• Migraines: More Than Meets the Eye


    During her William F. Hoyt Lecture, Kathleen B. Digre, MD, discussed the growing understanding of the link between migraine and the eye and explained why this common condition is not merely the concern of neurologists.

    “And now I’ve got the job of a lifetime, which is to convince all ophthalmologists that you need to know about the eye and migraine,” said Dr. Digre.

    Why migraines are within your scope. First, migraines are a common source of eye pain and visual disturbances: Dr. Digre estimated that every ophthalmologist at the meeting will have a patient with migraine in their clinic soon after AAO 2017. Second, these symptoms should be investigated. The “visual quality of life” for patients with chronic and episodic migraine “is similar to [that seen in patients with] Graves disease, idiopathic intracranial hypertension, and optic neuritis,” she said. “We have to pay attention to this disorder.”

    Pain in the eye. Dr. Digre explained that the overlap between migraine and eye pain becomes clear when you consider that the eye, orbit, and dura—which are known to be involved in migraine—are all innervated by the V1 branch of the trigeminal nerve. “That the eye should be a source of pain in migraine should not be surprising to anyone in this room,” she said.

    The dry eye connection. Studies have shown that patients with Sjögren syndrome have a higher incidence of migraines compared with the general population. Additionally, patients with chronic migraine have been shown to have shorter tear break-up time and lower tear production on Schirmer tests.

    The mechanism underlying the association between migraine and dry eye has yet to be elucidated, but the answer may lie in the trigeminal nucleus caudalis. This area of the brainstem receives input from the aforementioned eye-pain nerves as well as the integrated lacrimal functional unit, which is responsible for tear production.

    Key points for practice. While much is yet to be learned about migraine, ophthalmologists should be prepared to treat ocular effects of this very common condition. Dr. Digre’s take-home tips for any ophthalmologists are as follows:

    • Learn to recognize the unique visual phenomenon associated with migraine. Visual snow can be treated with lamotrigine. Patients may simply have to live with other symptoms. However, you can assure them that these symptoms are real and shared with other migraine sufferers.
    • Treat the dry eye. As these patients often experience dry eye, addressing this condition with medical therapy will improve patients’ vision-related quality of life and may improve migraine symptoms.
    • Diagnose the cause of photophobia. Many patients come to their physicians complaining of photophobia, and it is important to ask them if they have a history of migraines. If all other causes of photophobia have been eliminated, it may be due to the overactive and highly sensitive sensory systems that are a hallmark of the migraineur’s brain. These patients may benefit from FL-41 spectrum filter sunglasses, which have been proven to reduce photophobia by blocking blue light. —Aliyah Kovner

    Watch the Q&A. In an interview from AAO 2017, Dr. Digre explains why all ophthalmologists should take a closer look at migraines (video).

    Financial disclosures: Royalty on a book: P; One-quarter owner on a patent for thin filmed technology: P.

    Disclosure key. C = Consultant/Advisor; E = Employee; L = Speakers bureau; O = Equity owner; P = Patents/Royalty; S = Grant support.