Migraines with visual aura (commonly known as ophthalmic migraines), sensitive or phasic, are manifested by the appearance of neurological symptoms before migraine headache. These may be bright white spots, tingling or language disorders. When to consult? What treatments should be considered?
In Belgium, about one adult in five suffers from migraine, with a clear female predominance (women are three times more affected than men). This neurological disease does not result in violent headaches, called recurrent headaches. A distinction is made between migraines without aura (80% of attacks) and migraines with aura (20%) for which visual, sensory or phasic disorders (language) are observed before the onset of headache. These different symptoms can occur simultaneously. A few years ago, migraines with visual aura were nicknamed “ophthalmic migraines”, but this expression is no longer used.
Visual aura is a neurological phenomenon and not an ocular one. It is related to the activation of certain neurons in the brain region responsible for vision in the posterior cortex. This abnormal activation triggers the appearance of light spots sometimes described as lightning or kaleidoscopic vision, during which the vision is blurred. These signs are called scintillating scotomas.
“There is certainly a genetic component since several members of the same family may suffer from it. However, no gene has yet been identified,” says Dr Caroline Roos, neurologist and head of the Headache Emergency Centre at Lariboisière Hospital (AP-HP). Migraine patients would therefore have a brain predisposed to have seizures. A susceptibility that makes them more vulnerable to multiple triggering factors such as:
- the alcohol,
- sudden changes in brightness,
- hormonal variations,
- lack of sleep,
- emotional changes.
Symptoms and duration of headache
Migraines with aura are characterized by the appearance of visual (scintillating scotomas, loss of vision), sensory (tingling, tingling around the mouth) and/or phasic (language disorder) disorders. These auras precede migraine headache, which manifests itself as a headache that often affects only one side of the skull and is felt as pulsatile. It is accompanied by intolerance to light and noise, as well as nausea and vomiting. This violent headache, aggravated by everyday gestures such as climbing stairs, can last from 4 hours to 3 days.
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Diagnosis: Should an MRI be done?
To diagnose a migraine, with or without aura, the doctor relies on the symptoms described by the patient as well as clinical examinations, especially neurological ones, imaging examinations (MRI) are not necessary because this disorder cannot be explained by the existence of a lesion. “The diagnosis of migraine with aura is based on at least 2 of the following 6 criteria: presenting one of the neurological symptoms called positive symptoms, the progressive installation of the aura, the succession of the different symptoms, the duration of the aura must be between 5 and 60 minutes, be unilateral, followed or be accompanied by a headache,” explains the neurologist.
Treatment: what to do in case of migraine?
The treatment of migraine is based on the elimination of triggering factors as far as possible, the treatment of the attack and disease-modifying treatment. “The effectiveness of crisis treatment depends on how early it is. The earlier the patient takes his treatment, the faster the seizure will be relieved. The patient is advised to take 1g of aspirin at the time of the aura or a non-steroidal anti-inflammatory drug (NSAID) to limit the duration of the aura and prevent headache,” explains Dr. Roos. If headache still occurs, patients are advised to take the classic migraine treatment, triptans, which act on specific receptors in the brain. They can be combined with NSAIDs. However, the doctor will emphasize the risks of abuse and remind patients that NSAIDs should not be taken more than 15 days per month and triptans no more than 10 days per month.
When this crisis treatment is no longer effective enough or when patients have frequent migraine attacks, doctors can offer disease-modifying treatment. “This one is based on taking 1g of aspirin or amitriptyline, an antidepressant, daily. In the most severe cases, drugs that are not initially intended for migraine, such as antiepileptics or some anti-hypertensives, can be offered,” says Dr. Roos.
Non-pharmacological approaches have also been shown to relieve patients, such as relaxation-sophrology methods and cognitive-behavioural therapies that help to better manage stress. On the other hand, chiropractic techniques, osteopathy or homeopathy have not proven their effectiveness.
As a general rule, ophthalmic migraine attacks require the patient to be rested, if possible in total darkness.