Weird, but not fun. That’s one way of describing migraine headaches. But the term, migraine headache, itself, is very broad. What we’re talking about here is something that messes with the brain, and since the brain is the way everyone deciphers the electromagnetic wavelengths and atoms of the universe to construct a worldview through which to navigate in life, alterations there can be debilitating to that navigation. When it comes to the subject of “ocular” migraines, that is, disturbances in vision due to a migraine process, the bottom line is that it is still a migraine.
What are ocular migraines?
An ocular migraine, also called “retinal migraine,” is a migraine condition with repeated episodes of simple visual hallucinations or blindness, in one eye, associated with or followed by a headache.1 The word “ocular” is preferred over “retinal” because it is not just a disturbance of the retina, but with the circulation in the whole eye because of the migraine process. Ocular migraines are different from the visual “aura” which may precede the onset of a migraine. The biggest difference between a visual aura and a true ocular migraine is that the aura is usually a distortion of perception of both eyes (“binocular”), whereas an ocular migraine usually involves just one eye (monocular).
What causes ocular migraines?
They are migraine headaches, and the migraine mechanism is in play—a spreading of waves of nerve firings that enlarges to encompass areas in the brain that result in disturbances of perception.2 In other words, if the spread of the “depression wave” involves that area of the brain that receives input from the abdomen, the person may think he or she has a stomachache. If it involves the areas of visual reception, it may result in distortions of vision. The biggest, immediate problem associated with the ocular migraine is the headache that can come with it or follow it.
What are the symptoms of an ocular migraine? How long does an ocular migraine last?
Besides the migraine headache itself, which can be associated with it or follow it, the symptoms of an ocular migraine, typically lasting less than hour, are flashing lights (scintillations), blind spots (scotoma, pl., scotomata), or blindness, usually in only one eye. (The migraine visual aura, in contrast, usually involves both eyes.) The visual disturbances are simple, that is, do not involve complex imagery, but spots, lines, flashes, stars, etc.
Aside from the scotomata, scintillations, or vision loss in one eye, the symptoms are the same as those seen in migraines:
- Unilateral, pulsatile headache
- Sensitivity to light and noise
In the absence of a headache component, the whole problem self-resolves in less than hour.
It is important to note that visual disturbance on one side of your vision is not the same as visual disturbance in one eye. Both eyes contribute to all sides of vision, so the only way to tell if the problem is in one eye or both is to cover one and the other eye in alternating fashion.3
Can there be serious complications of ocular migraines?
The temporary visual loss described above can become permanent in a small percentage of those suffering ocular migraines. This may be caused by a blockage of circulation that occurs due to the migraine or repeated migraines.
How long do ocular migraines last?
Since an ocular migraine is usually part of the entire migraine process, the ocular migraine itself, lasting less than an hour, can morph into the generalized migraine lasting hours. Typically, an ocular migraine lasts 20-30 minutes, which is reassuring when the troubling symptoms diminish or resolve.
What else could symptoms like this be?
There are things that can present in the same way or in similar ways:
- Amaurosis fugax: temporary loss of vision in one (TMVL—temporary monocular vision loss) or both eyes (TBVL—temporary binocular vision loss). This is caused by retinal embolism (blood clot) or retinal ischemia (vascular spasm resulting in diminished blood flow). The same things can affect the optic nerve, as well. It differs from ocular migraines by its blank or fuzzy vision, and its common involvement in both eyes (TBVL).
- Ocular migraine stroke—this is a permanent deficit by the same mechanisms that cause the temporary amaurosis fugax.
- Transient monocular blindness: another term for amaurosis fugax which affects only one eye. Monocular symptoms can make the diagnosis very difficult to separate from that of ocular migraine.
- Visual epilepsy: a seizure involving the visual cortex of the brain. These are differentiated from ocular migraines by the fact that they start with a bang, then diminish over time, whereas ocular migraines build up over time, peaking with the onset of the migraine headache or ultimately peak and then resolve.
What triggers ocular migraines?
Since ocular migraines are migraines, the same triggers are identified:
- Dietary triggers
- Sinus conditions
- High blood pressure
- Hormonal changes
- Unknown—the most common trigger (or lack thereof)
For the ocular migraine specifically, eye strain from uncorrected vision (astigmatism) can start the ball rolling.
How are ocular migraines treated? What about ocular migraine prevention?
For those with only the ocular component, no treatment is necessary, because it will self-resolve in less than an hour.
For those whose ocular migraines are part of a larger migraine headache condition, prevention and/or treatment is separated into a first, second, and third choice, a hierarchy of sorts that provides a flowsheet of what to do when some medications fail. It is not etched in stone, offered as a guideline only. Many physicians and headache specialists will mix or jump classes according to their own preferences or experience. As always, prevention is a better strategy.
First choice includes
- propranolol (beta-blocker), verapamil (Calan—calcium channel blocker),
- amitriptyline (Elavil—antidepressant), and
- topiramate (Topamax) and valproate (Depakene)—anti-seizure meds.
Pregnancy is a contraindication to valproate, which can cause birth defects. The beta-blockers shouldn’t be used in smokers or people over 60, which may raise the risk of stroke.
Second choice: for those who don’t respond adequately to the first-choice medications, there are
- other beta blockers—atenolol (Tenormin), nadolol, metoprolol (Lopresor), timolol;
- botulinum toxin A;
- neuromodulators—gabapentin (Neurontin), verapamil); and
- other antidepressants—other tricyclic ones like nortriptyline (Aventyl) and protriptylne.
If these don’t work well either, there are also third choice drugs:
- the herb feverfew;
- tizanidine (Zanaflex);
- memantine (Namenda);
- pregabalin (Lyrica);
- cyproheptadine; and
The ocular migraine is just one weirdness associated with the migraine world. For those who are fortunate to suffer just this portion of the migraine spectrum, it is inconvenient and bothersome, but not devastating. For those who suffer ocular migraines as part of the oncoming migraine headache, it is a warning of trouble brewing.
- Headache Classification Committee of the International Headache Society (IHS). The International Classification of Headache Disorders, 3rd edition (beta version). Cephalalgia 2013; 33:629.
- Leão AA. Spreading depression of activity in the cerebral cortex. J Neurophysiol 1944; 7:359.
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