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What Facts Should I Know About Visual Migraines (Ocular Migraines)?
Migraine headache is one of the most common complaints in medicine today. Migraine headaches usually involve one side of the head. Various early symptoms may occur before a typical migraine episode. Other symptoms, together known as an aura, may also occur before a migraine headache, or they may begin when the headache starts.
- In children younger than 10 years, boys appear to have migraines more often than girls. After puberty starts, migraine headaches are much more common in females.
- In general, the rate of migraine occurrence in males drops to a low by age 28-29.
- For females, the rate of migraine occurrence with aura peaks at age 12-13 years (3-4 years before that of migraine without aura).
- Migraine occurrence among females increases sharply up to age 40 years and then declines gradually. The male peak rate is slightly less and decreases over a broader age range.
- The age when migraine headache with aura begins appears to peak at or before age 4-5 years, while the highest rate for migraine without aura occurs at age 10-11 years.
- Data suggests that migraine is a chronic (long-term) condition, although long remissions (illness-free periods) are common.
- The severity and frequency of attacks tend to lessen with age.
What Do Visual Migraines (Ocular Migraines) Look Like?
See images (right).
What Causes Visual Migraines (Ocular Migraines)?
Nobody knows for sure how migraines are caused, although many contributing factors have been identified.
- Family history
- Too much or too little sleep
- Medications -- vasodilators (drugs that make blood vessels widen), oral contraceptives (birth control pills)
- Foods and food additives -- alcohol, caffeine, chocolate, artificial sweeteners (aspartame, saccharin), monosodium glutamate (MSG), citrus fruits, meats with nitrites, salt
- Foods containing tyramines -- aged cheese, yogurt, sour cream, chicken livers, sausages, bananas, avocados, canned figs, raisins, peanuts, soy sauce, pickled fish, freshly baked bread, pork, vinegar, beans
- Exposure to bright or fluorescent lighting
- Strong odors -- perfumes, colognes, petroleum-based products
- Hormonal changes -- menstruation (common association), pregnancy, ovulation
- Head trauma
- Weather changes
- Metabolic or infectious diseases
- Physical exertion or fatigue
- Motion sickness
- Cold stimulus (eating ice cream)
What Are the Symptoms of Visual Migraines (Ocular Migraines)?
Migraine headaches typically occur on one side of the head and cause throbbing pain, but the features often vary. Migraineurs (people who get migraine headaches) often experience a bilateral event, meaning that the pain can be felt anywhere around the head or neck.
A majority of migraineurs experience early symptoms. Forewarning of a migraine may occur hours to days before a headache event. Although the specific symptoms vary, they tend to remain the same for a given individual over time. These warning symptoms may include the following:
- Photophobia, phonophobia, osmophobia (sensitivity to light, sound, and/or smells, respectively)
- Lethargy (weariness, fatigue, lack of energy)
- Mental and mood changes -- depression, anger, joy
- Polyuria (urinating often and in large amounts)
- Soreness and stiffness of neck muscles
- Anorexia (diminished appetite, aversion to food)
- Constipation or diarrhea
Some migraineurs experience aura. Aura is defined as focused symptoms that grow over 5-15 minutes and generally last about an hour. In most cases, the migraine headache follows the aura. However, the two events can happen at the same time, or the aura may develop after the headache starts. With aura, visual symptoms are most common and include the following:
- Negative scotomata (blurred or absent areas in the vision field), tunnel vision, or even complete blindness
- Positive visual problems, the most common of which consists of an absent arc or band of vision with a shimmering or glittering zigzag border: This is often combined with photopsia (a sensation of lights, sparks, or colors due to electrical or mechanical stimulation of the ocular [eye] system) or visual hallucinations that may take various shapes. This is a highly characteristic syndrome that always occurs before the headache phase of an attack and is specific to a diagnosis of classic migraine. It is called a "fortification spectrum" because the jagged edges of the hallucinated arc resemble a fortified town with bastions around it.
- Photopsia (uniform flashes of light) or simple forms of visual hallucinations that occur commonly with positive visual phenomena
Motor symptoms like hemiparesis (weakness on one side of the body) and aphasia (poor or absent understanding and/or production of speech, writing, or signs) may occur but much less frequently.
Some people have auras only, without headaches. Treatment is usually unnecessary once the diagnosis is recognized and the migraineur reassured about it. If the aura always occurs on the same side, the risk of a brain tumor or other abnormality is greater than in persons with routine headaches.
Typical headache characteristics are as follows:
- On one side of the head in a majority of migraineurs
- Slow onset (lasting 4-72 hours)
- Described as throbbing or pulsing pain but can evolve into a continuous ache or bandlike pattern
Physical examination findings
Upon examination, the doctor may discover the following:
- Head/neck muscle tenderness
- Horner syndrome (a syndrome characterized by contraction of the pupil and drooping of the eyelid and occurring on the same side as the headache)
- Conjunctival injection (bloodshot or red eyes)
- A heart rate that is too fast or too slow
- Blood pressure that is too high or too low
- Hemisensory (loss of feeling on one side of the body) or hemiparetic (weakness affecting one side of the body) deficits
The following physical examination findings are considered particularly worrisome, suggesting that the problem is not migraine but a potentially more serious condition:
- Dim scotoma (blurred or absent areas in the visual field) lasting a few seconds to several minutes
- Tenderness of the arteries in the temple (in elderly persons)
- Meningismus (pain caused by irritation of the layers [meninges] surrounding the brain and spinal cord)
- Increased lethargy (unrelated to medication use)
- Mental status changes
- High blood pressure
What Are the Exams and Tests to Diagnose Visual Migraines?
In older persons, the doctor may order specific laboratory studies in order to rule out physical causes like giant cell arteritis (an inflammation or infection involving certain arteries in the head and neck), brain tumor, meningitis, or brain hemorrhage. Other causes should be ruled out using appropriate laboratory and/or radiographic (X-ray) tests.
Visual-field testing should be done for those who have lasting visual problems.
A lumbar puncture (spinal tap) may be done to rule out infection, inflammation, elevated pressure in the head, or bleeding in the membranes covering the brain. When appropriate, the doctor may look inside arteries of the head and neck with a tiny camera, a procedure called endoscopy.
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What Are Home Remedies for Visual Migraines?
What Is the Medical Treatment for Visual Migraines?
After making the diagnosis, the doctor should provide counseling about treatments that do not include taking drugs, for example, regular rest, good sleep habits, and exercise. The doctor may ask neurologists, neuro-ophthalmologists, and/or neurosurgeons for their opinions and help.
Migraineurs should avoid potential triggering factors.
- They may need to stop taking drugs that worsen the headache.
- If oral contraceptives (birth control pills) or hormone replacement therapy might be a potential trigger mechanism, it is best to reduce dosages (if possible). If headaches persist, the migraineur, in consultation with the doctor, should consider stopping hormone therapy.
What Medications Treat Visual Migraines?
Drug therapy is mainly aimed at lessening pain during the early and generally most painful phases of migraine headaches. Those who have repeated migraine episodes may need long-term preventive therapy. The following drugs are used to quickly stop migraine headaches in progress. They are often called abortive drugs because they abort, or stop, the headache. These drugs are used only to treat headaches and do not help relieve problems like back pain, arthritis, or menstrual cramps. The first group of drugs is within the triptan class. Drugs in this class are all very similar in their action and chemical structure and target the brain's chemical serotonin. If 2-3 of these drugs have been tried without success, it is unlikely that others within the class will help.
- Sumatriptan (Imitrex, Imigran)
- Zolmitriptan (Zomig, Zomig-ZMT)
- Naratriptan (Amerge, Naramig)
- Rizatriptan (Maxalt, Maxalt-MLT)
- Almotriptan (Axert)
- Frovatriptan (Frova)
- Eletriptan (Relpax)
The following abortive drugs are also used only for headaches. Though they act on serotonin, they also act on other brain chemicals, including norepinephrine and dopamine. Sometimes, one of these drugs will be effective if the triptans fail.
- Ergotamine tartrate (Cafergot)
- Acetaminophen-isometheptene-dichloralphenazone (Midrin)
- Dihydroergotamine (D.H.E. 45 Injection, Migranal Nasal Spray)
The following drugs are not really for headaches; they are for nausea that often accompanies headaches. They occasionally have an abortive or preventive effect against migraine, however.
The following are nonspecific painkillers of the narcotic class. Rarely, they have a strong abortive effect. Because of their habit-forming risk, they should generally be held in reserve as a backup to a specific abortive treatment.
- Butalbital-acetaminophen-caffeine (Fioricet)
- Butalbital-aspirin-caffeine (Fiorinal)
- Acetaminophen with codeine (Tylenol With Codeine)
- Hydrocodone (Vicodin)
- Oxycodone (OxyContin)
- Morphine (MS Contin)
- Meperidine (Demerol)
The following agents are nonsteroidal anti-inflammatory drugs (NSAIDs). They are meant for many types of pain, but they are sometimes very effective for migraine headaches and may occasionally provide preventive benefits.
- Ibuprofen (Ibuprin, Advil, Motrin)
- Naproxen (Anaprox, Naprelan, Naprosyn)
- Ketorolac (Toradol)
- Aspirin (Anacin, Ascriptin, Bayer Aspirin)
The following drugs have preventive effects when taken daily. They are mainly useful in people who have more than 1-2 headaches per week. Most of these drugs were developed for the treatment of other conditions and were coincidentally found to help treat migraineurs.
What Is the Follow-up for Visual Migraines?
People whose migraine headaches do not respond to maximum medical treatment may need to be hospitalized. Migraineurs must stay in close contact with their health care professionals and remember to take medications as prescribed.
What Is the Outlook for Visual Migraines?
The prognosis is usually good. Most migraineurs gain some improvement with treatment.
For More Information on Visual Migraines
National Institute of Neurological Disorders and Stroke
Migraines and Headaches Resources
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"Pathophysiology, clinical manifestations, and diagnosis of migraine in adults"