NEUROOPHTHALMOLOGY OF MIGRAINE

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NEURO-OPHTHALMOLOGYOF MIGRAINE
HEADACHE
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HEADACHES 98

• A changing pattern

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Neuro-Ophth of MIGRAINEOBJECTIVES

• Classification
• Neuro-Ophthalmic Features
• Classic Migraine
• Retinal Migraine
• Ophthalmoplegic
• Rx

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HEADACHES DIAGNOSIS

• CLASSIFICATION OF HEADACHE
• WHATS COMMON
• WHEN TO WORRY
• WHEN TO TREAT
• WHERE TO FIND INFORMATION

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IHS Classification

• 1. Migraine
• 2. Tension
• 3. Cluster
• 4. Miscellaneous
• 5. Trauma
• 6. Vascular
• 7. Non-vascular intracranial

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IHS Classification

• 8. Substances or withdrawal
• 9. Noncephalic Infection
• 10. Metabolic Disorder
• 11. Cranium, neck, eyes, ears, sinuses, teeth, or
  mouth
• 12. Neuralgias
• 13. Headache not classifiable

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IHS CLASSIFICATION1. MIGRAINE
1.1 MIGRAINE WITHOUT AURA 1.2 MIGRAINE WITH
AURA 1.3 OPHTHALMOPLEGIC 1.4 RETINAL 1.5
CHILDHOOD 1.6 COMPLICATED
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1.1 MIGRAINE WITHOUT AURA
Idiopathic, recurring headache disorder manifestin
g in attacks lasting 4-72 hours Typically
unilateral, pulsating quality, moderate to
severe, aggravated by activity. With nausea,
photo- and phonophobia. Common migraine
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1.1 MIGRAINE WITHOUT AURA

• COMMON gt 10 POPULATION
• 18 OF WOMEN
• PERIODIC - ANY PATTERN
• AUTONOMIC DISTURBANCE
• USUALLY UNILATERAL
• USUALLY THROBBING SOMETIME

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1.1 MIGRAINE WITH AURA

• 1/50 MIGRAINE SUFFERERS
• VISUAL PATTERN - CLASSIC
• HEADACHE FOLLOWS WITHIN 1HR
• CAN OCCUR WITHOUT HEADACHE
• ISOLATED VISUAL AURAS IN ADULT LIFE

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1.1 MIGRAINE WITH AURA
Requires at least two attacks with any three of
the following four features 1 One or more
fully reversible aura symptoms 2 aura
developing over a course of more than four
minutes or 3 lasting less than sixty minutes
and 4 headache following aura within sixty
minutes.
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Visual Auras of Migraine
Varieties of migraine hallucination represented
in the visions of Hildegard during the 12th
Century
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Visual Auras of Migraine
Varieties of migraine hallucination represented
in the visions of Hildegard during the 12th
Century
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Visual Auras of Migraine
ONSET
10 MINUTES
MIGRAINE SCOTOMA
20 MINUTES
40 MINUTES
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Visual Auras of Migraine
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Visual Auras of Migraine

• OFTEN REPETITIVE IN A GIVEN PATIENT
• FORTIFICATION SPECTRA (LIKE A FORT)
• SLOW SPREAD 5 - 40 MINUTES
• VIVID, SCINTILLATING, PULSATING
• IMPRESSED UPON MEMORY

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Fortification Spectra
A "map of the bastions of a fortified
town Lashley KS Patterns of cerebral
integration indicated by scotomas of migraine.
Arch Neurol Psych 194146333
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Later Life Migraine with Aura

• Migraine with aura can antedate 40 years
• Acephalic - migraine without pain
• Spontaneous - no prior history
• Migraine Dissocieé

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1.3 OphthalmoplegicMigraine

• Rare ( 1/5000 migraine pts)
• Onset in males before 14
• Uniocular pain x 3-4 days
• Followed by III, IV or VI
• Pupil involved
• No studies needed, esp NO A/G

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1.3 Ophthalmoplegic Migraine

• Onset - Childhood
• No Family History
• Pain - ipsilateral to ocular paralysis Severe,
  periorbital Duration - Days
• Ocular Paralysis - ptosis first , pupillary
  involvement
  Duration 1-4 weeks, permament after years
  90 III, some VI, very rare IV

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Ophthalmoplegic Migraine is NOT

• 33 yo woman, new onset mild unilateral pain
• Complete III, involving pupil
• Negative CT !! ( double contrast)
• Need for urgent Arteriogram
• Grade I - Post-Co. A Aneurysm
• Successful surgery see final CT reading

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Ophthalmoplegic Migraine is NOT

• 66 yo diabetic man with very painful new onset
• Paresis of III, involving pupil, but incomplete
• Relative pupillary sparing
• Diabetic - Medical III
• No need for urgent Arteriogram
• Ischemic nerve or midbrain infarct

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Ophthalmoplegic Migraine is MAYBE

• 24 college student with periodic pupil dilation
• Usually painless, occasional mild discomfort
• No double vision
• No ptosis
• Episodic benign unilateral mydriasis

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1.4 RetinalMigraine

• Common ( 1/100 migraine pts)
• Similar visual pattern, but MONOCULAR
• Headache follows but may be on background of
  throbbing HAs

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Retinal Migraine is not

• 25 yo Medical student with episodic painless
  visual loss (30 min )
• Rare pain, no periodic migraine
• Amaurosis Fugax
• No MRI
• DX Retinal Migraine

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Retinal Migraine is not

• 25 yo Medical student with amaurosis fugax
• Finally MRI, Huge pituitary tumor invading
  cavernous sinus
• Episode of 45 min visual loss documented - NLP
  4 RAPD
• Cleared with surgery

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Retinal migraine NOT
Dirr LY, Janton FJ, Troost BT Non-benign
amaurosis fugax in a medical student. Neurology
199040349
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8.2 HEADACHE INDUCED BY CHRONIC SUBSTANCE USE OR
EXPOSURE
8.2.1 ERGOTAMINE INDUCED HEADACHE 8.2.2 ANALGESIC
ABUSE HEADACHE 8.2.3 OTHER SUBSTANCES
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ANALGESIC ABUSE

• MOST COMMON HEADACHE
• TRANSFORMED MIGRAINE
• CHRONIC DAILY HEADACHE
• 10-20 TYLENOL / DAY
• ENDORPHIN SUPRESSION
• TREATMENT PLAN

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THERAPY OF HEADACHEPRINCIPALS

• MAKE DIAGNOSIS - MOST HEADACHES HAVE VASCULAR
  COMPONENT
• AVOID ANALGESICS AS MUCH AS POSSIBLE BOTH CLASS
  II AND OTC
• PREVENTION

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PREVENTIVE THERAPY

• CALCIUM CHANNEL BLOCKERS
• BETA BLOCKERS
• DEPAKOTE
• SANSERT
• NSAIDS
• LITHIUM
• ANTIDEPRESSANTS

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THE WAR OF THE TRIPTANS

• Sumatriptan
• Naratriptan
• Zolmitriptan
• Rizutriptan

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ACUTE TREATMENT

• IMITREX
• ZOMIG
• MAXALT
• MIGRANAL - DHE NASAL
• FUTURE FROVATRIPTAN, ELETRIPTAN

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ACUTE THERAPY
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ACUTE THERAPY
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Zomig Contraindications
ZOMIG should not be given to patients with
ischemic heart disease (angina pectoris, history
of myocardial infarction, or documented silent
ischemia) or to patients who have symptoms or
findings consistent with ischemic heart disease,
coronary artery vasospasm, including Prinzmetal's
variant angina, or other significant underlying
cardiovascular disease (see WARNINGS).
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ACUTE THERAPY
FDA APPROVAL 6- 30-98, NOW IN PHARMACIES
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ACUTE THERAPY
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PATIENTS TO WORRY ABOUT

• OBESE 20 YO WOMAN PSEUDOTUMOR
• 75 YO WOMAN - NEW ONSET TEMPORAL ARTERITIS
• 40 YO MAN WITH DAILY HAs ANALGESIC ABUSE

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PATIENTS TO WORRY ABOUT

• STROKE WITH HEADACHE SAH OR TUMOR
• DIZZINESS WITH HEADACHE CEREBELLAR STROKE
• 46 YO MAN WITH CHANGED EXAMINATION METASTASIS

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