Dr Jo-Anne PonConsultant Ophthalmologist and Oculoplastic

Surgeon

Southern Eye Specialists

Christchurch

12:15 - 12:30 Visual Migraines to be Worried About

Visual Migraines To Be Worried About

Jo-Anne Pon

Ophthalmologist

Mr CS (57yo)

• Right visual field loss RE only– Like looking through water– Shimmering– Lasted 60mins– Associated with headache

• Started day before visual symptoms • lasted 48hrs• General ache/tension

– Visual sx’s resolved

• No history of migraine

• Headaches– Gets them intermittently (yrs)– Not severe– No assoc nausea or need to lie down– Assoc with tiredness

• No further episodes

Mr CS

• Normal ocular examination

• HVF 30-2 - normal

Management?

• Neuro-imaging?

• No investigations

• Didn’t return with symptoms

Outline

• Visual Migraine symptoms

– Typical

– Red flags/ who needs neuro-imaging

• Patterns of transient vision loss

Perspective

• Migraine with visual symptoms -common

• Lifetime prevalence in general population 18%

• 1-3% of general population or 1/3 of migraineurs will present c/o visual aura

• Which ones to worry about?

• Very few

• Moorfields/St Thomas study– over 23 years, 9 cases

– Literature 31 cases1950 to 2009 (59yrs)

International Classification of Headache Disorders –3 (ICHD-3)

• Prodromal phase

• Aura

• Headache

• Postdromal phase

Typical visual aura of migraine

Biphasic aura1. Positive visual phenomenon• Fortification spectra (Teichopsia)• Scintillations (flashing lights)• C-shape or semicircle surrounding scotoma

2. Negative symptoms minutes later• Blank scotoma• Hemianopia

Visual symptoms

Diagnostic criteria for typical migraine visual aura

• Develops gradually over 5mins

• Duration

5 to 60 mins

• Headache begins during or follows aura

Moorfields / St Thomas Hospital9 cases

Focal cerebral pathology

Moorfields / St Thomas Hospital9 cases

• Cavernous haemangioma (2)

• Capillary haemangioma (1)

• Infarction (1)

• Meningioma (3)

• AVM (1)

• Oligodendroglioma (1)

Literature 31 cases1950 to 2009• AVM (16)• Subependymoma• Intracranial calcification• Metastatic adenocarcinoma• Astrocytoma• Unspecified mass• Head injury• Meningioma• Cavernous haemangioma• Aneurysm• Infarction (ICA dissection, occlusion)• Abscess

DifferentiateMigraine vs Structural Lesion

?

Migraine vs Occipital lesion

Both can have

• Scintillating scotoma/teichopsia

• Past history cannot reliably exclude occipital lesion

• Duration 5-60mins in both

• Visual aura recurring in same hemifield

Occipital Lesion

• Visual symptoms– Brief <5 mins, Unformed

• Photopsia– Flicker rapidly

– Remain stationery

• Location– Same location in visual field,

contralateral to lesion

Migraine vs Occipital lesionRed Flags

• > 40yo, esp no past history of migraine– DDx TIA

• if < 50 yo, Acephalgic(Migraine-like visual aura without headache )

• Duration– brief (seconds) or < 5 mins (seizure related)

– Prolonged (persist)

• Symptoms exclusively negative e.g. hemianopia

Mr MK 68yo

• Left visual field loss with zigzag lines x 10 mins

• No history of migraines

• Went to Optometrist

Left inferior quadrantanopia

Visual Field Defects

Luu, Lee, Daly ChenVisual field defects after strokeAustralian Family Physician July 2010

Right Occipital CVA

Who needs neuro-imaging?

• Stereotypical visual aura: always in same location in visual field

• Increase in frequency or change in pattern to longstanding visual aura– Daily = epileptic visual phenomena

– Sudden alteration in aura characteristics

– E.g. previous headache, now acephalgic

– E.g. aura persisting throughout or beyond headache

– E.g. persistent darkening or dimming of homonymous region of visual field

• Unexplained visual field defect

• Subjective persistence of a scotoma following typical visual aura

• Co-existence of seizures

Mrs KO (76yo)

c/o sparkly waves BE, worse in LE (amblyopia)• x 10 years, no change in nature of symptoms• Last 10-15mins (longest 30mins)• Symptoms also present with BE closed• No headache

• Increase in frequency of symptoms– Previously occasionally– Now fortnightly– Recently a day – 3 episodes lasting 5mins each

Mrs KO (76yo)

• PMH:

– HT

– No CVA, IHD

• POH:

– Strabismus childhood

– L Amblyopia

• FH: Glaucoma (sister)

Normal ocular examination

• R 6/9, L CF

• No RAPD, normal optic discs 0.3

• IOP

– R 16mmHg, L 17mmHg

HVFNot reliable

Management?

• Neuro-imaging?

• CT and CTA Head:

– Dec 2012

– Normal

• Feb 2014

– Returned for R cataract management

– Acephalgic migraines less frequent again

Ms DC 52yo

• PC: spinning propeller in R Superotemporal VF, expands, becomes colourfulkaleidoscope obscuring VF

• Resolves > 20mins• Originally lasted 1 min, but increased duration and frequency• Occurring every other day• Sees symptoms with eyes closed• No headache• 1 episode assoc with nausea and vomiting• Between episodes, back to normal, well, no neurological symptoms

Ms DC 52yo

Ms DC 52yo

• PMH: Treatment for Breast Cancer– Surgery

– Radiotherapy

– Chemotherapy

– Hormone treatment

• CT scan with contrast 23/6/16– No cause to explain symptoms

• Presented Aug 2016

• Review 4 weeks with HVF

• If deterioration, MRI

• 1 day before appointment– Found confused, headache,

vomiting

– (didn’t turn up at work)

Ms DC 52yo

Acephalgic migraine vs retinal migraine

+No headache

•Usually young, well adults• Patchy fading vision over 5 min, then poor vision for 5-60mins•+/- headache

•Choroidal circulation in spasm•No neurologic symptoms•Normal eye examination

•Rx: Ca channel blocker to reduce frequency

Patterns of vision loss

• Monocular or binocular?

– Patients can mistake monocular for binocular or vice versa

• Other clinical /neurological signs

Patterns of vision lossMonocular

• Exercise or heat: Uhthoff’s phenomenon (optic neuritis/MS)

• Gaze evoked amaurosis: orbital tumour?

• Age?

– >50yo: Amaurosis fugax? (cardiovascular workup)

– > 50yo & older: GCA?

– All ages, <50yo

E.g. Carotid dissection (trauma, neck pain, Ipsilateral Horner’s syndrome, dysgeusia)

Patterns of vision lossTransient Binocular Vision Loss

Duration? Pattern of recovery?• Papilloedema – seconds, Transient Visual Obscurations (TVOs)• Vertebrobasilar insufficiency – onset sudden (seconds), then

recovers over seconds to minutes• D’s: dysarthria, diplopa, dizziness (vertigo), drop attacks, • >50yrs, vasculopathic risk factors• All symptoms resolve < 1hour

• TIA - < 15mins– Onset within seconds, lasts 1-10mins

• Visual Aura of Migraine – 20 mins (5-60 mins)• Retrochiasmal disease < 5 mins (20-30mins)

Migraine with visual symptomsTake home messages

Who to refer for investigation?

Pattern Recognition

• Typical Migraine Visual Aura

• Other patterns of vision loss

– Unilateral

– Bilateral

Diagnostic criteria for typical migraine visual aura

• Develops gradually over 5mins

• Duration

5 to 60 mins

• Headache begins during or follows aura

Migraine vs Occipital lesionRed Flags

• > 40yo, esp no past history of migraine– DDx TIA (can be acephalgic)

• if < 50 yo, Acephalgic(Migraine-like visual aura without headache )

• Duration– brief (seconds) or < 5 mins (seizure related)– Prolonged

• Symptoms exclusively negative e.g. hemianopia

Who needs neuro-imaging?

• Stereotypical visual aura: always in same location in visual field

• Increase in frequency (daily = seizure activity?)

• or change in pattern to longstanding visual aura– previous headache, now acephalgic

– Persisting aura/ persisting scotoma– persistent darkening or dimming of homonymous region of visual field

• Co-existence of seizures

Thank you