retinal migraine

7 September 2018

Another Reminder: Retinal Migraine may not be what it seems…

There has been a lot of confusion about retinal migraine over the years. We’ve all heard of migraine with aura – an attack which includes “aura” symptoms, usually visual.

Retinal migraine is a specific type of migraine with aura. It involves symptoms such as blindness, a blind spot, or patterns/flashes of light, but only in one eye. And always temporary.

Aura symtpoms - but what cause? Recently a report was published about a 47 year old woman who was diagnosed with retinal migraine. She had temporary blindness in one eye, and headache on the same side. This went on for a year, then 15 months.

Medication was a help – in this case, topiramate and propranolol.

But when these were discontinued, the symptoms eventually returned.

Now as we’ve talked about before (see “What is Retinal Migraine?”), it’s very important to see a doctor and rule out other possible diagnoses. In this case, it wasn’t migraine at all, but something else that looked a lot like it.

This woman actually had isolated orbital vasculitis, which involves an inflammation of the walls of certain blood vessels. When treatment for this condition was give (steroid pulse therapy), the symptoms cleared up completely.

The correct diagnosis was finally made using high-resolution vessel wall magnetic resonance imaging.

There are many conditions that “look like” various types of headache conditions, and may be resolve or temporarily resolve or appear to resolve using standard medication. But it’s still important to investigate other possibilities. In this case, it would have saved one woman months of disabling symptoms.

7 December 2017

Ocular Migraine Symptoms

James Information 0

Discussing ocular migraine symptoms can be frustrating because the term itself remains confusing. The International Headache Society has provided guidance in the diagnosis of migraine conditions and symptoms through their “International Classification of Headache Disorders”, which lists various types of headache and migraine disorders. But ocular migraine isn’t one of them.

Ocular Migraine Symptoms? So if your doctor is using the term, I would encourage them to refer to the classification system, which will help us all speak the same language!

Types of “Ocular Migraine”

Today, people who are talking about ocular migraine symptoms are typically referring to some type of migraine with aura (yes, there are many types!). But first let’s take a look at the warning symptoms, because visual symptoms can be a sign of various conditions. If you’re having vision problems, and any of the below describes you, see a doctor immediately.

Warning signs:

Visual symptoms last for less than 5 minutes.
Visual symptoms last more than an hour.
Symptom is primarily partial or complete blindness (as opposed to seeing flashing lights, etc).
You have recently had a stroke or brain injury.
The symptoms are new – this is especially a concern if you are over 40.

Even if none of the above is true, if these are new symptoms to you, you should see a doctor. Issues such as transient ischemic attack (TIA) (mini-stroke) and even stroke can closely mimic migraine. Your doctor will need to rule out other conditions before giving you a diagnosis.

Now you’re still experiencing ocular migraine symptoms, and you want to narrow down your diagnosis some more. This will help.

What type of migraine?

Are you experiencing “motor weakness” along with the visual symptoms? Motor or muscle weakness may be a sign that you’re suffering from a type of hemiplegic migraine.
Are you experiencing other strange symptoms, such as jerky movements, trouble speaking, trouble hearing, vertigo, double vision, or even a decreased level of consciousness? Some of these may be typical of migraine with aura, but they could indicate migraine with brainstem aura.
Is the aura strictly visual, and it’s happened several times? Do the visual symptoms always last between 5 minutes and 1 hour? And are they always in only one eye? If so, you may have retinal migraine.

If none of these fit you, you may have typical migraine with aura.

Now, you’ll notice I didn’t say a lot about headaches. Yes, it is common to have headaches along with retinal migraine – but it’s not always the case. It is possible to have retinal migraine attacks with no headache. It is also possible to have typical aura without headache, which is more common and can have more varied symptoms than the more specific retinal migraine.

Underneath many of these types of migraine, there are also sub-types.

If you’re wondering if it’s worth getting a specific diagnosis for your ocular migraine symptoms, it is. Some of these types of migraine have treatments that specifically work with that migraine type.

A neurologist with experience in migraine and headache conditions can help you find a diagnosis and a treatment.

The Mayo Clinic has a brief but helpful article on ocular migraine symptoms here.

Again, if these are new symptoms, you should go to a doctor who can help you rule out various other possibilities. Whether migraine or not, these can be serious and debilitating symptoms.

12 December 2014

What is Retinal Migraine?

James Information 3

What exactly is retinal migraine? Do I have it, or could it be another disease?
What is Retinal Migraine
Over the past year, our article from 2009 about retinal migraine (5 Signs You have Retinal Migraine) has become the most popular article at Headache and Migraine News. But almost six years later, it’s time to revisit the discussion.

There is a lot of confusion over just what retinal migraine is, and that confusion is making it difficult to find proper treatment.

First, retinal migraine is a type of migraine with aura. There are various different types of migraine with aura, and different treatments are commonly used depending on which type you have.

There are various types of “aura”, some visual but some involving muscle weakness or difficulty speaking, for example. Retinal migraine used to be in a category by itself, but it is now categorized along with other aura types. In fact, more specifically, it is considered migraine with typical aura.

Symptoms of Retinal Migraine

Retinal migraine symptoms must be temporary, must involve vision, must be in one eye, must be repeated, and must NOT be associated with a disorder other than migraine.

Visual symptoms will vary. You might have an area of vision blocked out, or you may go blind in one eye. Or, there may be visual patterns and flashes.

Typically, the aura spreads gradually over a few minutes, and lasts an hour or less. Usually (but not necessarily) the aura will be followed by a headache.

The important thing to remember here is that retinal migraine is still something pretty specific. If your symptoms are in both eyes, for example, you do not have retinal migraine.

Important: It May Not Be Migraine

It is absolutely critical to have a doctor examine you if you think you may have retinal migraine. There could be other causes of these symptoms.

For example, loss of vision in one eye could be a sign of a stroke. It could be a sign of carotid artery disease, in which arteries supplying blood to the brain are blocked. Needless to say, this could be very serious.

Aura symptoms could also be a sign of traumatic brain injury. A brain tumour may also lead to similar symptoms.

Some people still think of “retinal migraine” as a common, benign disorder. But a careful examination and proper treatment (whether it’s retinal migraine or not) is critical.

The diagnostic criteria above is based on The International Classification of Headache Disorders, 3rd edition (beta version) (pdf)

28 January 2011

But my doctor says…. (retinal migraine and dealing with different diagnosis)

James Information 5

Recently we have had some discussion on the post about retinal migraine. Many of the comments revolve around what exactly a "retinal migraine" is – which, of course, was why I brought the topic up in the first place.

Adele posted a helpful link to a Mayo Clinic article on ocular migraine and retinal migraine by Dr. Dennis Robertson. It’s a good place to start into this topic.

So Dr. Robertson’s information appears to disagree with the article here on retinal migraine. Why?

First off, we can start by affirming our respect for the work of the Mayo Clinic and also the work of Dr. Robertson. I have frequently sent visitors to the Mayo Clinic for information, and I’ve done a lot of research using their website and offline publications as resources.

Dr. Robinson, now retired, has had a distinguished career. He has specialized in eye disorders, such as retinal disorders and tumours of the eye.

Secondly, it should be pointed out that both articles do agree, for the most part. We’re not talking about major differences here. If you’re hoping for a big fight here, you’re not going to get it. 🙂

In fact, looking at the article from the Mayo Clinic again, I can’t find anything worth directly disagreeing about. Adele’s question actually has to do with the comparison between retinal migraine and ocular migraine. Does retinal migraine include "pattern" visual disturbances or not? Dr. Robinson seems to only mention these in relation to ocular migraine, whereas I mention them as a symptom of retinal migraine.

Ocular Migraine and Retinal Migraine: Terminology Alert

Dr. Robertson has worded his answer very carefully. He starts by saying,"The term "ocular migraine" can be confusing. It’s sometimes used to refer to two different conditions…"

Then he writes,"In some cases, "ocular migraine" describes a migraine aura that involves your vision…"

It’s what Dr. Robertson is referring to, but isn’t taking the time to explain, that’s causing the confusion (he’s trying to be concise, and I understand why he didn’t want to go off on rabbit trails).

There is a lot of confusion. These are not universal terms that everyone understands. In the medical community, even, people will diagnose the exact same thing calling it two different names. In the world of migraine, this situation has become horrendous, and has caused a lot of confusion.

Here at the Headache and Migraine News Blog, I support the use of The International Classification of Headache Disorders (ICHD-II) from the International Headache Society. The ICHD is an attempt to help us all work together by teaching us to speak a common language. It doesn’t force doctors to diagnose or treat you a certain way, it just helps them to use terminology that everyone can understand. Read more about the ICHD-II and why it’s useful here.

There is no "ocular migraine" listed in the ICHD-II. That’s not because people with these symptoms don’t have migraine, it’s simply because they use a different term for these symptoms.

Just as ocular migraine has been used to refer to very different sets of symptoms, so has retinal migraine. That’s confusing.

There is one difference, though. Retinal migraine is in the ICHD-II list. So we can define it in a way that can be understood.

What is Retinal Migraine?

Of course, I’ve already offered some information here, but I’m actually going to show you exactly what the committee from the International Headache Society wrote, so you have another source:

International Headache Society Classification of Retinal Migraine

There are more notes, and more we could say, but that’s the basic summary.

What did Dr. Robertson say? Retinal migraine involves repeated bouts of short-lasting, diminished vision or blindness. This may precede or accompany a headache.

Is he right? Yes. And he goes on to mention that this occurs in one eye (monocular above). Right again.

What about seeing "patterns", as I mentioned in my article? Well, Dr. Robertson didn’t really specify one way or another, simply saying that there was loss of vision.

The ICHD-II is more specific, mentioning scintillations (flashing or twinkling lights), and scotomata (an area of decreased vision which can be manifest in a number of ways, including odd patterns).

Dr. Rima M. Dafer, Associate Professor at the Department of Neurology and Neurological Surgery Loyola University in Chicago, USA, acknowledges the ICHD-II classifications and writes this about retinal migraine:

Retinal migraine (ophthalmic, ocular) is not an uncommon cause of transient monocular blindness in young adults. It is manifested by recurrent attacks of unilateral visual disturbance or blindness lasting from minutes to 1 hour, associated with minimal or no headache. This phenomenon is frightening to patients, who usually seek medical help to exclude amaurosis fugax due to ischemia of the retinal arteries. Patients describe a gradual visual disturbance in a mosaic pattern of scotomata that gradually enlarge, producing total unilateral visual loss….

Once again, notice that retinal migraine has been called ocular migraine at times. But the correct ICHD-II name is retinal migraine.

And, of course, notice that there are sometimes visual disturbances in "patterns".

Comparing apples and blanji fruit

It’s a challenge to compare apples and blanji fruit. Why? Because there’s no such thing as blanji fruit!

Of course, Dr. Robertson has a slightly easier job. Some doctors have used the term ocular migraine with some kind of consistency. But it’s an old term, being used less and less, and a term that’s been used for different symptoms. It’s better to compare retinal migraine with something with a generally accepted definition, such as migraine with aura.

So why use terms like ocular migraine?

Both Dr. Robertson and I have used the term ocular migraine in the past. Why? Because people are still being diagnosed with it, and people are still asking about it.

But I think we do need to be careful to point out that it’s an imprecise term (which Dr. Robertson did). I do think it would have been helpful if his article had been a little more specific. But his article was not intended to be a point-by-point comparison.

Take-Aways from Dr. Robertson

The main part of Dr. Robertson’s article is very important. He writes: Most often, loss of vision in one eye isn’t related to migraine. It’s generally caused by some other more serious condition. So if you experience visual loss in one eye, be sure to see an eye specialist.

Many of those more serious conditions are specialties of Dr. Robertson, and he should know. If you are experiencing visual disturbances in one eye, make sure you get it carefully checked out!

Take home lessons from James

So, what if my doctor is diagnosing me with something that doesn’t seem to agree with what I read online, or what I read in the ICHD-II document? Here are some thoughts:

Don’t assume your doctor is simply "ignorant". Not all doctors have the time to keep up with the latest in migraine research and terminology. That does not mean that your doctor is not treating you properly. She may just be using different older terminology, and she may be from a different field of expertise.
Then again, this may mean your doctor is ignorant. Sadly, some doctors simply haven’t bothered to learn much of anything about migraine. If you begin to suspect that is the case, you should start looking for a second opinion, and maybe a new doctor.
Of course, you already know this, but there is a LOT of misinformation out there! Some official-sounding websites have information that is completely wrong, and at worst they’re there to scam you (remember this one?). Keep asking questions, until you understand. Check sources you trust, and see if they’re all saying the same thing – if not, ask why not.
Remember that this is an ongoing conversation. Someday the ICHD-II will be updated again, and things will change. Just because your doctor doesn’t agree with some of the standard diagnosis and treatments, doesn’t mean she’s wrong. Please, let’s never think that. And remember, there are a lot of details we’re still discussing. For instance, should we require headache before diagnosing with retinal migraine? Are there certain types of visual disturbances that are more common in retinal migraine?
Consider pointing your doctor to the ICHD-II website, and talk together about which one of the migraine or headache types there fits with your symptoms.
Let’s keep trying to speak the same language. Doctors, specialists, advocates, patients, researchers – let’s keep trying to clarify what we’re talking about. It may seem at times like we’re being picky, but it really helps avoid a lot of confusion, and helps us focus on the main issues. In this world, more and more people are joining the conversation. A "secret language" all your own is no longer possible.

Anyone can be wrong, and anyone can make a mistake. That’s why it’s so important that people like Adele take the time to ask questions and compare things. Keep it up, and let’s see to it that someday soon retinal migraine is an obsolete term – because no one is suffering from it anymore!

9 January 2009

5 Signs You have Retinal Migraine

James Information 94

A diagnosis of retinal migraine may be more and more common, but there’s still confusion over what exactly it is. There are five signs that you can use to tell if you have retinal migraine, but don’t miss the important warning at the end…

One eye: First, the eye symptoms tend to be monocular, meaning they’re only in one eye.
Visual disturbances: So what’s going on in this one eye? There are a variety of disturbances which other migraine sufferers may be familiar with. This might include flashing lights, or patterns in your visual field. There may be an area where your vision is impaired (ie dark spots), or even loss. Even blindness in one eye is possible with retinal migraine.
Temporary: Permanent vision loss is another matter. With retinal migraine the symptoms are reversible.
Headache: A headache typically starts during the visual disturbances, or within an hour after they stop. The headache typically lasts between 4 hours and 3 days, is often one-sided and pulsating, and usually either includes sensitivity to light and/or sound, nausea, or both. There is an increasing body of evidence showing cases of retinal migraine without headache as well. There is an argument that the "headache" not be necessary for a diagnosis of retinal migraine, but usually it’s still included.
Repeated: In order to actually be diagnosed with retinal migraine, you need to have had at least 2 attacks.

Now that you’ve got the 5 signs, it’s time for the warning. It’s very important that other causes have been ruled out. It’s easy to get a misdiagnoses here, so some things are very important:

It’s helpful to see your doctor during an attack, so she can ask the appropriate questions to diagnose you.
You need to have a normal eye exam in between attacks. Remember, this is temporary. There are a number of things that can cause similar visual disturbances, such as brain damage, tumours, ischemic optic neuropathy (damage to the optic nerve) and other optic disorders. Even if the symptoms are coming and going, it’s very important to rule out other causes.
Make sure your doctor has your medical history, and family medical history as much as possible. This will help her narrow down the possibilities to the most likely.
If your symptoms don’t quite fit the above criteria, you may have another type of migraine. Migraine aura without headache is a typical suspect if you have no headache, especially if you’re having symptoms in both eyes. Migraine with aura is another possibility if you have the headache but your visual symptoms are more varied. If you’re not sure about what your doctor is telling you, get a second opinion.

Researchers suspect decreased blood flow to the eye or optic nerve may be to blame for the unique symptoms of retinal migraine. However, like other types of migraine, the overall cause is still a mystery.

The good news is that retinal migraine often decreases or disappears with typical migraine treatment. Be sure to see a specialist and discuss your options.