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Headache and the eye
Abstract
Because of the inextricable link between the eyes and headaches, ophthalmologists are often the first physicians to evaluate
patients with headaches, eye pain, and headache-associated visual disturbances. Although ophthalmic causes are sometimes diagnosed,
eye pain and visual disturbances are often neurologic in origin. Many primary headache disorders have ophthalmic features,
and secondary causes of headache frequently involve the visual system. Both afferent and efferent symptoms and signs are associated
with headache disorders. Moreover, the frontal or retro-orbital pain of some primary ophthalmic conditions may be mistaken
for a headache disorder, particularly if the ophthalmologic examination is normal. This article reviews common ocular conditions
that are associated with head pain, and some secondary causes of headache with neuro-ophthalmic neuro-ophthalmic manifestations.
... Most of the headaches are often accompanied by ocular or peri-orbital pain, along with some visual symptoms, therefore it is attributed to ocular disease. Although ophthalmic causes are sometimes diagnosed, most ocular pain and many types of visual disturbances are neurologic in origin [3]. Thus, there exist an inextricable relation between eye and headache. ...
... Any inflammatory disease like acute iritis, uveitis, orbital cellulitis and preseptal cellulitis also orbital pain and headache. Dry eye may also cause headache and the medication used to treat headache may cause or worsen pre-existing dry eye [3]. One of the most encountered symptom of computer vision syndrome is headache. ...
... Migraine with Aura and Ocular Migraine: Aura symptoms of migraine include amaurosis fugax, scintillating scotoma, blurred visions, entopic phenomenon (phosphenes), visual hallucinations, etc [3]. Retinal migraine (otherwise known as ophthalmic migraines, anterior visual pathway migraines, or ocular migraines) causes monocular visual loss for 10-20 minutes which can be associated with diffuse or unilateral headache [26]. ...
A vast majority of cause of headaches are ocular, prime cause being neurological. Therefore, eye care practitioners are often the first physicians to evaluate, manage or if needed refer to designated department and specialty, the patients with headaches, eye pain, and headache-associated visual disturbances. Refractive error, oculomotor anomalies and ocular diseases contribute to headache and hence these causes need to be ruled out before going for expensive, invasive and time-consuming investigation. Health care professionals should always be generous in referring the patients to fellow physician, optometrist, ophthalmologist or any other specialists as per necessity.
... Many clinical syndromes are associated with localized pain in the orbital region [16][17][18][19][20][21][22]. Previously, some authors suggested that orbital pain may also be categorized based on differences seen in pain characteristics, degree of severity, and type of onset [21,22]. ...
... Many clinical syndromes are associated with localized pain in the orbital region [16][17][18][19][20][21][22]. Previously, some authors suggested that orbital pain may also be categorized based on differences seen in pain characteristics, degree of severity, and type of onset [21,22]. All sensation coming from the orbit is transferred along with the V1 distribution, while the ocular-motor nerves have been presumed to be strictly motor in function with no pain receptors or pain pathways [19,20]. ...
Trochlear Migraine has been recently described as the concurrence of strictly unilateral
migraine and ipsilateral trochleodynia with relief of migraine after successful treatment of trochleodynia. This disorder has been interpreted as “cluster-tic syndrome” or “seizure-triggered migraine”. Trochlear Migraine is unrecognized and rarely described in childhood. The aim of this study is to review the few cases of Trochlear Migraine reported in the literature in addition to the cases observed in our clinical experience. In particular, our cases showed recurrent attacks of severe and pulsating headache associated with nausea, vomiting, phonophobia, photophobia, and strict trochlear localization of pain. They often presented with alternating side attacks. Therefore, we suggest that
the term “Trochlear Migraine” should be reserved for clinical migraine attacks strictly localized in the trochlear region, and we assume that the excessive increase in descriptions of new primary headache syndromes, according to the International Classification of Headache Disorders, can be probably be ascribed to the common physiopathological mechanisms characterizing these forms of migraine.
... An ophthalmic examination may help detect signs of raised intracranial or intraocular pressure, inflammation, including keratitis, and refractive errors [156]. • An ear, nose, and throat specialist should be consulted when local inflammation (e.g., otitis or mastoiditis) and craniomandibular dysfunction are suspected [157]. ...
Headaches can be nociplastic, neuropathic, and nociceptive. Pain related to the latter two categories occurs in the presence of nerve lesions and nociceptive stimuli; attributing pain to the last category requires a list of potential causes and arguments supporting the causal claim. Taking a history and examining patients serves to assess diagnostic criteria and screen for disorders whose diagnosis requires additional examinations. Screening information occurs in two types: one indicates that patients have a headache due to another condition; the other suggests they are at risk. Aspiring to make causal claims for a headache is reasonable because if underlying disorders appear independently and randomly, it is probable that there is only one cause. Thus, having found a cause often implies having found the cause. The prerequisites for causal claims are temporal sequencing, correlation, and elimination of alternate causes. Mechanistic, manipulative, and probabilistic evidence supports the second criterion. The importance of headaches lies in their frequent appearance as an early symptom of an incipient disorder (“sentinel symptom”). Hence, they provide the opportunity to diagnose early diseases with potentially deleterious consequences. Thus, it is sensible to assess each attack carefully and systematically.
... 30,31 Furthermore, headache is associated with eyestrain and can further aggravate the symptoms. 32,33 Based on the results of this study, we deduce that headache/eyestrain is caused by reduced blink rates, tension of eye muscles, irritation by light, and continuously repeated movement of the head and neck during VDT work. [34][35][36] Unlike previous studies, this study classified working hours into daily VDT working hours and weekly total working hours to investigate the risk of headache/eyestrain. ...
Background:
Prolonged use of visual display terminal (VDT) can cause eyestrain, dry eyes, blurred vision, double vision, headache and musculoskeletal symptoms (neck, shoulder, and wrist pain). VDT working hours among workers have greatly increased during the coronavirus disease 2019 (COVID-19) pandemic. Therefore, this study aimed to investigate the relationship between VDT working hours and headache/eyestrain in wage workers using data from the sixth Korean Working Conditions Survey (KWCS) (2020-2021) conducted during the COVID-19 pandemic.
Methods:
We analyzed the sixth KWCS data of 28,442 wage workers aged 15 years or older. The headache/eyestrain that occurred in the last year was assessed. The VDT work group included workers who use VDT always, almost always, and three-fourth of the working hours, while the non-VDT work group included workers who use VDT half of the working hours, one-fourth of the working hours, almost never, and never. To analyze the relationship between VDT working hours and headache/eyestrain, the odds ratios (ORs) and 95% confidence interval (CI) were calculated using logistic regression analysis.
Results:
Among the non-VDT work group, 14.4% workers experienced headache/eyestrain, whereas 27.5% workers of the VDT work group experienced these symptoms. For headache/eyestrain, the VDT work group showed adjusted OR of 1.94 (95% CI: 1.80-2.09), compared with the non-VDT work group, and the group that always used VDT showed adjusted OR of 2.54 (95% CI: 2.26-2.86), compared with the group that never used VDT.
Conclusions:
This study suggests that during the COVID-19 pandemic, as VDT working hours increased, the risk of headache/eyestrain increased for Korean wage workers.
... Ophthalmologists play an important role in the evaluation of headache as there is inseparable association between eye and headache. 1 The headache may include facial pain, migraine or neurological pain. There are several cause of primary and secondary headache, secondary headache being more common in >40 yrs age group. ...
Ophthalmologists play an important role in the evaluation of headache as there is inseparable association between eye and headache. The headache may include facial pain, migraine or neurological pain. Headache may present as a medical emergency or as a routine case in outpatient department. Ophthalmologist play as front line physicians in diagnosing and managing such cases with proper referral if required. Few cases of headache as the presenting symptom in choroidal osteoma have been reported. Cause of headache may be due to blurred vision, sinus involvement, mechanical pressure effect, ischemic damage or an incidental association. The diagnosis of choroidal osteoma is mainly clinical. Majority of the cases remain asymptomatic and choroidal osteoma may be an incidental finding in a patient presenting with other complaints. This case report throws light on complete ophthalmic evaluation of every case of headache to ensure no important findings are missed.
... AVALIAÇÃO DA SENSIBILIDADE AO CONTRASTE LIANA C. MENDES, MELYSSA K. C. GALDINO, JÁKINA G.VIEIRA, MARIA L. B. SIMAS E NATANAEL A. SANTOS A migrânea é uma desordem neurológica comum, caracterizada por cefaleia moderada a severa, unilateral ou bilateral, latejante, com duração média de 4 a 72 horas, comumente acompanhada de fotofobia, fonofobia e náuseas (Wolthausen, Sternberg, Gerloff, & May, 2008). Há uma estreita conexão entre esta patologia e o sistema visual, pois algumas estimulações visuais desencadeiam a migrânea, e alterações neuro-oftálmicas são frequentes durante e entre os episódios (Friedman, 2008; Shepherd, 2000). Estas alterações podem ser causadas por disfunções no processamento subcortical (Drummond & Anderson, 1992; McKendrick, Vingrys, Badcock, & Heywood, 2000) e cortical (Friedman, 2004; McKendrick & Badcock, 2003; Wolthausen et al., 2008). ...
In this work, the aim was to measure the Contrast Sensitivity Function (CSF) among patients with, and healthy volunteers without this pathology. The subjects of the tests were 12 female volunteers, aged 20-37 years six of them with migraine, and six other ones without migraine. CSF measurements were performed using static visual stimuli of angular sine-wave gratings, with spatial frequencies of 2, 3, 4, 24 and 64 cycles/360º. Method used was the psychophysical one, with forced choice between two temporal alternatives, conditions of photopic luminance (screen average luminance of 41 cd/m²), and binocular vision with natural pupil. The results demonstrate that visual perception of contrast by the volunteers with migraine was lower in the frequencies of 2, 3, 4 and 64 cycles/360°. These preliminary findings suggest changes in the CSF related to this pathology.
People of all ages are using mobile devices more frequently, and more children are reportedly using digital media as well, which raises the risk of Digital Eye Strain (DES). There have been few studies on how often DES affects children particularly post-pandemic. The purpose of this study is to review published literature concerning DES, including its pathogenesis and therapy options. A literature search was performed based on PubMed, EMBASE and Scopus databases published from 2003 to 2023 using the broad search term “digital eye strain”, “ocular asthenopia secondary to digital gadgets”, “computer vision syndrome”, “eye strain post-computer or mobile use”, “visual weariness”, and “children" in all fields. Of the 163 articles retrieved, 107 were retained for inclusion in this review. The result reveals that there is an urgent need to inform parents, caregivers, and youth about setting screen time limits and applying ergonomic practices due to the recent surge in digital electronic gadget usage among kids and young adults.
Objective:
To study the relationship between tension-type headaches and the oculomotor system in terms of binocular coordination, mechanosensitivity of the supraorbital nerve, and myofascial trigger points in the lateral rectus muscle, assessing the influence of visual effort caused by using a computer at work. DESIGN : Observational study with blind evaluation of the response variable. METHODS : Two groups were compared: 19 subjects with tension-type headaches and 16 healthy subjects, both exposed to computer use at work. A blinded assessor conducted three tests: measurement of the supraorbital nerve pressure pain threshold using a pressure algometer, evaluation of myofascial trigger points of the lateral rectus using the verbal numerical scale, and assessment of binocular coordination in smooth pursuit eye movements using an innovative video-oculography system. Tests were performed before work began and four hours later, and subjects in the headache group were examined when they presented a headache score of less than or equal to 3 on the verbal numerical scale. RESULTS : The headache group presented a greater sensitivity of the supraorbital nerve and greater local and referred pain of the lateral rectus (P < 0.05). Visual effort caused a significant worsening of these variables in both groups. However, binocular coordination after visual effort was only significantly affected in the headache group (P < 0.05), primarily in horizontal movements. CONCLUSIONS : The finding of a higher alteration of the sensitivity of the supraorbital nerve, the myofascial trigger points of the lateral rectus, binocular coordination, and the significant influence of visual effort in patients with tension-type headaches suggest a new clinical perspective for problems related to tension-type headaches.
Evaluation of the headache patient begins with the historical exam. Physical findings of concern associated with the headache include: unequal weakness; generalized malaise and inability to ambulate; fevers; neck stiffness; and unequal pupils. Primary causes for the headache include tension headache, migraine, cluster and caffeine withdrawal, and the secondary causes include infection, subarachnoid hemorrhage (SAH), eye complaints, and tumors. Secondary headache is tending to improve as underlying cause of the headache is treated. This chapter presents a review of the common treatment options for the management of headache in the EMS environment. These include inhaled oxygen, anti-emetics, opioids, nonsteroidal anti-inflammatory drugs (NSAIDS), and analgesics. EMS providers must have a heightened level of concern for the causes of headache requiring emergent treatment. The area of headache evaluation and management in the EMS environment needs further study.
Retinal migraine is a primary headache disorder, clinically manifested by attacks of transient monocular visual loss associated with migraine headache. Although isolated reports suggest that retinal migraine is rare, it likely is under-recognized. Retinal migraine usually is reported in women of childbearing age who have a history of migraine with aura. It typically is characterized by negative monocular visual phenomena lasting less than 1 hour. More than half of reported cases with recurrent transient monocular visual loss subsequently experienced permanent monocular visual loss. Although the International Headache Society diagnostic criteria for retinal migraine require reversible visual loss, our findings suggest that irreversible visual loss is part of the retinal migraine spectrum, likely representing an ocular form of migrainous infarction.
Ten patients with migraine developed persistent positive visual phenomena lasting months to years. The complaints were similar in their simplicity and involvement of the entire visual field and usually consisted of diffuse small particles such as TV static, snow, lines of ants, dots, and rain. Neurologic and ophthalmologic examinations were normal, and EEGs were normal in eight of eight patients tested. MRI was normal in all patients except one who had nonspecific biparietal white matter lesions and another with a small venous angioma. Treatment of this unusual complication of migraine was unsuccessful.
To describe the clinical features of the syndrome of neurologically isolated episodic unilateral mydriasis.
Information was obtained by reviewing the case records of 24 patients evaluated by the author and collected by polling other neuro-ophthalmologists.
Nineteen patients were women. The median age was 31 years. Fourteen patients had migraines. The median interval between onset of events and evaluation was 6 months. The median duration and frequency of events were 12 hours and two to three per month, respectively. Most patients did not identify any factor that could precipitate an occurrence. The most common associated symptoms during an episode included visual blur in 15 patients, headache in 9, and orbital pain in 5. Eleven patients were examined during an attack. Three patients who were examined had impaired near vision, four had impaired accommodative function, and six had an anisocoria that increased with added ambient light. None of these patients had a tonic pupil or cholinergic agonist-induced pharmacologic mydriasis. Five other patients examined during an attack had normal vision and unimpaired direct light reactivity of their large pupil. No neurologic disorder was identified after neurodiagnostic testing, clinical evaluation, and natural history observation.
The syndrome of idiopathic episodic unilateral mydriasis probably comprises a heterogeneous group of conditions that result in parasympathetic insufficiency of the iris sphincter in some patients, and sympathetic hyperactivity of the iris dilator in others. Patients with episodes similar in characteristics to the ones described in this survey appear to have a benign neurologic prognosis, and do not require further neurodiagnostic studies.
The syndrome of intracranial hypertension without structural brain or cerebrospinal fluid abnormalities and without identifiable cause, now most appropriately termed idiopathic intracranial hypertension, was described over a century ago. Although the pathogenesis of this condition remains unknown, diagnostic and therapeutic developments during the past two decades have substantially advanced patient management.
To perform a decision analysis of temporal arteritis (TA) to guide clinicians in the interpretation of diagnostic testing and choice of therapy.
Computer-based decision analytic model.
A 785-node decision tree was created that reflects common testing and therapeutic options for a patient with suspected TA. A comprehensive literature search was then performed. From this search, point estimates and distributions for pooled probabilities and utilities were derived using inverse variance weighting and random effects techniques. Employing utility analysis, this decision model selects the diagnostic/therapeutic pathway resulting in the greatest utility for any user-defined set of patient characteristics on presentation.
Using utility analysis, the diagnostic/therapeutic pathway that results in the least expected disutility is selected as the optimal course of action.
The choice of diagnostic testing depends on several factors, including patient age, symptoms, and clinical findings. These factors can be used to calculate the pretest probability of TA being present. The optimal selection of diagnostic tests (laboratory or biopsy) depends on the pretest probability of disease. A temporal artery biopsy is recommended under most circumstances, with the choice of a unilateral versus bilateral biopsy depending upon blood test results and calculated pretest probability. A few scenarios exist in which blood tests alone can rule in or rule out TA without the need for biopsy. Empiric steroid therapy is almost never recommended.
In TA, both the disease and its treatment are hazardous for the patient. Clinicians should have a very low threshold to initiate a diagnostic workup for TA. Physicians are often uncertain when a temporal artery biopsy is indicated and whether to perform a unilateral or bilateral biopsy. Often, the pathway chosen is not evidence based. Although the biopsy has long been considered the gold standard for diagnosis, it is invasive and less than 100% sensitive. The decision whether to undertake unilateral or bilateral biopsies is difficult, and our decision model delineates a method for choosing.
We present a patient with treatment refractory short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing (SUNCT) who was found to have low levels of serum testosterone supporting the hypothalamic connection to this trigeminal autonomic cephalalgia. Clomiphene citrate therapy induced a significant elevation of testosterone levels (by its effect on hypothalamic estrogen receptors) and led to a dramatic reduction in SUNCT attacks. Hormonal manipulation may be a treatment strategy for hypothalamic-influenced trigeminal autonomic cephalalgias.
We present the largest reported cohort of carotid cavernous aneurysms (CCA), comparing the neuro-ophthalmic presentation, complications, and outcome with and without endovascular treatment.
Retrospective review of 185 patients with 206 CCAs examined between 1980 and 2001 at a tertiary neuro-ophthalmology and neurovascular service. Patients' symptoms and findings at presentation were recorded and compared with those at outcome. The effect of treatment on outcome and on complication rate was analyzed using the chi test, multivariate analysis of covariance, model-selection log-linear analysis, and multinomial logistic regression.
Long-term follow-up was available for 189 of 206 CCAs. Seventy-four CCAs underwent treatment (endovascular, 67 [91%]; surgical treatment, 6 [9%]), and 115 were followed for an average of 4 years, two of which required later treatment. Treatment reduced the incidence and severity of pain, even after adjusting for the severity of initial pain (F(1,192 = 9.59, P = 0.002). Treatment did not significantly affect the patient's final diplopia after adjusting for their initial diplopia (F(1, 182 = 2.01, P = 0.158). Statistical examination revealed that the treated group had a higher proportion of neurological and visual complications than people who were not treated (2(2). = 25.26, P = 0.0003).
Endovascular treatment of carotid cavernous aneurysms leads to a significantly higher rate of pain resolution compared with untreated patients, even after adjusting for initial pain severity. Diplopia may not resolve after treatment. The results of this study underscore our approach indicating treatment only in cases of debilitating pain, visual loss from compression, or diplopia in primary gaze or in patients with risk factors for major complications such as pre-existing coagulopathy or sphenoid sinus erosion.
Increased pressure in the dural venous sinuses has been proposed as the cause of increased intracranial pressure in the condition known as idiopathic intracranial hypertension (IIH). This hypothesis has received further support from manometry of the dural venous sinuses, showing a substantial proximal-to-distal pressure gradient, and from reports of improvement of IIH following stenting of the dural sinuses. Increased intracranial venous pressure has also been proposed as the cause of IIH in morbid obesity through increased abdominal pressure that is transmitted through the thorax to the cerebral draining veins. Although these hypotheses are intriguing, neither has enough scientific support to be endorsed yet. Moreover, dural venous sinus stenting should not be adopted as a therapeutic procedure in IIH until larger clinical trials attest to its safety and efficacy.