Brennan KC. Synergistic but separable sensory changes in postural tachycardia syndrome and chronic migraine. Clin Auton Res 2020; 31:263-271. [PMID: 33174112 DOI: 10.1007/s10286-020-00740-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Accepted: 10/23/2020] [Indexed: 11/29/2022]
Abstract
PURPOSE Up to 90% of patients with postural tachycardia syndrome (PoTS) report headaches, and comorbid migraine headaches are common. Given this, pathophysiological interaction is possible, which may reveal key aspects of disease expression and treatment opportunities. We hypothesized that PoTS subjects-both with and without migraine-would show features of central sensitization, including allodynia and photophobia. METHODS Eighty participants were evaluated, including 30 PoTS, 30 chronic migraine (CM), and 20 non-headache healthy controls (NH), using tilt table testing, psychophysical assessment of sensory sensitivity thresholds, and an online questionnaire to assess measures of headache burden and associated symptoms. Clinical characteristics and sensory thresholds were compared between disease groups and controls, as well as in a subgroup analysis within the PoTS group, based on headache phenotype. RESULTS Sensory sensitivity thresholds were significantly lower and symptom scores were higher in both the PoTS and CM groups compared to controls. However, the patterns of expression differed between PoTS and CM, with pain threshold reductions in the forearm only of PoTS subjects (non-trigeminal sensory sensitization), compared to both periorbital and forearm sites in CM. Unexpectedly, light sensitivity thresholds were significantly lower in PoTS than in both CM and NH. CONCLUSIONS These findings reveal an underappreciated aspect of disease burden in PoTS, and suggest network sensitization similar to, but separable from, that of migraine. The presence of both photophobia and allodynia in PoTS is reflective of exteroceptive rather than strictly interoceptive disruption, and expands our fundamental understanding of the disorder.
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Affiliation(s)
- Melissa M Cortez
- Department of Neurology, University of Utah, 729 Arapeen Drive, Salt Lake City, UT, 84108, USA.
| | - Leah Millsap
- School of Medicine, University of Utah, Salt Lake City, UT, USA
| | - K C Brennan
- Department of Neurology, University of Utah, 729 Arapeen Drive, Salt Lake City, UT, 84108, USA
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18
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Investigation of light-induced lacrimation and pupillary responses in episodic migraine. PLoS One 2020; 15:e0241490. [PMID: 33125423 PMCID: PMC7598498 DOI: 10.1371/journal.pone.0241490] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Accepted: 10/15/2020] [Indexed: 12/17/2022] Open
Abstract
The purpose of this pilot study was to investigate the light-induced pupillary and lacrimation responses mediated by intrinsically photosensitive retinal ganglion cells (ipRGCs) in migraine. Ten participants with episodic migraine and normal tear production, as well as eleven visually normal controls participated in this study. Following an initial baseline trial (no light flash), participants received seven incremental and alternating red and blue light flashes. Pupillometry recording of the left eye and a 1-min anesthetized Schirmer’s test of the right eye (using 0.5% proparacaine) were performed simultaneously. Intrinsic and extrinsic ipRGC photoactivities did not differ between migraine participants and controls across all intensities and wavelengths. Migraine participants, however, had significantly lower lacrimation than controls following the highest blue intensity. A positive correlation was found between melanopsin-driven post-illumination pupillary responses and lacrimation following blue stimulation in both groups. Our results show that participants with self-reported photophobia have normal ipRGC-driven responses, suggesting that photophobia and pupillary function may be mediated by distinct ipRGC circuits. The positive correlation between melanopsin-driven pupillary responses and light-induced lacrimation suggests the afferent arm of the light-induced lacrimation reflex is melanopsin-mediated and functions normally in migraine. Lastly, the reduced melanopsin-mediated lacrimation at the highest stimulus suggests the efferent arm of the lacrimation reflex is attenuated under certain conditions, which may be a harbinger of dry eye in migraine.
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19
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Zele AJ, Dey A, Adhikari P, Feigl B. Melanopsin hypersensitivity dominates interictal photophobia in migraine. Cephalalgia 2020; 41:217-226. [PMID: 33040593 DOI: 10.1177/0333102420963850] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
PURPOSE To define the melanopsin and cone luminance retinogeniculate pathway contributions to photophobia in healthy controls and migraineurs. METHODS Healthy controls and migraineurs were categorized according to the International Classification of Headache Disorders criteria. Photophobia was measured under full-field illumination using electromyography in response to narrowband lights spanning the melanopsin and cone luminance action spectra. Migraineurs were tested during their interictal headache-free period. Melanopsin-mediated post-illumination pupil responses quantified intrinsically photosensitive Retinal Ganglion Cell (ipRGC) function. RESULTS A model combining the melanopsin and cone luminance action spectra best described photophobia thresholds in controls and migraineurs; melanopsin contributions were ∼1.5× greater than cone luminance. In the illumination range causing photophobia, migraineurs had lower photophobia thresholds (∼0.55 log units; p < 0.001) and higher post-illumination pupil response amplitudes (p = 0.03) than controls. CONCLUSION Photophobia is driven by melanopsin and cone luminance inputs to the cortex via the retino-thalamocortical pathway. In migraineurs, lower photophobia thresholds reflect hypersensitivity of ipRGC and cone luminance pathways, with the larger and prolonged post-illumination pupil response amplitude indicative of a supranormal melanopsin response. Our findings inform artificial lighting strategies incorporating luminaires with low melanopsin excitation and photopic luminance to limit the lighting conditions leading to photophobia.
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Affiliation(s)
- Andrew J Zele
- Centre for Vision and Eye Research, Institute of Health and Biomedical Innovation, Queensland University of Technology (QUT), Brisbane, Queensland, Australia.,School of Optometry and Vision Science, Queensland University of Technology (QUT), Brisbane, Queensland, Australia
| | - Ashim Dey
- Centre for Vision and Eye Research, Institute of Health and Biomedical Innovation, Queensland University of Technology (QUT), Brisbane, Queensland, Australia.,School of Biomedical Sciences, Queensland University of Technology (QUT), Brisbane, Australia
| | - Prakash Adhikari
- Centre for Vision and Eye Research, Institute of Health and Biomedical Innovation, Queensland University of Technology (QUT), Brisbane, Queensland, Australia.,School of Optometry and Vision Science, Queensland University of Technology (QUT), Brisbane, Queensland, Australia
| | - Beatrix Feigl
- Centre for Vision and Eye Research, Institute of Health and Biomedical Innovation, Queensland University of Technology (QUT), Brisbane, Queensland, Australia.,School of Biomedical Sciences, Queensland University of Technology (QUT), Brisbane, Australia.,Queensland Eye Institute, Brisbane, Queensland, Australia
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20
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Yoo YJ, Yang HK, Choi JY, Kim JS, Hwang JM. Neuro-ophthalmologic Findings in Visual Snow Syndrome. J Clin Neurol 2020; 16:646-652. [PMID: 33029971 PMCID: PMC7541978 DOI: 10.3988/jcn.2020.16.4.646] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Revised: 07/08/2020] [Accepted: 07/08/2020] [Indexed: 12/16/2022] Open
Abstract
Background and Purpose The findings of ophthalmic examinations have not been systematically investigated in visual snow syndrome. This study reviewed the abnormal neuro-ophthalmologic findings in a patient cohort with symptoms of visual snow syndrome. Methods We retrospectively reviewed 28 patients who were referred for symptoms of visual snow to a tertiary referral hospital from November 2016 to October 2019. We defined the findings of best corrected visual acuity (BCVA), visual field testing, pupillary light reflex, contrast sensitivity, full-field and multifocal electroretinography, and optical coherence tomography. Results Twenty patients (71%) were finally diagnosed as visual snow syndrome. Their additional visual symptoms included illusionary palinopsia (61%), enhanced entoptic phenomenon (65%), disturbance of night vision (44%), and photophobia (65%). A history of migraine was identified in ten patients (50%). The mean BCVA was less than 0.1 logarithm of the minimum angle of resolution, and electrophysiology showed normal retinal function in all patients. Contrast sensitivity was decreased in two of the seven patients tested. Medical treatment was applied to five patients which all turned out to be ineffective. Among the eight patients who were excluded, one was diagnosed with rod-cone dystrophy and another with idiopathic intracranial hypertension. Conclusions Neuro-ophthalmologic findings are mostly normal in patients with visual snow syndrome. Retinal or neurological diseases must be excluded as possible causes of visual snow.
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Affiliation(s)
- Yung Ju Yoo
- Department of Ophthalmology, Kangwon National University Graduate School of Medicine, Kangwon National University Hospital, Chuncheon, Korea
| | - Hee Kyung Yang
- Department of Ophthalmology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Jeong Yoon Choi
- Department of Neurology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Ji Soo Kim
- Department of Neurology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Jeong Min Hwang
- Department of Ophthalmology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Korea.
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21
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Time Course of Autonomic Symptoms in Postural Orthostatic Tachycardia Syndrome (POTS) Patients: Two-Year Follow-Up Results. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17165872. [PMID: 32823577 PMCID: PMC7460485 DOI: 10.3390/ijerph17165872] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Revised: 08/07/2020] [Accepted: 08/11/2020] [Indexed: 11/16/2022]
Abstract
Postural orthostatic tachycardia syndrome (POTS) is a multifactorial condition capable of chronically reducing the quality of life and the work ability of patients. The study aim was to assess the burden of autonomic symptoms in a cohort of POTS patients over 2 years. Patients’ clinical profiles were assessed by the 31-item Composite Autonomic Symptom Score questionnaire (COMPASS 31) and a visual analog scale (VAS). One-way ANOVA for repeated measures followed by Dunnett’s post-hoc test were used to compare symptoms at baseline and at 1 and 2 years. Out of 42 enrolled patients, 25 had a 1-year follow-up and 12 had a 2-year follow-up. At baseline, the reported burden of autonomic symptoms was high (overall COMPASS 31 = 49.9 ± 14.3 /100). Main complaints were related to orthostatic intolerance according to both COMPASS 31 and VAS. Fourteen patients were rendered inactive because of symptoms. At 1-year follow-up, a statistically significant improvement in pupillomotor function and overall score was detected by the COMPASS 31. These findings were confirmed at 2 years, together with a significant reduction in quality of life impairment, assessed by VAS. However, these improvements did not change patients’ occupational status. Awareness of POTS diagnosis, patient monitoring, and tailored therapies can help to improve patients’ condition.
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22
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McAdams H, Kaiser EA, Igdalova A, Haggerty EB, Cucchiara B, Brainard DH, Aguirre GK. Selective amplification of ipRGC signals accounts for interictal photophobia in migraine. Proc Natl Acad Sci U S A 2020; 117:17320-17329. [PMID: 32632006 PMCID: PMC7382295 DOI: 10.1073/pnas.2007402117] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
Second only to headache, photophobia is the most debilitating symptom reported by people with migraine. While the melanopsin-containing intrinsically photosensitive retinal ganglion cells (ipRGCs) are thought to play a role, how cone and melanopsin signals are integrated in this pathway to produce visual discomfort is poorly understood. We studied 60 people: 20 without headache and 20 each with interictal photophobia from migraine with or without visual aura. Participants viewed pulses of spectral change that selectively targeted melanopsin, the cones, or both and rated the degree of visual discomfort produced by these stimuli while we recorded pupil responses. We examined the data within a model that describes how cone and melanopsin signals are weighted and combined at the level of the retina and how this combined signal is transformed into a rating of discomfort or pupil response. Our results indicate that people with migraine do not differ from headache-free controls in the manner in which melanopsin and cone signals are combined. Instead, people with migraine demonstrate an enhanced response to integrated ipRGC signals for discomfort. This effect of migraine is selective for ratings of visual discomfort, in that an enhancement of pupil responses was not seen in the migraine group, nor were group differences found in surveys of other behaviors putatively linked to ipRGC function (chronotype, seasonal sensitivity, presence of a photic sneeze reflex). By revealing a dissociation in the amplification of discomfort vs. pupil response, our findings suggest a postretinal alteration in processing of ipRGC signals for photophobia in migraine.
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Affiliation(s)
- Harrison McAdams
- Department of Neuroscience, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104
| | - Eric A Kaiser
- Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104
| | - Aleksandra Igdalova
- Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104
| | - Edda B Haggerty
- Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104
| | - Brett Cucchiara
- Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104
| | - David H Brainard
- Department of Psychology, University of Pennsylvania, Philadelphia, PA 19104
| | - Geoffrey K Aguirre
- Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104;
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23
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Abstract
OBJECTIVE To review clinical and pre-clinical evidence supporting the role of visual pathways, from the eye to the cortex, in the development of photophobia in headache disorders. BACKGROUND Photophobia is a poorly understood light-induced phenomenon that emerges in a variety of neurological and ophthalmological conditions. Over the years, multiple mechanisms have been proposed to explain its causes; however, scarce research and lack of systematic assessment of photophobia in patients has made the search for answers quite challenging. In the field of headaches, significant progress has been made recently on how specific visual networks contribute to photophobia features such as light-induced intensification of headache, increased perception of brightness and visual discomfort, which are frequently experienced by migraineurs. Such progress improved our understanding of the phenomenon and points to abnormal processing of light by both cone/rod-mediated image-forming and melanopsin-mediated non-image-forming visual pathways, and the consequential transfer of photic signals to multiple brain regions involved in sensory, autonomic and emotional regulation. CONCLUSION Photophobia phenotype is diverse, and the relative contribution of visual, trigeminal and autonomic systems may depend on the disease it emerges from. In migraine, photophobia could result from photic activation of retina-driven pathways involved in the regulation of homeostasis, making its association with headache more complex than previously thought.
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Affiliation(s)
- Rodrigo Noseda
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - David Copenhagen
- Department of Ophthalmology, UCSF School of Medicine, San Francisco, CA, USA
| | - Rami Burstein
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
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24
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Abstract
Migraine has long been associated with disturbances of vision, especially migraine with aura. However, the eye plays an important role in sensory processing as well. We have found that the visual quality of life is reduced in migraine. In this review, we discuss how the migraine and eye pain pathways are similar and affect many of the common complaints which are seen in ophthalmology and neuro-ophthalmology offices, such as dry eye and postoperative eye pain. We also review other related phenomena, including visual snow and photophobia, which also are related to altered sensory processing in migraine.
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25
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Cortez MM, Digre K, Uddin D, Hung M, Blitzer A, Bounsanga J, Voss MW, Katz BJ. Validation of a photophobia symptom impact scale. Cephalalgia 2019; 39:1445-1454. [PMID: 31116567 DOI: 10.1177/0333102419845641] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
BACKGROUND Routine assessment of photophobia in the clinical setting may underestimate the presence and severity of this condition. We aimed to develop and validate a questionnaire to improve evaluation of the impact of photophobia on activities of daily living, and to determine the relationship of this questionnaire to psychophysical assessment of light sensitivity thresholds. METHODS We developed the 17-item Utah Photophobia Symptom Impact Scale (UPSIS-17) and compared its psychometric properties to the 8-item Korean Photophobia Questionnaire (KUMC-8). Ninety five subjects with or without light sensitivity completed both questionnaires; 72 also completed laboratory-based assessment of light sensitivity thresholds. We used Rasch analysis to evaluate instrument targeting, including internal consistency and reliability. Correlation analysis was used to assess the relationship between questionnaire scores and light sensitivity thresholds. RESULTS We observed correlation between UPSIS-17 and KUMC-8, r = 0.72 (p < 0.0001). Higher UPSIS-17 scores correlated with light sensitivity thresholds, r = -0.42 (p < 0.0001), whereas KUMC-8 scores did not significantly correlate with light sensitivity thresholds, r = -0.21 (p = 0.072). UPSIS-17 showed better instrument targeting than KUMC-8 on Rasch analysis. Person-item maps allowed for identification of questions that could be removed without affecting questionnaire validity measures. CONCLUSION This study resulted in a shortened, 12-item questionnaire. The UPSIS-12 retained significant correlation with both the KUMC-8 and light sensitivity thresholds, yielding a simpler tool for symptom assessment, while retaining validity. This expanded tool may be useful in clinical, as well as research settings, for collection of data about disability due to photophobia.
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Affiliation(s)
- Melissa M Cortez
- University of Utah, Department of Neurology, Salt Lake City, UT, USA
| | - Kathleen Digre
- University of Utah, Department of Ophthalmology and Visual Sciences, Salt Lake City, UT, USA
| | - Durin Uddin
- University of Utah, Department of Ophthalmology and Visual Sciences, Salt Lake City, UT, USA.,University of Nevada, Reno School of Medicine, Reno, NV, USA
| | - Man Hung
- Roseman University of Health Sciences, College of Dental Medicine, South Jordan, UT, USA.,University of Utah, Department of Orthopaedic Surgery Operations, Salt Lake City, UT, USA.,University of Utah, Population Health Research Foundation, Study Design and Biostatistics Center, Salt Lake City, UT, USA.,University of Utah, Department of Family and Preventive Medicine, Salt Lake City, UT, USA
| | - Andrea Blitzer
- University of Utah, Department of Ophthalmology and Visual Sciences, Salt Lake City, UT, USA
| | - Jerry Bounsanga
- University of Utah, Department of Orthopaedic Surgery Operations, Salt Lake City, UT, USA
| | - Maren W Voss
- University of Utah, Department of Orthopaedic Surgery Operations, Salt Lake City, UT, USA
| | - Bradley J Katz
- University of Utah, Department of Neurology, Salt Lake City, UT, USA.,University of Utah, Department of Ophthalmology and Visual Sciences, Salt Lake City, UT, USA
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26
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Cortez MM, Rae N, Millsap L, McKean N, Brennan KC. Pupil Cycle Time Distinguishes Migraineurs From Subjects Without Headache. Front Neurol 2019; 10:478. [PMID: 31139137 PMCID: PMC6518457 DOI: 10.3389/fneur.2019.00478] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Accepted: 04/23/2019] [Indexed: 01/03/2023] Open
Abstract
Migraine is a neurological disorder characterized by paroxysms of head pain accompanied by trigeminovascular system activation and autonomic dysfunction. Diagnosis is currently based on clinical diagnostic criteria. Though physiological differences exist between migraineurs and non-headache controls, true physiological biomarkers have been elusive, especially for the full clinical spectrum of migraine, inclusive of chronic, episodic, and probable migraine. We used edge-light pupil cycle time (PCT) as a probe of the pupillary light circuit in migraine, paired with clinical assessment of migraine characteristics, and compared these to non-headache controls. We found significantly increased PCT in probable, episodic, and chronic migraine, compared to controls. Additionally, increased PCT correlated with the presence of craniofacial autonomic symptoms, linking pupillary circuit dysfunction to peripheral trigeminal sensitization. The sensitivity of PCT, especially for all severities of disease, distinguishes it from other physiological phenotypes, which may make it useful as a potential biomarker.
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Affiliation(s)
- Melissa M Cortez
- Department of Neurology, University of Utah, Salt Lake City, UT, United States
| | - Natalie Rae
- School of Medicine, University of Utah, Salt Lake City, UT, United States
| | - Leah Millsap
- Department of Neurology, University of Utah, Salt Lake City, UT, United States
| | - Nick McKean
- Department of Neurology, University of Utah, Salt Lake City, UT, United States
| | - K C Brennan
- Department of Neurology, University of Utah, Salt Lake City, UT, United States
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27
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Migraine: The Disease of the Year. J Neuroophthalmol 2019; 39:1-2. [DOI: 10.1097/wno.0000000000000769] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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28
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La Morgia C, Carelli V, Carbonelli M. Melanopsin Retinal Ganglion Cells and Pupil: Clinical Implications for Neuro-Ophthalmology. Front Neurol 2018; 9:1047. [PMID: 30581410 PMCID: PMC6292931 DOI: 10.3389/fneur.2018.01047] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2018] [Accepted: 11/19/2018] [Indexed: 02/02/2023] Open
Abstract
Melanopsin retinal ganglion cells (mRGCs) are intrinsically photosensitive RGCs that mediate many relevant non-image forming functions of the eye, including the pupillary light reflex, through the projections to the olivary pretectal nucleus. In particular, the post-illumination pupil response (PIPR), as evaluated by chromatic pupillometry, can be used as a reliable marker of mRGC function in vivo. In the last years, pupillometry has become a promising tool to assess mRGC dysfunction in various neurological and neuro-ophthalmological conditions. In this review we will present the most relevant findings of pupillometric studies in glaucoma, hereditary optic neuropathies, ischemic optic neuropathies, idiopathic intracranial hypertension, multiple sclerosis, Parkinson's disease, and mood disorders. The use of PIPR as a marker for mRGC function is also proposed for other neurodegenerative disorders in which circadian dysfunction is documented.
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Affiliation(s)
- Chiara La Morgia
- Unità Operativa Complessa Clinica Neurologica, IRCCS Istituto delle Scienze Neurologiche di Bologna, Ospedale Bellaria, Bologna, Italy.,Dipartimento di Scienze Biomediche e Neuromotorie, Università di Bologna, Bologna, Italy
| | - Valerio Carelli
- Unità Operativa Complessa Clinica Neurologica, IRCCS Istituto delle Scienze Neurologiche di Bologna, Ospedale Bellaria, Bologna, Italy.,Dipartimento di Scienze Biomediche e Neuromotorie, Università di Bologna, Bologna, Italy
| | - Michele Carbonelli
- Unità Operativa Complessa Clinica Neurologica, IRCCS Istituto delle Scienze Neurologiche di Bologna, Ospedale Bellaria, Bologna, Italy
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Aguilar MC, Gonzalez A, Rowaan C, de Freitas C, Alawa KA, Durkee H, Feuer WJ, Manns F, Asfour SS, Lam BL, Parel JMA. Automated instrument designed to determine visual photosensitivity thresholds. BIOMEDICAL OPTICS EXPRESS 2018; 9:5583-5596. [PMID: 30460148 PMCID: PMC6238927 DOI: 10.1364/boe.9.005583] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/07/2018] [Revised: 10/01/2018] [Accepted: 10/02/2018] [Indexed: 06/09/2023]
Abstract
The Ocular Photosensitivity Analyzer (OPA), a new automated instrument to quantify the visual photosensitivity thresholds (VPT) in healthy and light sensitive subjects, is described. The OPA generates light stimuli of varying intensities utilizing unequal ascending and descending steps to yield the VPT. The performance of the OPA was evaluated in healthy subjects, as well as light sensitive subjects with achromatopsia or traumatic brain injury (TBI). VPT in healthy, achromatopsia, and TBI subjects were 3.2 ± 0.6 log lux, 0.5 ± 0.5 log lux, and 0.4 ± 0.6 log lux, respectively. Light sensitive subjects manifested significantly lower VPT compared to healthy subjects. Longitudinal analysis revealed that the OPA reliably measured VPT in healthy subjects.
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Affiliation(s)
- Mariela C. Aguilar
- Ophthalmic Biophysics Center, Bascom Palmer Eye Institute, Department of Ophthalmology, University of Miami Miller School of Medicine, Miami, FL, USA
- Department of Industrial Engineering, College of Engineering, University of Miami, Coral Gables, FL, USA
| | - Alex Gonzalez
- Ophthalmic Biophysics Center, Bascom Palmer Eye Institute, Department of Ophthalmology, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Cornelis Rowaan
- Ophthalmic Biophysics Center, Bascom Palmer Eye Institute, Department of Ophthalmology, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Carolina de Freitas
- Ophthalmic Biophysics Center, Bascom Palmer Eye Institute, Department of Ophthalmology, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Karam A. Alawa
- Ophthalmic Biophysics Center, Bascom Palmer Eye Institute, Department of Ophthalmology, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Heather Durkee
- Ophthalmic Biophysics Center, Bascom Palmer Eye Institute, Department of Ophthalmology, University of Miami Miller School of Medicine, Miami, FL, USA
- Department of Biomedical Engineering, College of Engineering, University of Miami, Coral Gables, FL, USA
| | - William J. Feuer
- Anne Bates Leach Eye Center, Bascom Palmer Eye Institute, Department of Ophthalmology, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Fabrice Manns
- Ophthalmic Biophysics Center, Bascom Palmer Eye Institute, Department of Ophthalmology, University of Miami Miller School of Medicine, Miami, FL, USA
- Department of Biomedical Engineering, College of Engineering, University of Miami, Coral Gables, FL, USA
| | - Shihab S. Asfour
- Department of Industrial Engineering, College of Engineering, University of Miami, Coral Gables, FL, USA
| | - Byron L. Lam
- Anne Bates Leach Eye Center, Bascom Palmer Eye Institute, Department of Ophthalmology, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Jean-Marie A. Parel
- Ophthalmic Biophysics Center, Bascom Palmer Eye Institute, Department of Ophthalmology, University of Miami Miller School of Medicine, Miami, FL, USA
- Department of Biomedical Engineering, College of Engineering, University of Miami, Coral Gables, FL, USA
- Brien Holden Vision Institute, University of New South Wales, Sydney, Australia
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McAdams H, Igdalova A, Spitschan M, Brainard DH, Aguirre GK. Pulses of Melanopsin-Directed Contrast Produce Highly Reproducible Pupil Responses That Are Insensitive to a Change in Background Radiance. Invest Ophthalmol Vis Sci 2018; 59:5615-5626. [PMID: 30481278 PMCID: PMC6262648 DOI: 10.1167/iovs.18-25219] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2018] [Accepted: 10/04/2018] [Indexed: 12/22/2022] Open
Abstract
Purpose To measure the pupil response to pulses of melanopsin-directed contrast, and compare this response to those evoked by cone-directed contrast and spectrally narrowband stimuli. Methods Three-second unipolar pulses were used to elicit pupil responses in human subjects across three sessions. Thirty subjects were studied in session 1, and most returned for sessions 2 and 3. The stimuli of primary interest were "silent substitution" cone- and melanopsin-directed modulations. Red and blue narrowband pulses delivered using the post-illumination pupil response (PIPR) paradigm were also studied. Sessions 1 and 2 were identical, whereas session 3 involved modulations around higher radiance backgrounds. The pupil responses were fit by a model whose parameters described response amplitude and temporal shape. Results Group average pupil responses for all stimuli overlapped extensively across sessions 1 and 2, indicating high reproducibility. Model fits indicate that the response to melanopsin-directed contrast is prolonged relative to that elicited by cone-directed contrast. The group average cone- and melanopsin-directed pupil responses from session 3 were highly similar to those from sessions 1 and 2, suggesting that these responses are insensitive to background radiance over the range studied. The increase in radiance enhanced persistent pupil constriction to blue light. Conclusions The group average pupil response to stimuli designed through silent substitution provides a reliable probe of the function of a melanopsin-mediated system in humans. As disruption of the melanopsin system may relate to clinical pathology, the reproducibility of response suggests that silent substitution pupillometry can test if melanopsin signals differ between clinical groups.
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Affiliation(s)
- Harrison McAdams
- Department of Neurology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, United States
| | - Aleksandra Igdalova
- Department of Neurology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, United States
| | - Manuel Spitschan
- Department of Experimental Psychology, University of Oxford, Oxford, United Kingdom
| | - David H. Brainard
- Department of Psychology, University of Pennsylvania, Philadelphia, Pennsylvania, United States
| | - Geoffrey K. Aguirre
- Department of Neurology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, United States
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Affiliation(s)
- Parisa Gazerani
- Department of Health Science and Technology, Faculty of Medicine, Aalborg University, Aalborg, Denmark
| | - Brian Edwin Cairns
- Department of Health Science and Technology, Faculty of Medicine, Aalborg University, Aalborg, Denmark
- Faculty of Pharmaceutical Sciences, The University of British Columbia, Vancouver, BC, Canada
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