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  5. 头痛的视觉症状：类型、诊断与治疗综述

头痛的视觉症状：类型、诊断与治疗综述

文献检索匿名用户发表于 2026年06月12日 19:5814阅读
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头痛的视觉症状

头痛的视觉症状多种多样，既可以是头痛的常见伴随症状，也可能预示着其他潜在的眼科或神经系统疾病。了解这些视觉症状对于正确诊断和有效管理至关重要。

一、 偏头痛相关的视觉症状

偏头痛是一种常见的致残性疾病，影响全球15.2%的人口，是导致健康损失的第二大原因，在女性中居首位 。偏头痛的临床表现具有异质性，包括发作频率、有无先兆、对治疗的反应、伴随共病或其他症状等，这可能反映了偏头痛异质的遗传和分子基础 。

1. 偏头痛无先兆 (Migraine without aura) 这是儿童和成人中最常见的偏头痛形式 。虽然名称为“无先兆”，但发作症状多样且复杂。常见的视觉相关症状包括：

  • 畏光 (Photophobia)：对光线敏感，是偏头痛发作期间最常见的症状之一 。
  • 模糊视力 (Blurred vision)：在偏头痛发作时可能出现，但不是先兆性症状。
  • 眼痛 (Eye pain)：尽管偏头痛主要表现为头部疼痛，但眼部疼痛也可能伴随出现。

2. 偏头痛伴先兆 (Migraine with aura) 偏头痛伴先兆是一种常见的神经系统疾病，其特征是短暂的视觉、感觉和较少见的失语性先兆障碍 。先兆症状通常在头痛前发生，但有时也会在头痛之后出现 。

  • 视觉先兆 (Visual aura)：这是偏头痛伴先兆最常见的表现。视觉先兆可以是多种多样的，最典型的模式是“特征性的闪烁性幻视 (teichopsia)” 。
    • 闪烁性幻视 (Scintillating scotoma / Fortification spectrum)：由闪烁的锯齿状线条组成，从视野中心向外扩散，并在其后留下短暂的暗点（盲区） 。这些视觉症状的行进速度与视觉皮层中皮层扩散性抑制（CSD）的传播速度相似 。
    • 光幻视 (Phosphenes)：指眼前出现亮光、闪光点或闪光。常见的有明亮的闪光、小的亮点 。
    • 雾状视力 ("Foggy" vision)：感觉像透过雾气看东西 。
    • 锯齿状线条 (Zigzag lines)：视觉中出现锯齿状或波浪形的线条 。
    • 暗点 (Scotoma)：视野中出现盲区或部分视野缺失。可以是短暂的，也可以是持续的 。
    • 像透过热浪或水看东西 (Like looking through heat waves or water)：一种扭曲的视觉感知 。
    • 复杂而精细的幻觉 (Complex and elaborate hallucinations)：除了基本的视觉现象，还可能出现更复杂的幻觉 。
    • 多种视觉现象并存：患者报告的视觉先兆类型数量从2到23种不等 。
  • 偏头痛先兆无头痛 (Migraine aura without headache / Acephalgic migraine)：这是一种罕见的偏头痛亚型，其病理生理学可能与经典偏头痛相似，即皮层扩散性抑制（CSD）导致先兆形成，但没有相关的头痛 。这种形式主要表现为视觉先兆，但没有随后的头痛。它在4%的偏头痛患者中单独发生，在38%的偏头痛伴先兆患者中可能会在某个时间点出现 。

3. 视网膜偏头痛 (Retinal migraine) 视网膜偏头痛通常定义为“反复发作的完全可逆性单眼视力丧失，多伴有先兆” 。国际头痛疾病分类（ICHD）将其定义为“反复发作的单眼视觉障碍，包括闪烁、暗点或失明，并伴有偏头痛样头痛，且这些症状是完全可逆的” 。

  • 单眼视觉丧失 (Monocular visual loss)：这是视网膜偏头痛的主要特征，通常是暂时性和完全可逆的 。
  • 闪烁 (Scintillation)：视野中出现闪烁的光线或图案 。
  • 暗点 (Scotoma)：单眼视野中出现盲区 。

需要注意的是，视网膜偏头痛是一个排他性诊断，需要排除其他导致短暂性单眼视力丧失的原因 。

4. 偏头痛性脑梗死 (Migrainous infarction) 这是一种罕见的偏头痛并发症，可能导致持续性视觉改变 。例如，一名有偏头痛伴先兆史的患者在一次偏头痛发作后出现右眼持续性模糊视力，经检查发现左枕叶急性缺血性梗死，表现为右侧视野上半部分缺损（right superior homonymous quadrantanopia） 。

二、 其他疾病相关的视觉症状

除了偏头痛，多种其他眼科和神经系统疾病也可能表现出头痛和视觉症状。

1. 数字眼疲劳 (Digital Eye Strain, DES) / 电脑视力综合征 (Computer Vision Syndrome) 这是一种日益普遍的全球性问题，因为数字设备在工作和家庭生活中广泛使用 。DES的常见症状包括：

  • 头痛 (Headache)
  • 眼疲劳 (Eye strain)
  • 眼红 (Eye redness)
  • 眼痒 (Eye itching)
  • 流泪 (Tearing)
  • 畏光 (Photophobia)
  • 灼烧感 (Burning sensation)
  • 模糊视力 (Blurred vision)
  • 眼痛 (Eye pain)
  • 颈肩痛 (Neck and shoulder pain)
  • 眼干 (Eye dryness) DES的 ocular surface 症状与眨眼频率降低密切相关，这会导致眼表干燥、渗透压升高和类似干眼的症状 。

2. 青光眼急性发作 (Acute Angle Closure Glaucoma) 这是一种眼科急症，可能被误诊为偏头痛发作 。

  • 头痛 (Headache)
  • 恶心 (Nausea)
  • 模糊视力 (Blurred vision)
  • 双侧瞳孔散大固定 (Bilateral dilated and fixed pupils)
  • 眼睑下垂 (Ptosis)
  • 流泪 (Tearing) 一名33岁孕妇最初被诊断为偏头痛发作，但后来确诊为双侧急性闭角型青光眼，导致严重的视野缺损，影响了日常活动和驾驶能力 。

3. 颅内高压 (Intracranial Hypertension) 颅内高压是指颅内压持续升高，通常超过200 mm H2O，这是一种综合征，可由多种神经系统和全身性疾病引起 。其临床体征和症状包括：

  • 头痛 (Headache)
  • 视乳头水肿 (Papilledema)：视神经盘肿胀，是颅内压升高的重要体征 。
  • 短暂性视力模糊 (Transient visual obscurations)
  • 复视 (Diplopia)：看东西出现双影 。
  • 眼球运动障碍 (Ocular motor disorders)
  • 耳鸣 (Tinnitus)
  • 恶心、呕吐 (Nausea, vomiting)
  • 精神异常 (Mental irregularities)
  • 循环和呼吸系统功能障碍 (Dysfunctions of the circulatory and respiratory systems) 颅内高压最常见的原因是占位性病变、张力性脑积水和假性脑瘤 。

4. 眼睑下垂 (Ptosis) 上眼睑下垂可分为轻微、中度或重度，可能完全遮盖瞳孔，可影响单眼或双眼 。除了下垂，患者可能抱怨：

  • 疲惫的外观 (Tired appearance)
  • 模糊视力 (Blurred vision)
  • 流泪增多 (Increased tearing)
  • 肌张力性头痛 (Tension headache)：持续激活前额和头皮肌肉可能导致肌张力性头痛 。
  • 眼疲劳 (Eyestrain) 未经纠正的先天性眼睑下垂可能导致弱视，从而造成永久性视力不良 。

5. 巨型胶样囊肿 (Giant Colloid Cyst) 巨型胶样囊肿指直径超过3厘米的囊肿，非常罕见 。

  • 头痛 (Headache)
  • 模糊视力 (Blurred vision)
  • 发作性行为改变 (Episodic behavioral changes)
  • 双侧视乳头水肿 (Bilateral papilledema) 一名15岁女性因头痛、模糊视力和发作性行为改变就诊，发现巨型第三脑室病变，导致梗阻性脑积水，伴有双侧视乳头水肿 。

6. 视神经曲霉病 (Optic nerve Aspergillosis) 曲霉菌是一种普遍存在的空气传播腐生真菌，在免疫功能低下患者中可致病 。

  • 新发眼后头痛 (New onset headache behind the left eye)
  • 模糊视力 (Blurred vision)
  • 暗点 (Scotoma) 一名55岁女性曾有高血压和偏头痛史，在死亡前一年出现左眼后方新发头痛，随后出现模糊视力和暗点，最终确诊为视神经曲霉病 。

7. 抗胆碱能综合征 (Anticholinergic syndrome) 这种综合征可能导致：

  • 模糊视力 (Blurred vision)
  • 头痛 (Headache)
  • 瞳孔异常 (Pupil abnormality)：如逆向阿盖尔-罗伯逊瞳孔（对光反应保留，但调节功能丧失） 。 一名年轻女性因服用多种药物导致抗胆碱能综合征，表现为模糊视力和头痛 。

8. 空蝶鞍 (Empty sella) 空蝶鞍指蝶鞍内有空气，其临床症状多种多样且非特异性 。

  • 相对性视野缺损 (Relative visual field deficits)：可在无颅内压升高的情况下发生 。
  • 视乳头水肿 (Papilledema)：部分患者可出现，并被诊断为良性颅内压升高 。

9. 日光性视网膜病变 (Solar retinopathy) 这是由于未受保护的过度光线照射（如直视太阳）导致的视网膜损伤 。

  • 不对称性视力下降 (Asymmetric decreased vision)
  • 中心或旁中心暗点 (Central or paracentral scotoma)
  • 畏光 (Photophobia)
  • 视物变形 (Metamorphopsia)
  • 头痛 (Headache) 症状通常是双侧的，大多数病例在数周至6个月内自发恢复 。

10. 枕叶癫痫 (Occipital epilepsy) 在某些情况下，枕叶癫痫和偏头痛的视觉先兆可能存在诊断混淆 。这两种疾病在临床表达、发作性及慢性性质、以及半月形症状，特别是视觉现象方面都有相似之处 。

三、 诊断和管理

识别偏头痛的特点和患者的个体特征，有助于开具具体的药物和非药物治疗方案 。对于具有复杂或非典型视觉症状的头痛患者，需要进行彻底的医学检查和全面的眼科评估，以排除其他严重的神经系统疾病或眼科疾病 。

1. 诊断标准

  • 国际头痛疾病分类第三版 (ICHD-3)：是诊断偏头痛无先兆的关键工具，需要根据其特定的症状学进行正确诊断 。
  • ICHD-3亚节1.4.4：对偏头痛先兆触发的癫痫发作做出了诊断规定 。
  • ICHD-3亚节7.6：对归因于癫痫发作的头痛做出了诊断规定，进一步细分为7.6.1发作期癫痫性头痛和7.6.2发作后头痛 。
  • 计算机视觉综合征问卷 (CVS-Q) 和计算机视力症状量表 (CVSS17)：是评估数字眼疲劳的两种最常用和经验证的问卷 。

2. 鉴别诊断 头痛和视觉症状的鉴别诊断非常重要，因为许多疾病可能表现出相似的症状。例如：

  • 偏头痛与急性闭角型青光眼：可能被误诊 。
  • 偏头痛与颅内高压：颅内高压可导致头痛、视乳头水肿和短暂性视力模糊 。
  • 偏头痛与枕叶癫痫：二者的视觉先兆有时难以区分 。

3. 治疗方法

  • 偏头痛：急性治疗和预防性治疗的方法非常广泛，寻找最适合单个患者的治疗方案是挑战之一 。
    • 药物治疗：包括传统偏头痛治疗方法，如舒马曲普坦和地佐辛 。钙基因相关肽（CGRP）拮抗剂是较新的偏头痛疗法，对一些遗传性神经系统疾病（如线粒体脑肌病伴乳酸酸中毒和卒中样发作，以及伴有皮层下梗死和白质脑病的常染色体显性遗传性脑动脉病）中以偏头痛为主要特征的患者，能显著减少偏头痛发作频率 。
    • 神经阻滞：双侧枕大神经阻滞可能有助于中止持续性先兆偏头痛 。
    • 经颅磁刺激 (Transcranial magnetic stimulation)：已显示能有效中止伴先兆偏头痛发作，但尚未专门针对孤立性先兆进行测试 。
    • 生活方式干预：改善生活习惯和脑健康教育，可以减少需要专科护理的患者数量 。
  • 数字眼疲劳：
    • 环境改善
    • 人工泪液
    • 眨眼练习
    • 近距离工作休息
  • 颅内高压：治疗可能包括药物治疗（如利尿剂、皮质类固醇）、手术干预（如脑脊液分流术、视神经鞘减压术） 。
  • 眼睑下垂：治疗取决于年龄、病因、受累眼睑、严重程度、提肌功能以及是否存在其他眼科或神经系统异常，可包括观察等待、佩戴假体、药物或手术 。
  • 日光性视网膜病变：大多数病例在数周至6个月内自发恢复，急性期可考虑使用类固醇治疗以减轻炎症 。

四、 总结

头痛的视觉症状是一个复杂且异质性的临床表现，可能是偏头痛的典型特征，也可能是其他严重疾病的警示信号。全面的临床评估、准确的诊断工具和针对性的治疗策略对于改善患者预后至关重要。医生需要具备跨学科的视野，与眼科、神经科等相关专科紧密合作，为患者提供综合性的护理 。

References

1Migraine without aura.PubMed

Koen Paemeleire, Nicolas Vandenbussche, Richard Stark
Migraine without aura is the commonest form of migraine in both children and adults. The diagnosis is made by applying the International Classification of Headache Disorders Third Edition subsection for migraine without aura (ICHD-3 subsection 1.1). Attacks in patients with migraine without aura are characterized by their polyphasic presentation (prodrome, headache phase, postdromal phase). The symptomatology of attacks is diverse and heterogeneous, with most common symptoms being photophobia, phonophobia, nausea, vomiting, and aggravation of pain by movement. The clinician and researcher who wants to learn about migraine without aura needs to be able to apply the ICHD-3 criteria with its specific symptomatology to make a correct diagnosis, but also needs to be aware about the plethora of symptoms patients may experience. In this chapter, the reader will explore the clinical phenotypical features of migraine without aura.

2Hallmarks of primary headache: part 1 - migraine.PubMed

Alberto Raggi, Matilde Leonardi, Marco Arruda, et al.
BACKGROUND AND AIM: Migraine is a common disabling conditions which, globally, affects 15.2% of the population. It is the second cause of health loss in terms of years lived with disability, the first among women. Despite being so common, it is poorly recognised and too often undertreated. Specialty centres and neurologists with specific expertise on headache disorders have the knowledge to provide specific care: however, those who do not regularly treat patients with migraine will benefit from a synopsis on the most relevant and updated information about this condition. This paper presents a comprehensive view on the hallmarks of migraine, from genetics and diagnostic markers, up to treatments and societal impact, and reports the elements that identify migraine specific features. MAIN RESULTS: The most relevant hallmark of migraine is that it has common and individual features together. Besides the known clinical manifestations, migraine presentation is heterogeneous with regard to frequency of attacks, presence of aura, response to therapy, associated comorbidities or other symptoms, which likely reflect migraine heterogeneous genetic and molecular basis. The amount of therapies for acute and for prophylactic treatment is really wide, and one of the difficulties is with finding the best treatment for the single patient. In addition to this, patients carry out different daily life activities, and might show lifestyle habits which are not entirely adequate to manage migraine day by day. Education will be more and more important as a strategy of brain health promotion, because this will enable reducing the amount of subjects needing specialty care, thus leaving it to those who require it in reason of refractory condition or presence of comorbidities. CONCLUSIONS: Recognizing the hallmarks of migraine and the features of single patients enables prescribing specific pharmacological and non-pharmacological treatments. Medical research on headaches today particularly suffers from the syndrome of single-disease approach, but it is important to have a cross-sectional and joint vision with other close specialties, in order to treat our patients with a comprehensive approach that a heterogeneous condition like migraine requires.

3[Not Available].PubMed

Anna Elizabeth Mao, Daniella Bach-Holm
In this case report, a 33-year-old pregnant woman with migraine and visual aura complained of headache, nausea, and blurred vision. Clinically, she presented with bilateral dilated and fixed pupils, ptosis, and tearing. She was erroneously diagnosed as having a migraine attack, but after referral to an ophthalmological department she was diagnosed with bilateral acute angle closure. At one-year follow-up her visual acuity was normalized but the severe visual field defects affected her daily activities and prevented her from having a driving licence.

4Digital Eye Strain: Updated Perspectives.PubMed

Andrew D Pucker, Aaron M Kerr, Jennifer Sanderson, et al.
PURPOSE: Digital eye strain (DES) is a growing worldwide concern because digital devices are prevalent in both our work and home lives. The purpose of this review was to summarize clinically relevant and evolving key topics related to DES. METHODS: A PubMed.gov search was conducted on or before June 8, 2024. No date restrictions were used during the primary search. The search was aimed at detecting all articles related to DES; thus, the search terms only included "digital eye strain" or "computer vision syndrome". RESULTS: The two most used, validated DES questionnaires are the Computer Vision Syndrome Questionnaire (CVS-Q) and Computer Vision Symptom Scale (CVSS17). The world-wide prevalence of DES ranges from 8.2% to 100% depending upon the subjects evaluated and the method used to evaluate them. The most common DES symptoms include headache, eye strain, eye redness, eye itching, tearing, photophobia, burning sensation, blurred vision, eye pain, neck and shoulder pain, and eye dryness. Ocular surface symptoms in DES are integrally tied to decreased blink frequency, which causes ocular surface desiccation, increased osmolarity, and dry eye-like symptoms. The most studied DES-specific treatments are improving subjects' environment, artificial tears, blinking exercises, and near work breaks. CONCLUSION: DES is a highly prevalent condition that should be regularly screened for in clinic with a validated diagnosis instrument. While there are several treatment options, the community's treatment approach is evolving and primarily focused on treating the visual and dry eye-like symptoms associated with the condition.

5Migraine Aura Without Headache [corrected].PubMed

Divya R Shah, Sonam Dilwali, Deborah I Friedman
PURPOSE OF REVIEW: This review evaluates and explains our current understanding of a rare subtype of migraine, typical aura without headache, also known as migraine aura without headache or acephalgic migraine. RECENT FINDINGS: Typical aura without headache is a known entity within the spectrum of migraine. Its pathophysiology is suggested to be similar to classic migraines, with cortical spreading depression leading to aura formation but without an associated headache. No clinical trials have been performed to evaluate treatment options, but case reports suggest that most patients will respond to the traditional treatments for migraine with aura. Bilateral greater occipital nerve blocks may be helpful in aborting migraine with prolonged aura. Transcranial magnetic stimulation has shown efficacy in aborting attacks of migraine with aura but has not been specifically tested in isolated aura. Typical aura without headache occurs exclusively in 4% patients with migraine, and may take place at some point in 38% of patients with migraine with aura. Typical aura without headache commonly presents with visual aura without headache, brainstem aura without headache, and can also develop later in life, known as late-onset migraine accompaniment.

6Clinical features of visual migraine aura: a systematic review.PubMed

Michele Viana, Erling Andreas Tronvik, Thien Phu Do, et al.
BACKGROUND: Migraine aura (MA) is a common and disabling neurological condition, characterized by transient visual, and less frequently sensory and dysphasic aura disturbances. MA is associated with an increased risk of cardiovascular disorders and is often clinically difficult to distinguish from other serious neurological disorders such as transient ischemic attacks and epilepsy. Optimal clinical classification of MA symptoms is important for more accurate diagnosis and improved understanding of the pathophysiology of MA through clinical studies. MAIN BODY: A systematic review of previous prospective and retrospective systematic recordings of visual aura symptoms (VASs) was performed to provide an overview of the different types of visual phenomena occurring during MA and their respective frequencies in patients. We found 11 retrospective studies and three prospective studies systematically describing VASs. The number of different types of VASs reported by patients in the studies ranged from two to 23. The most common were flashes of bright light, "foggy" vision, zigzag lines, scotoma, small bright dots and 'like looking through heat waves or water'. CONCLUSIONS: We created a comprehensive list of VAS types reported by migraine patients based on all currently available data from clinical studies, which can be used for testing and validation in future studies. We propose that, based on this work, an official list of VAS types should be developed, preferably within the context of the International Classification of Headache Disorders of the International Headache Society.

7Intracranial hypertension.PubMed

A G Kabat
Intracranial hypertension is not a definitive diagnosis, but rather a syndrome that may result from a number of neurologic and systemic disorders. Intracranial hypertension refers to prolonged elevation of intracranial pressure, generally above 200 mm H2O. This condition may be recognized by the various clinical signs and symptoms that are manifest in most patients, including headache, papilledema, transient visual obscurations, diplopia, ocular motor disorders, tinnitus, nausea, vomiting, and mental irregularities, as well as dysfunctions of the circulatory and respiratory systems. Thorough medical testing as well as a comprehensive ocular evaluation is indicated in these cases. Intracranial hypertension most commonly results from mass lesions, tension hydrocephalus, and pseudotumor cerebri. Other causes include disorders of venous outflow, such as dural sinus thromboses or arteriovenous malformations, and various encephalopathies. Management for intracranial hypertension may involve medical treatment, drug therapy, or surgical intervention. Typically, diuretics are used initially. Corticosteroids may be used as well, although they are not the first choice for treatment. Cerebrospinal fluid shunting procedures may be necessary if medical treatment fails. Optic nerve sheath decompression may also be attempted when chronic papilledema threatens visual function. It is important that the primary care optometrist recognize the manifestations of intracranial hypertension in order to make necessary referrals for management of the underlying etiologies.

8Ptosis: causes, presentation, and management.PubMed

Josef Finsterer
Drooping of the upper eyelid (upper eyelid ptosis) may be minimal (1-2 mm), moderate (3-4 mm), or severe (>4 mm), covering the pupil entirely. Ptosis can affect one or both eyes. Ptosis can be present at birth (congenital) or develop later in life (acquired). Ptosis may be due to a myogenic, neurogenic, aponeurotic, mechanical or traumatic cause. Usually, ptosis occurs isolated, but may be associated with various other conditions, like immunological, degenerative, or hereditary disorders, tumors, or infections. Besides drooping, patients with ptosis complain about tired appearance, blurred vision, and increased tearing. Patients with significant ptosis may need to tilt their head back into a chin-up position, lift their eyelid with a finger, or raise their eyebrows. Continuous activation of the forehead and scalp muscles may additionally cause tension headache and eyestrain. If congenital ptosis is not corrected, amblyopia, leading to permanently poor vision, may develop. Patients with ptosis should be investigated clinically by an ophthalmologist and neurologist, for blood tests, X-rays, and CT/MRI scans of the brain, orbita, and thorax. Treatment of ptosis depends on age, etiology, whether one or both eyelids are involved, the severity of ptosis, the levator function, and presence of additional ophthalmologic or neurologic abnormalities. Generally, treatment of ptosis comprises a watch-and-wait policy, prosthesis, medication, or surgery. For minimal ptosis, Müller's muscle conjunctival resection or the Fasanella Servat procedure are proposed. For moderate ptosis with a levator function of 5-10 mm, shortening of the levator palpebrae or levator muscle advancement are proposed. For severe ptosis with a levator function <5 mm, a brow/frontalis suspension is indicated. Risks of ptosis surgery infrequently include infection, bleeding, over- or undercorrection, and reduced vision. Immediately after surgery, there may be temporary difficulties in completely closing the eye. Although improvement of the lid height is usually achieved, the eyelids may not appear perfectly symmetrical. In rare cases, full eyelid movement does not return. In some cases, more than one operation is required.

9[Migraine with visual aura].PubMed

S Bidot, D Biotti
Migraine with visual aura is marked by recurrent episodes of transient visual disturbance, often followed by headaches. Its pathophysiology has not been fully understood, but visual auras might be related to a self-propagating wave of cortical depolarization called "cortical spreading depression", triggering a trigemino-vascular "storm" ultimately leading to headaches. The most specific visual symptom is the "fortification spectrum" consisting of glimmering jagged lines spreading from the center to the periphery, and leaving a transient scotoma in its wake. Other visual symptoms are numerous, ranging from elementary positive or negative visual phenomena to complex and elaborate hallucinations. The diagnosis can be made according to the International Classification of Headache Disorders revised in 2013. The main goal of the treatment is to relieve the patient's pain quickly and to decrease the frequency of the episodes.

10Vision and migraine.PubMed

Maurice B Vincent
BACKGROUND: Migraine, a common brain disorder, disrupts vision more than any other motor or sensory function. The possible visual aura symptoms vary from occasional small flashes of light to complex visual hallucinations, the stereotyped teichopsia being the most typical pattern. It is unclear as to why aura occurs serendipitously, sometimes preceding, but also occurring after the headache, and why aura can present with multiple phenotypes. METHODS: To better understand the nature of visual disturbances in migraine, 4 aspects must be considered: What are the visual perceptions in migraine; why vision is affected in migraine; the role of cortical spreading depression (CSD); how does vision could affect migraine. Evidence supporting each of these topics is reviewed. RESULTS: CSD travels at a similar pace as the march of symptoms in the visual field. Functional neuroimaging studies show spreading changes compatible with CSD regardless of aura. Computerized models reproducing the CSD march on the visual cortex predict a sensory experience compatible with naturally occurring visual auras. Rather than spreading in all directions, these models suggest that CSD moves preferentially in one direction. Migraine-preventive drugs increase the CSD threshold and reduce CSD velocity. Blind migraineurs may present atypical visual aura, with more colors, shorter duration, different shapes, and atypical symptoms, such as auditory experiences. CONCLUSIONS: CSD is the underlying phenomenon in migraine with and without aura. In migraine without aura, CSD probably does not run over silent areas of the cortex, but rather does not reach symptomatology threshold. Normal vision is important in migraine, as lack of sight may change the visual experience during migraine aura, probably due to cortical reorganization and changes in local susceptibility to CSD.

11The 'empty' sella.PubMed

J P Berke, L F Buxton, E Kokmen
Records of all patients diagnosed as having an "empty" sella turcica at the University of Michigan Medical Center after 1972 were retrospectively reviewed. Nineteen patients satisfied the two criteria, absence of prior surgical or radiotherapeutic intervention and air within the sella turcica at pneumoencephalography. Associated clinical signs and symptoms were varied and nonspecific. Two patients had relative visual field deficits without increased intracranial pressure. Three patients had papilledema and were diagnosed as having had benign increased intracranial pressure. Increased intracranial pressure was not a consistent enough finding to be considered an etiology for the empty sella syndrome.

12Giant Colloid Cyst.PubMed

Ali Alkhaibary, Sami Khairy
Giant colloid cysts are defined as cysts of more than 3 cm in maximal diameter. Few cases of giant colloid cysts have been reported in the literature. We herein describe a giant colloid cyst. A 15-year-old female presented with headache, blurred vision, and episodic behavioral changes for 3 months. Neurological examination was limited due to agitation and confusion. Fundoscopy was notable for bilateral papilledema. Brain computed tomography revealed a giant third-ventricular lesion, causing obstructive hydrocephalus. The patient underwent urgent ventriculoperitoneal shunt insertion initially and then cyst excision. The histopathological sections of the lesion were compatible with a colloid cyst. Five years following surgical resection, a brain magnetic resonance imaging did not demonstrate any evidence of residual or cyst recurrence. To our knowledge, giant colloid cysts have been rarely reported and pose a management dilemma in the literature. The present article highlights the symptomatology, radiological findings, and outcome of a giant colloid cyst.

13Optic nerve aspergillosis.PubMed

Lisi Yuan, Richard A Prayson
We report a 55-year-old woman with optic nerve Aspergillosis. Aspergillus is an ubiquitous airborne saprophytic fungus. Inhaled Aspergillus conidia are normally eliminated in the immunocompetent host by innate immune mechanisms; however, in immunosuppressed patients, they can cause disease. The woman had a past medical history of hypertension and migraines. She presented 1 year prior to death with a new onset headache behind the left eye and later developed blurred vision and scotoma. A left temporal artery biopsy was negative for giant cell arteritis. One month prior to the current admission, she had an MRI showing optic nerve thickening with no other findings. Because of the visual loss and a positive antinuclear antibody test, she was given a trial of high dose steroids and while it significantly improved her headache, her vision did not improve. At autopsy, the left optic nerve at the level of the cavernous sinus and extending into the optic chiasm was enlarged in diameter and there was a 1.3 cm firm nodule surrounding the left optic nerve. Histologically, an abscess surrounded and involved the left optic nerve. Acute angle branching, angioinvasive fungal hyphae were identified on Grocott's methenamine silver stained sections, consistent with Aspergillus spp. No gross or microscopic evidence of systemic vasculitis or infection was identified in the body. The literature on optic nerve Aspergillosis is reviewed.

14Retinal migraine.PubMed

Bogdan Marius Istrate, Crisanda Vîlciu, Carmen Răgan
Retinal migraine is usually defined by transitory attacks of fully reversible monocular visual loss, mostly with aura. An accurate diagnostic can be completed based upon the International Classification of Headache Disorders-2 (ICHD-2) criteria. In view of this, we summarized some clinical features, treatment principles, complications, prognosis and prophylaxis.

15Borderlands of Migraine and Epilepsy.PubMed

Divyani Garg, Manjari Tripathi
BACKGROUND: The complex relationship between migraine and epilepsy has frequently been described to represent a clinical and electrographic "borderland." These two conditions share clinical expressions such as paroxysmal and chronic nature, as well as semiology, particularly visual phenomenon. OBJECTIVE: We aimed to review the current literature on the overlapping phenomena of migraine and epilepsy. MATERIALS AND METHODS: We searched the PubMed for relevant literature and conducted a narrative review on migraine and epilepsy. RESULTS: Migraine and epilepsy share a complex and pathophysiologically intriguing relationship. The International Classification of Headache Disorders, 3 edition (ICHD-3) makes diagnostic provisions for migraine aura-triggered seizures (Subchapter 1.4.4) and headache attributed to epileptic seizure (Subchapter 7.6), the latter being further categorized as 7.6.1 Ictal epileptic headache, and 7.6.2 post-ictal headache. Neurological conditions such as certain channelopathies and epilepsy syndromes exhibit both conditions within their phenotypic spectrum, suggesting shared genetic and molecular underpinnings. Diagnostic confusion may arise, particularly between occipital epilepsy and the visual aura of migraine. Antiseizure medications may be effective for the treatment of migraines that occur in concert with epilepsy. CONCLUSIONS: Migraine and epilepsy share several clinical features and have intertwined genetic and molecular underpinnings, which may contribute to common pathogenesis. Electroencephalography may be useful as a diagnostic tool in selected cases.

16Anticholinergic syndrome: blurred vision and headache.PubMed

Lisa McAnena, Gordon T Plant, Sui Hsien Wong
A young woman presented with blurred vision due to anticholinergic syndrome. We highlight the importance of considering this condition in the context of multiple medications and increased anticholinergic burden. The documented pupil abnormality gives an opportunity to review the syndrome of the reverse (inverse) Argyll Robertson pupil (preserved pupil light response with loss of accommodation). We review other situations in which the reverse Argyll Robertson pupil may occur and its possible mechanism in this case.

17Genetic migraine disorders and the response to calcitonin gene-related peptide antagonist treatment.PubMed

Andrea M Kuczynski, William S Kingston
Calcitonin gene-related peptide (CGRP) is a potent cerebral vasodilator and part of the trigeminal migraine cascade. Newer migraine therapies target CGRP signaling for both acute and preventative management of headache. In this series, we present two cases of genetic conditions, of which migraine is a key feature, responsive to CGRP antagonist therapy. A 31-year-old female with mitochondrial encephalopathy with lactic acidosis and stroke-like episodes and a phenotype of chronic migraine with visual aura, and a 62-year-old female with cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy with a phenotype of chronic migraine and side-locked headache with cranial autonomic symptoms. Each experienced a significant reduction in the frequency of their migraine attacks with monoclonal antibody treatment against CGRP. In this case series, we add to the growing body of evidence that CGRP-blocking medications are safe and effective in some heritable neurological disorders in which vasomodulation is a common underlying pathology. To our knowledge, we present the first cases of galcanezumab use in an individual with mitochondrial encephalopathy with lactic acidosis and stroke-like episodes and eptinezumab in an individual with cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy.

18Not just any headache.PubMed

Janet Fan, Pamela Davila, Noor Laylani, et al.
A 40-year-old man with a history of traumatic retinal detachment in the left eye treated with scleral buckle and migraine with aura presented to clinic for persistent blurry vision of the right eye following an episode of migraine with aura. The patient had experienced migraines with visual auras starting as a teenager, which normally resolve within an hour except for the most recent episode. Humphrey visual field showed right superior homonymous quadrantanopia. Computed tomography of the head without contrast showed acute ischemia in the left occipital lobe. Magnetic resonance imaging of the brain confirmed an ischemic infarct of the left occipital lobe. There were no significant abnormalities in complete blood count, metabolic panel, coagulation studies, and infectious testing. Echocardiogram and transthoracic echocardiography were normal as well, but further work up by cardiology revealed a patent foramen ovale on transesophageal echocardiogram. This case illustrates a rare case of migrainous infarction, which should be considered as a possible complication of migraine with aura, presenting with persistent visual changes.

19Solar retinopathy: A literature review.PubMed

Mohammad Jourieh
Solar retinopathy (SR) refers to retinal injury that results from unprotected excessive exposure to light. It has been associated with direct sungazing, sunbathing, laser pointers, and welding arc exposure. Symptoms are typically bilateral and are characterized by asymmetric decreased vision, central or paracentral scotoma, photophobia, metamorphopsia, and headache. In most cases, recovery occurs spontaneously with no specific treatment within weeks to 6 months after exposure. However, few cases have been reported in the literature using steroids in acute SR because of their anti-inflammatory effects. The aim of this review is to present an update about this entity, describing the pathogenesis, risk factors, and diagnostic methods, with focus on management and outcomes of SR.

20Current Perspective on Retinal Migraine.PubMed

Yu Jeat Chong, Susan P Mollan, Abison Logeswaran, et al.
Retinal migraine was first formally described in 1882. Various terms such as "ocular migraine" and "ophthalmic migraine" have since been used interchangeably in the literature. The lack of a consistent consensus-based definition has led to controversy and potential confusion for clinicians and patients. Retinal migraine as defined by the International Classification of Headache Disorders (ICHD) has been found to be rare. The latest ICHD defined retinal migraine as 'repeated attacks of monocular visual disturbance, including scintillation, scotoma or blindness, associated with migraine headache', which are fully reversible. Retinal migraine should be considered a diagnosis of exclusion, which requires other causes of transient monocular visual loss to be excluded. The aim of this narrative review is to summarize the literature on retinal migraine, including: epidemiology and risk factors; proposed aetiology; clinical presentation; and management strategies. It is potentially a misnomer as its proposed aetiology is different from our current understanding of the mechanism of migraine.
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