Ocular Migraines and Glaucoma
Chat Highlights
September 14, 2005

On Wednesday, September 14, 2005, Dr. Rick Wilson a glaucoma specialist at Wills, and the glaucoma chat group discussed "Ocular Migraines and Glaucoma."

Moderator:  The topic tonight is "Ocular Migraines and Glaucoma."  Dr. Wilson, what causes migraine headaches?

Dr. Rick Wilson:  Migraines are caused by a vasospasm of the vessels in the brain.  In some areas of the brain, the vasospasm can cause intense headache after the visual "scotomata" (scintillating lights and grayed out or blurred vision).  In other areas of the brain, the visual changes occur without a headache following.

P:  What is the difference between an "ocular" migraine, a "classic" migraine, and a "common" migraine?

Dr. Rick Wilson:  Dr. Mark Moster, who is a neurologist, would be much better at explaining that than I am.  The ocular migraine has the visual changes that are not followed by a headache.  The classic migraine has the classic "fortification scotoma" (a zigzag shimmering line across the vision on either the right or left half of both eyes), followed a short time later by a severe, one-sided headache and often nausea.  The common migraine may not have all the "classic" scotomata (visual changes), but usually has one-sided visual changes, followed by a one-sided headache.

P:  Does the aura usually occur on the same side as the migraine headache will occur?

Dr. Rick Wilson:  It's usually on the opposite side, since the left half of the brain sees the right half of the vision, and vice versa.

P:  So pain is not a symptom of ocular migraines?

Dr. Rick Wilson:  Correct.

P:  Does it make a difference in the treatment of my glaucoma if I also suffer from migraines?

Dr. Rick Wilson:  A spasm of the vessel wall muscles constricts the flow of blood in the vessel and decreases blood flow to the area served by that vessel.  If you are prone to vasospasm, you are more at risk of normal-tension glaucoma.

P:  Why is that?

Dr. Rick Wilson:  The vasospasm may decrease the blood flow to the optic nerve during periods of vasospasm or, more likely, the body is unable to regulate blood flow to many parts of the body as well as it should.

P:  Do some migraneurs develop a blind spot during an attack?

Dr. Rick Wilson:  Yes, they may not be able to see at all to one side.

P:  Do auras signal the beginning of a migraine headache?  How long do they last?

Dr. Rick Wilson:  Auras (the visual changes) do signal the beginning of a migraine.  For some people, the severity of the attacks forces them to go to bed.  Often, if they get to sleep, the headache will be gone when they awaken.  The headache can last for more than 24 hours.

P:  What do the visual auras look like?

Dr. Rick Wilson:  The auras look like shimmering lights in a darkened area of vision, the zigzag lines I spoke of earlier, and blind spots in the vision on either the right or left side of both eyes.

P:  Besides affecting vision, can auras cause other sensory changes?

Dr. Rick Wilson:  Some patients have told me that before their migraines start their skin feels different, etc.

P:  How do migraine medications work, and what's in them?

Dr. Rick Wilson:  Some medications are for pain.  Others try to stop the vasospasm.  In the past, beta-blockers were prescribed for frequent migraines to try to prevent them from occurring.  The newer medications are better, but I am not familiar with them.

P:  What effect does Imetrex have on blood flow to the eye?  I use it a great deal, and it seems to help my headaches, which usually feel as there's a tight rubber band around my eye.

Dr. Rick Wilson:  I don't want to tell you, because I'm not sure.  I would think it would either improve flow or have no effect, but since I don't prescribe it, I am not sure.

P:  Should my treatment be any different for glaucoma if I have optic nerve damage and suffer from migraines?

Dr. Rick Wilson:  You should perhaps be monitored more closely, and may need a lower target IOP (intraocular pressure).

P:  Do people with little or no vision remaining suffer from migraines?

Dr. Rick Wilson:  Yes.  Since the vasospasm is in the brain, they are still subject to pain even if the visual changes are not noticeable.

P:  Migraines used to be called "sick headaches."  Is that because they were often accompanied by nausea and vomiting?

Dr. Rick Wilson:  Yes.

P:  Do many of your glaucoma patients have migraine headaches?

Dr. Rick Wilson:  About 25% have migraines, but 48% of patients with normal-tension glaucoma have migraines.

[Editor's Note: "Recent studies show that 23 million Americans, approximately 18% of females and 6% of males, have at least 1 migraine headache a year. . . The estimated cost of lost productivity is $1-13 billion a year."  Migraine Headaches, Vision Effects, http://www.emedicinehealth.com/articles/35023-1.asp]

P:  Do sub-acute attacks of angle-closure glaucoma, with pain and nausea, feel similar to migraines?

Dr. Rick Wilson:  The visual changes are much different, and the pain with migraines is a headache, rather than an eye ache or pain.  Both can cause nausea.

P:  Can eye surgery start the incidence of migraine?

Dr. Rick Wilson:  No.  In women, migraine is often related to hormonal changes.

P:  I have ocular migraines (painless scintillation), normal intraocular pressures, nerve damage in one eye (the one that tends to have ocular migraines), and no progression (with no medication).  I had sudden vision loss.  The damage is in the eye with the slightly lower pressure.  Would you be inclined to regard that as glaucoma or ischemic optic neuropathy, and what would cause you to distinguish between the two?

Dr. Rick Wilson:  The appearance of the optic nerve.  Glaucoma is usually a slowly progressive disease without symptoms, so any sudden change in vision would certainly incline me toward ischemic optic neuropathy.  ("Ischemic" meaning loss of blood supply.)

P:  Do ocular migraines ever manifest as vertigo or light arrays and patterns?

Dr. Rick Wilson:  I don't think vertigo is a part of it, but the light arrays and patterns, like zigzag lines, are very common.

On September 21, Dr. Spaeth discussed "The Competent Physician" in the Chat room. Click here for highlights of that meeting.

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