micro- or micro- both eyes both Examples include Examples in either or either in ) scotomas, or a totala or scotomas, ) The patient’s visualpatient’s The constriction of the (ie,field visual the of constriction vision tunnel vision of loss center). (Figure, No. 3: Visual distortions/ . realitymisrepresents right). (Figure, metamorphopsia, bilateral kaleidoscopichalos, macropsia, ofsensation scenes, fractured or orheat of waves through looking imagery,visual of persistence water, vision. color of loss or patterns, or something obstructingsomething or patterns, migraineclassic the are These vision. scintillatingof descriptions spectrafortification or scotoma left).(Figure, No. 2: Negative visual phenomena. missing,are vision of Areas loss,field homonymous as such  s  s Figure. Visual snow is one type of chronic altered Figure. Visual snow is one type of chronic altered perception commonly reported by patients with a history of . They describe a TV static-like disruption of their entire visual field that is constant and present even in the absence of headache.

1 This chronic This chronic 1 . . 1995;45(4):664-668. visual snow The patient sees thingssees patient The is commonly used toused commonly is No. 1: Positive visual phenomena/ hallucinations. lights,including there, not are that A persistent positive visual phenomenon persistent positive visual phenomenon A from persistent migraine is distinct Visual snow Aura in migraine consists of recurrentof consists migraine in Aura The headache is accompanied byaccompanied is headache The  1. Liu GT, Schatz NJ, Galetta SL, Volpe NJ, Skobieranda F, Kosmorsky GS. Persistent positive visual phenomena in migraine. associated with migraine but distinct from persistent but distinct from persistent associated with migraine as known migraine aura is acute attacks and in the absence of persists history in patients with a frequently found more is phenomenon as describe the of migraine. They often or snowfall. static looking through TV harmless in (Figure). Although visual snow is aura isolation, any positive visual phenomenon that is and further prompt visual field testing should new on accompanying historical details as workup based this article. elsewhere in described ocular migraine ocular auras.visual typical painless, to refer migrainein seen Visualdisturbances types.three into divided be may aura VISUAL SNOW AURA AURA reversiblefully unilateral, of attacks nervouscentral other or sensory, visual, overevolve that symptoms system houran than less last and minutes minutes). 10–30 commonly (most dynamicand unilateral often is Aura visualpositive one least at involves and byfollowed usually isIt phenomenon. isolationin occur can but headache termThe . reported without at least nausea and/or vomiting or byor vomiting and/or nausea least at phonophobia. and/or s

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Migraine isMigraine 2,3 Just a pain for the patient or a canary in a coal mine? or a canary in a the patient Just a pain for MD BY KIMBERLY M. WINGES, 4

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Left untreated, the headache in headache the untreated, Left Migraine is the second most common most second the is Migraine following four characteristics: having a having characteristics: four following pulsatinga exhibiting location; unilateral severeor moderate a carrying quality; by,aggravated being and intensity; pain physicalroutine of, avoidance causing or stairs).climbing or walking (eg, activity who experience migraine with aurawith migraine experience who migraine experience who those versus aura. without isand hours 72 to 4 lasts migraine theof two least at with associated worldwide in both men and womenand men both in worldwide age. of years 50 than less classified into migraine with and without importantis distinction This aura. theof meta-analyses several because increasetwofold a shown have literature patientsfor stroke ischemic of risk the in MIGRAINE MIGRAINE disorder,headache primary of form headache, tension-type only behind disabilityof cause third-highest the and with aura produce positive visualpositive produce aura with headachessecondary and phenomena, lesionsintracranial compressive as such increasedto due changes visual cause oneffect mass or pressure intracranial pathways. visual intracranial the evaluate these patients for ocular causesocular for patients these evaluate thosetreat to and disturbances visual of ophthalmologistspresent, if causes, experiencingare who patients face often absencethe in disturbances visual Primarypathology. ocular visible of migraineas such disorders headache Although it is always important to important always is it Although

VISUAL DISTURBANCES IN HEADACHE IN DISTURBANCES VISUAL H CATARACT & REFRACTIVE SURGERY TODAY EUROPE

16 s NEURO-OPHTHALMOLOGY n . J Headache Cephalalgia

. 2017;16(11):877-897. Lancet Neurol . 2016;17(1):104. J Headache Pain require an emergency workup forworkup emergency an require immediateand arteritis cell giant treatment.steroid empiric providers care eye Many Significant associated systemicassociated Significant tenderness,scalp as such symptoms, thatarthralgias and claudication, jaw loss vision transient accompany may Theseheadache. with diplopia or . 2019;20(1):96. Comprehensive and neuro-ophthalmologist Assistant Chief of Surgery for Clinical Assistant Professor of Ophthalmology and [email protected] Financial disclosure: None Operations, VA Portland Health Care System, Oregon Neurology, Casey Eye Institute, Oregon Health & Science University, Portland, Oregon    KIMBERLY M. WINGES, MD n n n n n CONCLUSION CONCLUSION headache in undertrained are basic the knowing but classification, patients among common features disturbances visual associated with warning the recognizing and are headache secondary of signs decisions. clinical making to critical may specialists to referral Prompt or diagnosis the when necessary be uncertain. is strategy management Pain • 1. Headache Classification Committee of the International Headache Society (IHS): The International Classification of Headache Disorders, 3rd edition. 2018;38(1):1-211. 2. Steiner TJ, Stovner LJ, Vos T. GBD 2015: migraine is the third cause of disability in under 50s. 3. GBD 2015 Neurological Disorders Collaborator Group. Global, regional, and national burden of neurological disorders during 1990-2015: a systematic analysis for the Global Burden of Disease Study 2015. 4. Hansen JM, Charles A. Differences in treatment response between migraine with aura and migraine without aura: lessons from clinical practice and RCTs. - a retinal and cardiac workup forworkup cardiac and retinal a and stroke; embolic Persistent vision loss or positive visualpositive or loss vision Persistent resolve;fully not do that phenomena olderpatients in of Onset age;of years 50 than orcharacter the in change Dramatic ormigraines of severity worsening aura;migraine loss,vision monocular Transient overcurtain a as described often fewa only lasting usually and vision resolution.complete before minutes indicativeis phenomenon This requiresand fugax amaurosis of Homonymous visual field defects; field visual Homonymous consciousness;of alteration or Loss orsigns neurologic Concurrent speech,slurred as such symptoms, syndrome,Horner hemiparesis, Targetedpalsy. nerve cranial or neurologya and neuroimaging toperformed be should workup strokeembolic or ischemic exclude atherosclerosis,artery carotid from mal arteriovenous dissection, artery aneurysm;intracranial or formation, Several situations should raise concern • • • • about a secondary headache syndrome: headache secondary a about • • • highly recommended to identifyto recommended highly homonymousor neuropathy optic posteriordefect the localizing defects, theof imaging OCT chiasm. the to retinaland layer cell ganglion macular localizeto help may layer fiber nerve nerveoptic of baseline a obtain and opticif especially changes, structural suspected.is atrophy nerve RED FLAGS | MARCH 2020| MARCH

). Visual auras can be can auras Visual ). Visual Snow Visual The examination of a patient a of examination The A thorough history provides criticalprovides history thorough A A migraine patient may experiencemay patient migraine A a centrifugal, spreading pattern (left). Negative visual (left). Negative visual view moves from center to periphery in a centrifugal, spreading pattern in migraine aura. An object in the way of the patient’s Figure. Visual disturbances seen underwater, or otherwise altered, often in a dynamic pattern (right). distortions or illusions of a normal scene that look fractured, phenomena (center). Visual disturbances should include carefulinclude should disturbances colorand BCVA of documentation afferentrelative a for assessment vision, fundusdilated a and defect, pupillary confrontationBoth examination. istesting field visual formal and bright sunlight, strong odors, extremeodors, strong sunlight, bright oruse medication and/or exertion, areTriggers blame. be to also overuse can time.over change can and individualized visualand headache with presenting to identify environmental triggers and triggers environmental identify to moretreatment to responses their gauge environmentalCommon accurately. consumptiondietary include triggers orsugar, wine, red chocolate, of High-stress glutamate. monosodium schedules,sleep erratic environments, and workup. Neurologists frequently ask frequently Neurologists workup. and headacheor headache a keep to patients aura journal or calendar. By documenting evolutionand timing, characteristics, the associatedany as well as symptoms of ablebe may patients features, neurologic such as driving because these aurasthese because driving as such field.visual the with interfere DIAGNOSIS diagnosisdifferential the on guidance aforementioned visual symptoms,visual aforementioned ahave reverse, completely which patient,each for pattern stereotyped lifetimea over change can and (see patientsin fear instilling debilitating, tasksvisual demanding highly during any single or combined version of theof version combined or single any CATARACT & REFRACTIVE SURGERY TODAY EUROPE

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