Migraine Headaches, Vision & Why

Background

The pain from a headache does not start from inside the brain as the brain itself cannot feel pain.  Instead, headache pain begins elsewhere such as the tissues covering the brain or muscles, blood vessels, or nerves around the scalp face and neck.  Many factors can contribute towards headaches.  I often see patients in the clinic here at Alpine EyeCare Center who were referred by their family doctors/GP to rule out a visual cause of headaches.  Uncorrected refractive errors (myopia/hyperopia/presbyopia/astigmatism, etc) can often contribute significantly towards aesthenopia or eye strain among other binocular vision disorders.  It is very interesting how many headache disorders have a visual component.  Ruling-out ocular/visual sources of headaches can save big dollars and time, possibly reducing the necessity of expensive imaging studies such as MRIs.

A headache is considered Primary when a disease or other medical condition does not cause it.

  • Tension headaches is the most common primary headache and accounts for almost all headaches.
  • Neurovascular headaches are the second most common primary headaches including migraine and cluster headaches and are caused by an interaction between blood vessel and nerve abnormalities.

Secondary headaches are caused by other medical conditions, such as sinusitis, neck injuries or abnormalities, and stroke.  These headaches are far less common.  It is quite possible for someone to experience a combination of headache types.

Migraine Headaches

Migraine is the most common form of disabling headache that prompts patients to seek care from doctors.  Migraines are sometimes classified as occurring with aura (previously called classic migraine) or without aura (previously called common migraine).  By vascular theory, a migraine is a vascular spasm of the cerebral artery.  It is also possible to have a migraine just affecting the retina – resulting in an aura & visual changes without a headache!

There may be up to four phases of a migraine: prodrome phase, auras, the attack, and the postdrome phase.  These phases may not occur in every patient or every headache.

The prodrome phase is a group of vague symptoms that may precede a migraine attack by several hours, or even a day or two.  Symptoms include:

  • Sensitivity to light or sound
  • Changes in appetite, including decreased appetite or food cravings
  • Thirst
  • Fatigue and drowsiness
  • Mood changes, including depression, irritability, or restlessness

Auras are sensory disturbances that occur before the migraine attack in 1 in 5 patients.  An aura can referred to as being positive or negative:

  • Positive auras include bright, shimmering light or shapes at the edge of the field of vision called scintillating scotoma. They may enlarge and fill the line of vision. Other positive aura experiences are zigzag lines or stars.
  • Negative auras are dark holes, blind spots, or tunnel vision (inability to see to the side).
  • Patients may have mixed positive and negative auras. This is a visual experience that is sometimes described as a fortress with sharp angles around a dark center.

Other neurologic symptoms may occur at the same time as the aura, although they are less common & should be assessed immediately:

  • Changes in your ability to communicate
  • Tingling, numbness or weakness in an arm or leg
  • Perceptual vision changes such as space or size distortions
  • Confusion and lack of normal thought

A migraine headache is different than a typical headache that people may have from time to time.  Migraine headaches involve severe pulsating, throbbing or pounding pain on one side of the head frequently accompanied by other symptoms like nausea, vomiting, and sensitivity to light and/or sound.  Untreated, migraine headaches can last between a few hours to a few days.   The cause of many migraine headaches remains unknown, however acute and preventative treatments are available.  Successful management of migraine headaches is centered on identification of what triggers an individual’s migraine headaches and making every effort to avoid those triggers.  Frequency and severity of migraine headaches can also be reduced through lifestyle changes and medications.

How Common Are Migraine Headaches?

Migraine headaches affect approximately 18% of women and 6% of men in the United States.

Symptoms, Diagnosis, Treatment

Symptoms that may be experienced in the pro-drome phase, a day or two prior to onset of the migraine, include:

  • Constipation
  • Depression
  • Food cravings
  • Hyperactivity
  • Irritability
  • Neck stiffness
  • Uncontrollable yawning

Symptoms that may occur during the aura, headache and post-drome phases include:

  • Seeing shapes, bright spots or flashes of light
  • Vision loss
  • Pins and needles sensations in limbs
  • Speech or language problems (aphasia)
  • Pain on one side or both sides of the head
  • Pulsating, throbbing pain
  • Sensitivity to light, sounds and smells
  • Nausea and vomiting
  • Blurred vision
  • Light-headedness
  • Fainting
  • Feeling drained or “washed out”
  • Feeling mild euphoria

How is Migraine Diagnosed?

Migraine headaches are diagnosed by a neurologist, often after consultation with other medical providers.  If your migraine headaches are severe or have sudden onset, additional tests like blood tests, CT scans, MRIs or a spinal tap to rule out other physiological causes may be indicated.

How Are Migraine Headaches Treated?

There are a variety of medications used in the treatment of migraine headaches, one category is abortive: these are pain-relieving medications designed to stop migraine symptoms that have already started.  The other category is preventative and is designed to be taken regularly to reduce the frequency and severity of migraine headaches.

Abortive migraine medications include:

  • Over the Counter Pain Relievers – NSAIDs- non-steroidal anti-inflammatory medications like aspirin, Advil®, Motrin IB®, or combinations of acetaminophen and caffeine (Excedrin Migraine®) may relieve mild to moderate migraine pain in some individuals.
  • Triptans – Triptans promote constriction of blood vessels and block pain pathways in the brain. Triptan containing drugs are available in nasal sprays, injections, tablets and a patch. Examples include: Almotriptan (Axert®), Eletriptan (Relpax®), Frovatriptan (Frova®), Naratriptan (Amerge®), Rizatriptan (Maxalt®), Sumatriptan ( Alsuma®, Dosepro®, Imitrex®, Sumavel®, Treximet®, Zecuity®), and Zolmitriptan (Zomig®). Triptan drugs can cause chest tightness, flushing, tachycardia (rapid heartbeat), nausea, dizziness, drowsiness, and muscle weakness.
  • Dihydroergotamine (D.H.E. 45, Migranal®) – Migranal® is available as a nasal spray and in injection form. Dihydroergotamine may cause blood vessels in the body to constrict (become narrower) which can lead to serious side effects if blood flow to many parts of the body is restricted.
  • Anti-nausea Medications – Chlorpromazine, metoclopramide (Reglan®) or prochlorperazine (Compro®) can reduce the nausea and vomiting that can accompany migraine headaches.

Preventive migraine treatments include:

  • Cardiovascular Medications – Beta blockers propranolol (Inderal La®, Innopran XL®, others), metoprolol tartrate (Lopressor®) and timolol (Betimol®) which are typically used to lower blood pressure and treat coronary artery disease, have also been proven to reduce the frequency and severity of migraine headaches. Calcium channel blockers, Verapamil (Calan®, Verelan®, others) are drugs that are typically used to treat high blood pressure and keep blood vessels intact are also used to prevent migraines. ACE inhibitor, lisinopril (Zestril®), may also be useful in reducing the length and severity of migraines. Angiotensin II receptor blocker (ARB) drugs like candesartan (Atacand®) may also be used to prevent migraine headaches.
  • Antidepressant Medications – Tricyclic antidepressants, like amitriptyline (Elavil®) and nortriptyline (Pamelor®, Aventyl HCI®), may lower the frequency of migraine headaches by impacting the level of serotonin and other brain chemicals. Tricyclic antidepressants can cause dryness of mouth, constipation, weight gain and other side effects. Serotonin and norepinephrine reuptake inhibitor drugs (SNRIs) like venlafaxine (Effexor®) and duloxetine (Cymbalta®) are also used to reduce migraine headache frequency.
  • Antiseizure Medications – Anti-seizure drugs, like topiramate (Topamax®), may reduce frequency of migraine headaches. Topamax® may cause diarrhea, nausea, weight loss, memory difficulties and concentration problems.
  • OnabotulinumtoxinA (Botox®) – Botox® has been shown to be helpful in treating chronic migraine headaches in adults. Injections of onabotulinumtoxinA (Botox®) are made into the muscles of the forehead and neck. When effective, treatment usually needs to be repeated every 12 weeks to maintain the benefits.

What Are the Causes and Risk Factors For Migraine Headaches?

  • Being female
  • Hormonal changes (birth control, menstrual cycle fluctuation)
  • Hormone replacement therapy
  • Being underweight or being overweight
  • Foods (aged cheeses, salty food)
  • Food additives (aspartame, MSG)
  • Alcohol
  • Caffeine
  • Medications (oral contraceptives, vasodilators can aggravate migraines)
  • Sensory stimuli (bright lights, loud sounds, strong odors)
  • Stress
  • Physical exertion
  • Environmental changes (barometric pressure)
  • Sleep-Wake pattern (too little or too much sleep, jet lag)
  • Family history of migraine headaches
  • Genetics

Genetic vs. Environmental Causes

Migraine is caused by a combination of multiple genes and the environment.  It is estimated that for women, approximately 48% of the risk is due to genetic factors while the remaining 52% is due to lifestyle and environmental factors.  For men, approximately 38% of the risk is due to genetic factors while the remaining 62% is thought to be due to lifestyle and environmental factors.  There are currently no screening guidelines or tests available for diagnosis of migraine headaches. Therefore, there are currently no recommended screening tests to detect migraine headaches among asymptomatic individuals.

Can Migraine Headaches be Prevented?

In addition to taking preventative medications, there are lifestyle changes that can help reduce exposure to triggers associated with the onset of migraine headaches.  Some people have migraines in response to trigger foods, either from the smell of the food alone or consumption of the food.  It is highly recommended to keep a journal of foods, medications, activities, etc which may proceed a headache.  Often the answer is right in front of the patient.  Avoiding stimulants, like caffeine and tobacco, and depressants like alcohol may also reduce migraines.  Keeping a stable daily routine with regular sleep and wake times, regularly scheduled meals, and regular exercise will help manage stress levels and lower the likelihood of a migraine.  Some women may notice an increase in migraine headaches at times when hormones may be fluctuating.  Women who are sensitive to hormones may find themselves with fewer migraines if they can lower their exposure to estrogen containing medications like birth control and hormone replacement therapy.

I hope you were able to walk away with some information you can use.  Either way, schedule your eye exam today to insure your eyes are healthy & functioning properly.

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