Kaiti R and Shyangbo R. Ocular Consultation in Headache-A Prerequisite Or an Absolute Copyright© Kaiti R and Shyangbo R

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Ocular Consultation in Headache-A Prerequisite or an Absolute Necessity?

Kaiti R1* and Shyangbo R2 Mini Review 1Consultant Optometrist, Nepal Eye Hospital, Nepal Volume 5 Issue 2 2National Academy of Medical Sciences, Nepal Received Date: September 07, 2020

Published Date: September 28, 2020 *Corresponding author: Raju Kaiti, Consultant Optometrist, Nepal Eye Hospital, Kathmandu, DOI: 10.23880/oajo-16000200 Nepal, Email: [email protected]

Abstract

A vast majority of cause of headaches are ocular, prime cause being neurological. Therefore, eye care practitioners are

headaches, eye pain, and headache-associated visual disturbances. Refractive error, oculomotor anomalies and ocular diseases often the first physicians to evaluate, manage or if needed refer to designated department and specialty, the patients with contribute to headache and hence these causes need to be ruled out before going for expensive, invasive and time-consuming

ophthalmologist or any other specialists as per necessity. investigation. Health care professionals should always be generous in referring the patients to fellow physician, optometrist,

Keywords: Oculomotor Anomalies; Ocular Diseases; Unilateral Neuralgia; Trigeminal Autonomic Cephalgias; Nervous System Disorders

Abbreviations: GP: General Practitioner; BASH: British conditions, but because the symptom can represent an early Association for the Study of Headache; TAC: Trigeminal manifestation of a potentially serious disorder, it necessitates Autonomic Cephalgias; SUNCT: Short-Lasting Unilateral thorough evaluation. A vast majority of cause of headaches are ocular, prime cause being neurological. Therefore, eye Tearing; SUNA: Short-Lasting Unilateral Neuralgia Headache Neuralgia Headache Attack with Conjunctival Injection and manage or if needed refer to designated department care practitioners are often the first physicians to evaluate, AttackIntroduction with Cranial Autonomic Symptoms headache-associated visual disturbances. Most of the headachesand specialty, are theoften patients accompanied with headaches, by ocular or eye peri-orbital pain, and

all symptoms and probably a universal experience at some attributed to ocular disease. Although ophthalmic causes are pointHeadache, of life. It is also not known a disease as cephalgia,in itself but is merely the commonest a symptom of sometimespain, along diagnosed, with some most visual ocular symptoms, pain and thereforemany types it of is of a disease or health condition. Collectively, headache visual disturbances are neurologic in origin [3]. Thus, there disorders are among the most common of the nervous system disorders [1]. A headache can affect any part of the head, and As frequent as it may sound, but the appropriate diagnosis pain may be present in one or several locations. Headache exist an inextricable relation between eye and headache.

line [2]. A large proportion of headaches result from benign hasof headache been underestimated, is still murky under-recognized with only minority and of under- people has been defined as the pain located above orbitomeatal worldwide diagnosed with headache disorders. Headache

Ocular Consultation in Headache-A Prerequisite or an Absolute Necessity? J Ophthalmol 2 Open Access Journal of Ophthalmology

• or immunocompromised status treatedThe throughout prevalence the of worldheadache [1]. in general population is • SignsNew headache of a systemic in the illness setting (e.g., of fever, HIV risk stiff factors,neck, rash) cancer, thought to around 48.9% [4]. It has been estimated that • almost half of the adult population have had a headache at • Headache in pregnancy/postpartum period • Triggered by cough, exertion, Valsalva maneuver • Aura symptoms that careleast practitioners once within the[5]. Aroundlast year 95% making of the headache general populationone of the i. LastFirst longeror worst than headache an hour most frequent reasons to seek a consultation with health ii. iii. Are different from previous aura have experienced headache at some stage in their life with iv. Include motor weakness generala 1-year practitioner prevalence (GP) of nearly consultations one in [6], two 1 adults in 3 neurology [4]. The referralsprevalence [7] of headacheand 1 in is5 widespread,of all acute accounting medical admissions for 1 in 10 ThereOccur forare themany first ocular time conditionson using oral that contraceptive causes headache, pill [8]. Although the evidence in the literature for a strong Moreover, certain secondary causes of headache also have neuro-ophthalmic manifestations. Broadly, the causes of examinationassociation between and treatment oculo-visual help to problems lessen their and headache headache visit is optometristsweak [5], still and patients ophthalmologists who believe thatvery appropriate frequently [9,10].ocular ocularOcular headaches Headache can be studied Caused in the Due following to Uncorrected subheadings: Headache affects people of all ages, races and socioeconomic Refractive Errors Headaches caused due to uncorrected refractive error statusThe and International is more common Headache in women. Society [11,12] broadly afternoon or at the end of the day. The constant effort exerted Secondary headache. Primary headaches have no underlying or wrongly corrected refractive error usually occur during causeclassifies and headache constitute into the twovast groups:majority Primary of headache headache disorders and headache. It starts as heaviness in eye and continuous use of including migraine, cluster and tension headaches, and most eyein order leads to see headache. clearly causes The symptoms eye strain are andmore finally prominent lead toin common entities being the migraine and tension headache. Migraines, in general, have a prevalence of 18.2% in females prominent in astigmatism in comparison to myopia and and 6.5% in male patients [13]. The tension headache is hyperopia.low grades Oneof refractive hypothesis error states than that in evenhigh theerrors minor and degree more of astigmatic errors of refraction causes changes to visual perception that alter the hyper-excitability in the visual prevalencethe most common of 0.1% affecting only [14]. 60-80% Secondary of the populationheadaches with are cortex of the brain of headache sufferers [16]. Astigmatic uncommoncluster headache but their being recognition the most uncommon is extremely with important estimated as blur may exacerbate the perception of striped patterns timely intervention may be lifesaving. The most common cause of secondary headaches includes: space occupying different types of headaches [17]. The uncorrected refractive lesions-mainly intracranial tumors, infections of the which are thought to be important in the visual triggers of central nervous system, mainly meningitis or encephalitis, subarachnoid hemorrhage, giant-cell arteritis, cerebral errors are often believed to be associated with frontal venous thrombosis, idiopathic intracranial hypertension, headachesand/or occipital [19,20]. headache We have [18]. many However, clinical some examples research of etc. Headache caused due to psychiatric problems are refractivehas established error being low prevalencecause of headache of refractive and taking error them related to also considered as secondary headache. Fortunately, the emergency and physician consultation. Most of these cases vast majority of patients who present to the primary care inwere investigations, normal in blood taking investigation, medicines, they blood are pressure, not relieved even and CT provider for an evaluation will have a primary headache thenscan andthey MRI. get toAfter visit a weekeye care of rush, practitioners. spending bulkWe have of money seen disorder. However, secondary headaches may be caused due small refractive corrections (mostly astigmatism) alleviate to underlying life threatening conditions and present with Associationcertain red flagsfor the which Study points of Headache towards (BASH) the immediate [15] as listedneed of thorough evaluation. The red flags adapted from British theirOcular symptoms Headache in 3-4 days Caused of spectacle due wear. to Oculomotor • Anomalies • below:Abnormal neurologic examination including papilledema Though international headache society does not andNew change headache in mental in older status patients recognize it, very often some literatures tend to point out • headache New change in headache pattern or progressive it [5]. The disruption of coordination between the muscles Kaiti R and Shyangbo R. Ocular Consultation in Headache-A Prerequisite or an Absolute Copyright© Kaiti R and Shyangbo R. Necessity?. J Ophthalmol 2020, 5(2): 000200. 3 Open Access Journal of Ophthalmology

Trigeminal Autonomic Cephalgias (TAC): TACs are transferred to the head, resulting in headache. characterized by unilateral pain in the ophthalmic division of of the two eyes may bring about the strain that may be phorias and especially vertical phoria or tropia, tend to mostthe trigeminal common nerve.form of It TAC may is present cluster withheadache. lacrimation, eye lid be theMost culprit. commonly, Ocular significant muscle imbalance decompensated as latent and squint, large Clusteroedema, HeadacheHorner’s syndrome: It is the and most conjunctiva common injection.form of TAC,The accommodative and vergence dysfunctions [21] and region of ipsilateral side lasting for about 15 to 180 minutes. reported that in migraine headache often binocular vision presenting with pain centered around eye or temporal anomaliesconvergence in insufficiencythe form of decompensated cause headache heterophoria [22]. It has been and reduced stereopsis might be present in subtle form [5]. otherDuring symptoms cluster attack, of TACs. frequently post ganglionic Horner’s syndrome, miosis and anisocoria are observed along with Beside the above-mentioned type of headaches, headachePatients who symptoms fail Sheard’s [23]. criterion (Prism Fusional Vergence paroxysmal hemicranias, short-lasting unilateral neuralgia less than twice the near phoria) are expected to suffer from Ocular Headache Secondary to Organic Eye and (SUNCT) and short-lasting unilateral neuralgia headache Systemic Disease headache attack with conjunctival injection and tearing

Headache and ocular pain are frequent complaints veryattack infrequent. with cranial autonomic symptoms (SUNA) also in ophthalmic practice. Headaches that present to an eye presents with ocular manifestation but these headaches are care practitioner include migraine, facial pain syndromes, It is necessary to perform a detail evaluation of patients ocular disease. Ophthalmological studies on headache have reportedand pain associatedthe role of with different cranial ocular neuropathies, diseases orbital, like acute and becausepresenting it withmay headache,harbor a andlife-threatening more precautions disease. should Since be glaucoma, uveitis, optic neuritis [24] etc. Headache may be majoritytaken if theof patients history pointsconsider towards eye to abe secondary the culprit headache behind their headache, eye care practitioners like optometrist and mayassociated also cause with headaches. an ipsilateral Acute defect elevation in oculo-sympathetic in intraocular pathways as in Horner’s Syndrome. Cranial nerve palsies ophthalmologist may be the first one to detect secondary disease like acute iritis, uveitis, orbital cellulitis and pre- nerveheadaches involvement and their etc. causeIn these by cases, finding early certain diagnosis ophthalmic may be septalpressure cellulitis is usually also associated orbital pain with andpain. headache. Any inflammatory Dry eye lifesaving.manifestations From like the papilledema,perspective of early an eye field care defect, practitioner, cranial may also cause headache and the medication used to treat

One of the most encountered symptom of computer vision • the followingA detailed work-up history ofon headache type of headache, should be onset, done iffrequency, a patient syndromeheadache is may headache. cause or worsen pre-existing dry eye [3]. present with complains of headache in eye OPD: duration, aggravating and relieving factors should be Temporal headache in an elderly person should alert one taken.whether episodic or continuous, time to peak, time and • A thorough general examination including vital signs, [25]. Headache from elevated blood pressure may be general appearance, scalp examination, palpitation of to a possibility of giant cell arteritis, which is an emergency temporal artery and temporomandibular joint should be Pituitary apoplexy is a neurological emergency presenting done accompanied by bilateral disk swelling or Papilloedema. • • Meticulous refraction withPrimary headache, Headachevision loss, ophthalmoparesisDisorders Presenting and delirium. with • BinocularVisual acuity vision should assessment be assessed and ocular motility- Cover Ophthalmic Manifestations test • Detailed anterior segment evaluation Migraine with Aura and Ocular Migraine: Aura symptoms • Gonioscopy and Tonometry of migraine include amaurosis fugax, scintillating scotoma, • Pupillary response blurred visions, entopic phenomenon (phosphenes), visual • • Detailed funduscopy • DependingVisual field uponassessment signs in suspected cause and associated orhallucinations, ocular migraines) etc [3]. causes Retinal monocular migraine visual (otherwise loss for known10–20 as ophthalmic migraines, anterior visual pathway migraines, Lumbar puncture may be required. headache [26]. symptoms, X ray PNS, CT or MRI, Carotid flow study, minutes which can be associated with diffuse or unilateral • Prompt referral in suspected case of secondary

Kaiti R and Shyangbo R. Ocular Consultation in Headache-A Prerequisite or an Absolute Copyright© Kaiti R and Shyangbo R. Necessity?. J Ophthalmol 2020, 5(2): 000200. 4 Open Access Journal of Ophthalmology

headaches Edinb 36(3): 196-200. first century district general hospital. J R Coll Physicians Conclusion 9. Brien OB, Goeree R, Streiner D (1994) Prevalence of In conclusion, headache is very common among migraine headache in Canada: a population-based general population. Not every headache imposes serious survey. Int J Epidemiol 23(5): 1020-1026. 10. Thomas E, Boardman HF, Ogden H, Millson DS, Croft PR ramifications, but those which do may be life threatening which requires urgent neurological evaluation and gives it?. Cephalalgia 24(9): 740-752. (2004) Advice and care for headaches: who seeks it, who practicemanagement. most Thoughcases of only headaches few literatures have certain have established aspect of 11. ocularstrong symptoms. association Ophthalmologic between eye and aspects headache, of headache in general thus Disorders, 3rd edition (beta version) Headache encompass problems that range from simple and benign to (2013) The International Classification of Headache complex and formidable. Careful ophthalmic examination Society (IHS) Cephalalgia 33(9): 629-808. including visual acuity, eye movements, pupils, anterior eye Classification Committee of the International Headache segments and dilated fundoscopy is the key to successful 12. management of cases of headaches presenting to the eye International Headache Society (IHS) The International (2013) Headache Classification Committeerd of(Edn.) the Cephalalgia 33:762. expensiveclinic. Our and recommendation more sensitive. for thoseHealth with care headache professionals is to Classification of Headache Disorders, 3 have ocular examination first, it being less invasive, less 13. specialists, physician, optometrist, ophthalmologist or any J, et al. (2003) The prevalence and disability burden of othershould specialists always be to generous be involved. in referring the patients to fellow adultSteiner migraine TJ, Scher in AI,England Stewart and WF, their Kolodner relationships K, Liberman to age, gender and ethnicity. Cephalalgia 23(7): 519-527.

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