Migraines and Glaucoma
Chat Highlights
December 17, 2008

On Wednesday, December 17, 2008, Dr. Michael Pro, a glaucoma specialist at Wills, and the glaucoma chat group discussed "Migraines and Glaucoma".

Moderator: Tonight's topic is Migraines and Glaucoma.

P: Is there a correlation between all types of glaucoma and migraines or just certain forms of glaucoma?

Dr. Pro: For many years we have considered a relationship between normal tension glaucoma (NTG), also known as low tension glaucoma and migraines.

I should mention that much has been made about vasospasm and migraines. The thought was that migraines are due to defective cerebral circulation, but recent studies, such as those using functional MRIs, have not shown this. By the same token, there is now some debate about the role of migraines in glaucoma.

P: Doctor, can you define migraines? For example,I understand there can be ocular migraineswith no pain.

Dr. Pro: Great point. A classic migraine is some sort of aura (be it auditory, visual, olfactory, gustatory, etc.) followed by a terrible headache. The headache could last hours to even days. There are also ophthalmic migraines, which feature a visual aura but with no headache.

P: Is the visual field loss in those with migrainesdifferent than in those without?

Dr. Pro: Again, data from earlier research suggested that persons with NTG may be more prone to visual field defects closer to fixation (more centrally located). Unfortunately this kind of visual field loss is more disabling.

P: In those with migraines and glaucoma, does vision loss occur on the opposite side of the migraine?

Dr. Pro: Great question, but I am not aware of this. In fact, in many cases, visual field loss can be unilateral, and on the same side as the migraine.

P: Is visual field loss greater in those with migraines?

Dr. Pro: I often see severe field loss in patients with NTG. I have not seen the same correlation in migraines and extent of field loss.

P: Is glaucoma a side effect of the migraine medication, Topamax?

Dr. Pro: Topamax can cause a rare and unusual phenomenon of spontaneous angle closure glaucoma from uveal effusions (swelling of fluid in the eye wall). This attack can lead to very high pressure, but the attacks usually subside once the medication is stopped.

P: Are migraines a risk factor in the development or progression of glaucoma?

Dr. Pro: Some studies have demonstrated that it can be a risk factor.

P: Are there problems with other migraine medications and glaucoma medications?

Dr. Pro (Dec 17, 2008 7:46:07 PM)
Except for Topiramate (Topamax), the other medications used are not problematic.

P: Would someone with a history of severe and frequent migraines, malignant glaucoma attacks in both eyes, and who has had lasers, trabs, vitrectomies, and lens implants be a good candidate to try Topamax?

Dr. Pro: Well, I would say that the uveal effusions leading to angle closure attacks are more likely in persons who have not had cataract surgery (lens implants).

P: Why is glaucoma sometimes misdiagnosed as a migraine?

Dr. Pro (Dec 17, 2008 7:51:29 PM)
Migraines can lead to visual field defects which can be misdiagnosed as glaucoma, and thus visa versa. The defects due to migraines are poorly understood and may be either transient or permanent.

P: What conclusions does the Blue Mountains Eye Study make about glaucoma and migraines?

Dr. Pro: I think the Blue Mountain Study found an association between migraines and primary open angle glaucoma.

P: Can opthalmic migraines with the aura cause pigmentary glaucoma?

Dr. Pro: Pigmentary glaucoma is usually inherited from your parents. It is caused by pigment that falls off the iris and may lead to high pressure, but is not associated with migraines.

P: Would someone with NTG and migraines be more likely to lose vision than someone who never has experienced migraines and has Open Angle Glaucoma?

Dr. Pro: I would be more worried that the person with NTG and migraines is at risk for losing vision.

P: Can a migraine cause fixation defects in someone with open angle glaucoma?

Dr. Pro: If you mean central visual field defects, then I would say yes.

P: I have been having a lot of headaches, not migraine. Are those likely associated with my glaucoma?

Dr. Pro: When the pressure in the eye is high you can get eye pain and a referred headache. Most people have tension headaches, which are not associated with glaucoma.

P: I have migraines and open angle glaucoma. Is there anything I should ask my doctor. Outside of mentioning migraines, is there anything else I need to tell him?

Dr. Pro: I think it depends on the frequency of the migraines. Perhaps more frequent visual fields would be indicated, as you may be at risk for visual field worsening. If your neurologist is considering a beta blocker for prophlaxis then you may need to discontinue a beta blocker drop if you feel fatigue.

P: Is it possible that the medications may have caused deterioration in my visual filed since my pressures have always been low at eight and nine.

Dr. Pro: Glaucoma drops are not a cause of worsening glaucoma. There is a case report of the patient who had migraine headaches with a prostaglandin analogue (like Xalatan) which went away when the drop was stopped, but that is a different issue.

Moderator: Dr. Pro, our time is now up. Thank you again for joining us in the chat room and for a very educational chat. We will see you in 2009. Happy New Year!

Dr. Pro: Thank you. Until 2009 everyone!

On January 7, Dr. Pro discussed "Steroids and Intraocular Pressure" in the Chat room. Click here for highlights of that meeting.

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