Dr Jo-Anne Pon Consultant 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 • Headaches – Like looking through water – Gets them intermittently (yrs) – Shimmering – Not severe – Lasted 60mins – No assoc nausea or need to lie down – Associated with headache – Assoc with tiredness • Started day before visual symptoms • lasted 48hrs • General ache/tension – Visual sx’s resolved • No further episodes • No history of migraine Mr CS • Normal ocular examination Management? • Neuro-imaging? • HVF 30-2 - normal • 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 - • Which ones to worry about? common • Very few • Lifetime prevalence in general population 18% • Moorfields/St Thomas study – over 23 years, 9 cases • 1-3% of general population or – Literature 31 cases 1/3 of migraineurs will present 1950 to 2009 (59yrs) c/o visual aura International Classification of Headache Disorders – 3 (ICHD-3) • Prodromal phase • Aura • Headache • Postdromal phase Typical visual aura of migraine Biphasic aura 1. 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 Hospital 9 cases Focal cerebral pathology Moorfields / St Thomas Hospital Literature 31 cases 9 cases 1950 to 2009 • Cavernous haemangioma (2) • AVM (16) • Subependymoma • Capillary haemangioma (1) • Intracranial calcification • Infarction (1) • Metastatic adenocarcinoma • Astrocytoma • Meningioma (3) • Unspecified mass • AVM (1) • Head injury • • Oligodendroglioma (1) Meningioma • Cavernous haemangioma • Aneurysm • Infarction (ICA dissection, occlusion) • Abscess Differentiate Migraine vs Structural Lesion ? Migraine vs Occipital lesion Both can have Occipital Lesion • Scintillating scotoma/teichopsia • Visual symptoms • Past history cannot reliably – Brief <5 mins, Unformed exclude occipital lesion • Photopsia • Duration 5-60mins in both – Flicker rapidly • Visual aura recurring in same – Remain stationery hemifield • Location – Same location in visual field, contralateral to lesion Migraine vs Occipital lesion Red 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 Chen Visual field defects after stroke Australian Family Physician July 2010 Right Occipital CVA Who needs neuro-imaging? • Stereotypical visual aura: always in • Unexplained visual field defect same location in visual field • Subjective persistence of a scotoma following • Increase in frequency or change in pattern to longstanding visual aura typical visual aura – Daily = epileptic visual phenomena • Co-existence of seizures – 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 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: Normal ocular examination – HT • R 6/9, L CF – No CVA, IHD • No RAPD, normal optic discs 0.3 • POH: • IOP – Strabismus childhood – R 16mmHg, L 17mmHg – L Amblyopia • FH: Glaucoma (sister) HVF Not reliable Management? • Neuro-imaging? • Feb 2014 – Returned for R cataract management • CT and CTA Head: – Acephalgic migraines less frequent – Dec 2012 again – Normal Ms DC 52yo • PC: spinning propeller in R Superotemporal VF, expands, becomes colourful kaleidoscope 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 • Presented Aug 2016 Cancer • Review 4 weeks with HVF – Surgery • If deterioration, MRI – Radiotherapy – Chemotherapy – Hormone treatment • 1 day before appointment – Found confused, headache, vomiting • CT scan with contrast 23/6/16 – (didn’t turn up at work) – No cause to explain symptoms Ms DC 52yo Acephalgic migraine vs retinal migraine •Usually young, well adults • Patchy fading vision over 5 min, then poor vision for 5-60mins •+/- headache •Choroidal circulation in spasm + •No neurologic symptoms No headache •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 loss Monocular • Age? • Exercise or heat: – >50yo: Amaurosis fugax? Uhthoff’s phenomenon (cardiovascular workup) (optic neuritis/MS) – > 50yo & older: GCA? • Gaze evoked amaurosis: – All ages, <50yo orbital tumour? E.g. Carotid dissection (trauma, neck pain, Ipsilateral Horner’s syndrome, dysgeusia) Patterns of vision loss Transient 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 symptoms Take 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 lesion Red 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.