How Do You Draw Circles?
Random correlation: only 46% of the general population draws circles counterclockwise (or anticlockwise), but 64% of migraine sufferers draw circles counterclockwise. No one knows why.
Is Visual Snow a Migraine Aura?
What is Visual Snow?
Visual snow looks like falling snow, static on a TV, or tiny dots in all or part of the visual field. It can be considered to be a form of visual hallucination, and can also present as a migraine phenomenon. The technical term for this is Positive Persistent Visual Disturbance. Persisting visual snow in a migraineurs is also called persistent aura without infarction.
Visual snow can also be a manifestation of Hallucinogen Persisting Perception Disorder, following the use of hallucinogen drugs (LSD, ecstasy, psychedelic mushrooms, and others). In HPPD, other visual distortions are frequent, including starbursts, afterimages, palinopsia (trails on moving objects), and others.
In a prospective study of 120 patients with persistent visual snow, substance abuse was present in 40%. This study found that in addition to visual snow, many patients also experienced floaters (73%), persistent after-images (63%), photophobia (54%), flashes (44%), moving objects leaving trails (palinopsia – 48%), difficulty seeing at night (58%), “little cells that travel on a wiggly path” (57%), and “swirls with eyes closed” (41%).
A more recent study has found that on PET studies, subjects with visual snow had evidence of a brain dysfunction (a hypermetabolic lingual gyrus) that is different from what is found in migraine. Of 120 patients with “visual snow”, 70 patients also had migraine and 37 had typical migraine aura. The migraineurs with visual snow were more likely to experience palinopsia (trailing objects or afterimages) as well.
For the migrainous form of persisting visual snow, acetazolamide has been propsed, as well as valproate, topiramate, and lamotrigine. Visual snow related to HPPD has been managed with pharmaceutical as well as non-pharmaceutical strategies.
References:
1.Chen WT, Fuh JL, Lu SR, Wang SJ. Persistent migrainous visual phenomena might be responsive to lamotrigine. Headache 2001; 41: 823-825.
2. Haan J, Sluis P, Sluis LH, Ferrari MD. Acetazolamide treatment for migraine aura status. Neurology 2000; 55: 1588-1589.
3. Haas DC. Prolonged migraine aura status. Ann Neurol 1982; 11: 197-199.
4. Jäger HR, Giffin NJ, Goadsby PJ. Diffusion- and perfusion-weighted MR imaging in persistent migrainous visual disturbances. Cephalalgia 2005; 25: 323-332.
5. Rothrock JF. Successful treatment of persistent migraine aura with divalproex sodium. Neurology 1997; 48: 261-262.
6. Rozen TD. Treatment of a prolonged migrainous aura with intravenous furosemide. Neurology 2000; 55: 732-733.
7. Schankin C, et al “Visual snow: a new disease entity distinct from migraine aura” AAN 2012; Abstract S36.006.
8. Schankin, C. J., Maniyar, F. H., Sprenger, T., Chou, D. E., Eller, M. and Goadsby, P. J. (2014), The Relation Between Migraine, Typical Migraine Aura and “Visual Snow”. Headache: The Journal of Head and Face Pain, 54: 957–966.
Post updated 6/17/19
Traumatic Brain Injury
Acquired Head Injuries an Increasing Source of Headache?
The Centers for Disease Control have recently released updated information regarding traumatic brain injury. From this data, the leading cause of TBI was unintentional falls, and the second most common cause was due to motor vehicle-traffic injury. Motor vehicle-related injury was the primary cause of death due to head injury, and was more common in men.
Groups at highest risk were children from birth to age four, and adults aged 75 years and older. Adolescents aged 15-19 years were at somewhat increased risk over other groups. In all age ranges, males were more affected by TBI than were females.
The direct medical costs in addition to the indirect costs of TBI, from things such as lost productivity in the workplace, totaled an estimated $60 billion in the US in 2000. With the rate of TBI increasing, these costs will also increase accordingly.
Consensus has been reached that headache is common in the initial phases of MTBI. Thus, an increase in the rate of posttraumatic headache can be expected if the rate of TBI is increasing.
References:
1 Faul M, Xu L, Wald MM, Coronado VG. Traumatic Brain Injury in the United States: Emergency Department Visits, Hospitalizations and Deaths 2002–2006. Atlanta (GA): Centers for Disease Control and Prevention, National Center for Injury Prevention and Control; 2010.
2 Carroll LJ, Cassidy JD, Peloso PM, Borg J. von Holst H, Holm L, Paniak C, Pepin M. Prognosis for Mild Traumatic Brain Injury: Results of the WHO Collaborating Centre Task Force on Mild Traumatic Brain Injury. J Rehabil Med 2004; Suppl. 43: 84–105.
3 Finkelstein E, Corso P, Miller T and Associates. The Incidence and Economic Burden of Injuries in the United States. New York (NY): Oxford University Press; 2006.
TRPV1, Migraine, and Sumatriptan
What on earth is TRPV1? TRPV1 is an ion channel brain receptor – the long name is transient receptor potential vanilloid 1 (for you biology geeks). It is also known as the capsaicin receptor.
TRPV1 is activated by chemical irritants, inflammatory mediators, and physical mediators of tissue damage, like high temperatures and acid pH. The TRPV1 receptors are located in skin, tissues of the airways, gastrointestinal linings, and the outer coverings of the eye (cornea and conjunctiva). It has also been identified in various areas of the brain. It is thought to have a central role in neurogenic inflammation.
Although the functions of TRPV1 are still being identified, its role in central nervous system inflammation has made it a target for migraine research, as it may possibly play a role in causing hyperalgesia and allodynia. TRPV1 is thought to affect craniofacial pain via the trigeminal nerve system, in addition to other painful conditions. TRPV1 antagonists have been a target for drug development for various painful conditions, including migraine.
However, we already have an existing drug for migraine that has TRPV1 activity. Sumatriptan (Imitrex®, Imigran®, Sumavel®, Alsuma®) has been found to block the effects of capsaicin (the substance that makes chili peppers hot) on the trigeminal neurons in the brainstem. This confirms the role of TRPV1 receptors in the migraine process, and helps our understanding of migraine pathways. It may lead us to new therapies.
References:
1. Evans MS, Cheng X, Jeffry JA, Disney KE, Premkumar LS. Sumatriptan Inhibits TRPV1 Channels in Trigeminal Neurons. Headache: The Journal of Head and Face Pain. 2012;52(5):773–784.
2. Menigoz A, Boudes M. The Expression Pattern of TRPV1 in Brain. J. Neurosci. 2011;31(37):13025–13027.
3. Veronesi B, Oortgiesen M. The TRPV1 Receptor: Target of Toxicants and Therapeutics. Toxicol. Sci. 2006;89(1):1–3.
4. Meents JE, Neeb L, Reuter U. TRPV1 in migraine pathophysiology. Trends Mol Med. 2010;16(4):153–159.
New Film Depiction of Chronic Migraine: A Review of Lily’s Mom
If you have the opportunity to see Lily’s Mom, do so. This movie is about a woman, Mary, from a dysfunctional family who is in a bad marriage, and who has frequent headaches. She is in danger of losing her job because of her chronic migraine headaches, and has no practical support system. But she wants to do her best to support her daughter, Lily.
The story unfolds as Mary, Lily’s mom, sees a therapist and gradually gains control of her life, and then her migraine headaches.
Lily’s Mom starts on a dark note, but quickly pulls you in and you find that you are rooting for Mary as she makes choices to reclaim her life. The movie ends with hope for a bright future.
Lily’s Mom was written, produced, and directed by Dr. Ed Messina, a headache specialist in Michigan. Find out more about Lily’s Mom.
Can Bad Vision Cause Headaches?
Uncorrected Vision Problems and Headache
Guest post by Dr. Ingo Anderle, ophthalmic optician
There is a correlation between headaches and migraines and improperly corrected refractive errors and undetected strabismus. This indicates a need to build closer interprofessional relationships between neurology and optometry
This article serves to illustrate the experience I have had with headache patients in my optometric and optical practice, the effects of detecting improper correction of refractive errors, and the detection of hidden strabismus. The correction of these problems results in patients seeing better, having a better life, and having found relief.
To emphasize the need for a closer collaboration between neurology and optometry, I will use two cases I have seen at my practice and treated accordingly.
CASE I
Female patient, 42 years of age, wearing glasses for close to 35 years. Myopic (near-sighted), with astigmatism and anisometropia of 2dpt.
Patient comes in for a check-up to get new glasses. Her history reveals that she has been suffering almost daily from headaches since puberty and increasingly from migraines, which at the time of consultation averaged 3 days per week. Consulting a number of doctors about her migraines and headaches did not provide effective treatment and left her with medication to be taken as required. Patient is working in an office environment, spending about 8 hours on a computer. Hobbies include knitting and other close range activities and the use of a laptop computer at home.
Initial exam reveals her current Rx (2 years old) is over-minussed with 1dpt OS, overall, slight changes in prescribed correction for astigmatism. Fundus eye exam is normal, anterior part doesn’t show any pathologies.
During binocular testing, the patient was shown a split screen red/green image and trial frames fitted accordingly with red and green filter. The patient was asked to describe what she sees and reported that the clarity of image was identical, but that the left hand side green image kept wandering over to the left. This procedure, as well as the way the question was posed, revealed the strabismus and the need of 5pdpt, Base 0º of correction OS. Had the patient only been asked which side was better, rather than to describe her experience, she would have answered they were identical and that would have left the strabismus undiagnosed.
Accomodation is still fine for near vision and only long distance Rx is prescribed.
(New Rx OD: -3.00(cyl -0,50 x5º) / OS: -5,75 (cyl -0,50 x75º) P 5pdpt Base 0º)
Glasses were made at our in-house workshop. Prism is fitted only OS. (Lenses used: Zeiss Clarlet 1.67 Aspheric with Lotutec AR.) Centres are fitted at 3mm below pupil centre and at exactly the same I.P.D. as in the trial frames during the eye exam. After wearing the glasses with the new Rx for only 3 days the patient is reporting a significant improvement in visual acuity and not suffering from headaches as before.
At the annual check-up the patient reported an almost complete cessation of headaches and only occasionally suffering from a migraine (usually weather dependent). Vision Rx is stable and reading glasses with Add 1.00 are prescribed.
At the 2 year check-up the patient is reporting the same as the year before, Rx is stable and reading Add has changed to 1.25.
The patient requested seperate reading glasses. Prism is fitted at 4pdpt and patient is reporting her satisfaction with her new glasses.
CASE II
Female patient, 35 years of age turns up for a new Rx for new glasses. Medical history reveals that the patient is suffering from moderate to severe headaches over a period of 5 years. The average daily medication taken is Ibuprofen 1200mg or equivalent in Paracetamol (acetaminophen). Her current glasses are of the following RX: OD -4.00 (cyl -0,75 x 25º) P 1,5pdpt Base 270 (vertical prism) OS: -2,00 (cyl -1,00 x 5º). The glasses appeared to be very tilted and not in a straight position on the patients face. When mentioned this, she said “I see better that way.”
Over the past 5 years the patient underwent a number of exams and consulted a neurologist numerous times. An MRI and CT scan were performed, both normal. The patient was at the point of giving up trying to find a cure for the headaches and was trying to live with them and not expecting any improvement.
The exam revealed the following RX: OD -3.00 (cyl -0,50 x30º) /OS: -2,00 (cyl-0,75 x 175º), no vertical prism was detected, and again overminussed OD.The vertical prism in her glasses must have been caused by a mistake during the fitting process of the lenses, since no vertical prism was detected during the exam. Her problems with headaches started soon after she had the current pair of glasses made and since then she did not have an eye exam and no new glasses.
The patient did not want to believe that just a new Rx and new glasses would make a significant difference in regard to her headaches. Understandably, after a 5 year ordeal, MRI and CT scans, and consulting neurologists, she did not have any confidence in finding a cure.
However, new glasses were made and after only 2 days she reported back and could not believe that she had not had a headache and that she was generally feeling a lot better. Two weeks later, I called for a follow up and she reported a continued absence of headaches and came in to order a second pair of glasses.
CONCLUSION
As both cases illustrate, there can be a lack of good quality service available when it comes to eye examinations, and there is a shortfall in interprofessional collaboration between neurology and optometry.
Both patients would have benefitted greatly from being referred to an optometrist by their doctors, but both patients also had the unlucky experience with incorrect prescriptions and/or incorrectly made glasses and a lack of experience in binocular testing.
Current practice here in Andalucia (southern Spain) is that a doctor (mostly the GP) refers patients with symptoms such as headaches and blurred vision to consult an optometrist IF they currently do not wear glasses. If a patient is wearing glasses, it is widely assumed that they must be correct (both regarding Rx and correctly fitted) and I hardly ever see a referral to an optometrist.
The relationship between wrongly corrected eyesight or undercorrection and headaches is known and nothing new.
In my opinion it would be good to see more referrals from neurologists to the optometrist, even if it is to exclude wrongly/undercorrected eyesight in the diagnostic process.
POINTERS FOR THE OPTOMETRIC PROFESSION
There is a large shortfall in the quality of eye examinations by ophthalmologists and optometrists, especially in the way they conduct the pre-examination medical history (neither age, nor medications taken, underlying health conditions not explored, workplace and hobbies that give an idea on the demand the patient will have on vision and glasses not identified). Also, during the exam itself, leading questions do not assist in getting the correct picture. If the only question asked is whether one or the other option is better or worse, it does not allow the patients to accurately describe the visual picture they actually see. After all, the issued Rx is a subjective Rx.
Dr. Anderle is an optometrist practicing in southern Spain.
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