What is Ocular Migraine?
Anyone who has ever experienced an ocular migraine can probably recall their very first episode. They might have been sitting at their desk, feeling perfectly normal, then suddenly started seeing flickering lights, zigzagging lines, or a rash of colorful, kaleidoscopic waves. To say that the experience can be alarming would be an understatement. The good news is: it’s not dangerous.
Some people experience these “light show” symptoms regularly, usually before the onset of a painful headache. Others experience the symptoms alone – without the accompaniment of a classic migraine headache. And some may have experienced them only once or twice, never to be repeated again.
Symptoms
Ocular migraine is a term commonly used to describe certain visual disturbances associated with migraine. The symptoms are varied and can include:
- flashing lights, or kaleidoscope- or prism-like visual sensations
- zigzagging lines
- stars
- blind spots or scotomas
The condition – a type of migraine with “aura” – can be disturbing, but symptoms are generally benign and most last less than an hour.
Aura is a term that refers to sensations other than head pain that can accompany a classic migraine. Visual symptoms are the most common type of migraine with aura, though aura can affect other senses and cause symptoms ranging from numbness and tingling in various parts of the body, nausea and vomiting, or even altered motor and language skills.
These visual disturbances usually affect both eyes and can occur with or without a headache.
Approximately one-third of migraine patients will experience migraine with aura. Some may have only one or two in their life, others may have a couple a month, and some may have an aura with every attack. About 15% of individuals who experience aura have one with every attack.1
Terminology Confusion
The term “ocular migraine” is considered a misnomer, in that the visual disturbances associated with it occur in the brain, not in the eye or in the retina.
Though many people – including some medical specialists – continue to use the term “ocular migraine” to refer to a migraine with visual disturbances, it is more accurate to refer to ocular migraine as “migraine with aura” or “migraine with visual aura.”
Ocular migraine is sometimes referred to as “retinal migraine,” and although some of the symptoms overlap, the two diagnoses are not the same. Retinal migraine is a different and much rarer type of migraine.
On occasion, ocular migraine is also called “visual migraine,” “ophthalmic migraine” or “eye migraine,” but these are vague, general terms that refer to any migraine displaying visual impairments.
What Causes Ocular Migraine?
Ocular migraine – or migraine with visual aura – is generally thought to be caused by electrical disturbances in the brain, triggered by a phenomenon called cortical spreading depression. This refers to electrochemical waves that spread slowly across the cortex, the outer surface of the brain. Most of the time, these disturbances occur in the occipital lobe, the part of the cortex that controls vision, causing visual symptoms.1,2
How Does Ocular Migraine Differ From Retinal Migraine?
Though the terms “ocular” and “retinal” migraine are frequently used interchangeably, the two are not the same. While both types of migraine generally involve unusual temporary visual phenomena, ocular migraine symptoms generally involve both eyes. Symptoms can occur with or without a headache.
Retinal migraine is a very rare cause of temporary vision loss in one eye (monocular), and can be – but is not always – followed by a headache within an hour of the onset of symptoms.
The transient vision loss experienced in retinal migraine can range from partial to full. Symptoms may include flashing lights and scintillating blind spots.
A retinal migraine diagnosis is made only after excluding other possible causes of single eye vision loss. An eye doctor should be able to make the diagnosis after conducting a comprehensive eye exam with dilation, including a formal visual field exam.
Ocular Migraine Triggers
Ocular migraine attacks can be triggered by the same symptoms that trigger other migraine attacks and vary from person to person. Common triggers include:
- stress
- weather (including excessive heat or barometric pressure changes)
- alcohol (including red wine)
- caffeine
- skipping meals
- certain foods (including aged cheeses, or foods containing additives such as nitrates, MSG, or artificial sweeteners)
- dehydration
- family history of migraine
- hormonal fluctuations
- loud noises
- bright lights, including sunlight
- strong odors
- lack of sleep
Additional triggers may include activities that involve:
- eye strain
- extended computer screen use
- harsh lighting
- long-distance driving
Which Specialist to See When Experiencing Visual Symptoms?
A person experiencing visual disturbances, such as flashing lights, zigzagging lines, or even blind spots may first go to an eye doctor, who can conduct a comprehensive eye exam with dilation and rule out other causes of the symptoms before diagnosing migraine. An ocular migraine diagnosis does not mean the symptoms are occurring in the eye or caused by some dysfunction of the eye. The visual activity is caused by electrical disturbances in the part of the brain that controls vision. These symptoms can occur with or without headache. Patients who experience these symptoms are generally referred to a neurologist for ongoing migraine management.
When to Seek Immediate Medical Attention
Because a number of migraine-related symptoms can affect vision, it is not always easy to determine which are unrelated, but persons experiencing the following should seek medical attention right away to rule out stroke or another diagnosis that could lead to irreversible vision loss:
- Any significant change or increase in duration of usual visual symptoms.
- New floaters or flashes of light or dark spots in one eye that do not go away within an hour.
- Episodes of temporary vision loss in one eye.
- Vision loss that presents as darkness or complete blindness.
- Experiences of tunnel vision or inability to see out of one side of one’s vision field.
Treatments for Ocular Migraine
Drugs that treat regular migraine symptoms may be used to treat ocular migraine attacks. These include over-the-counter pain relievers, including:
- ibuprofen
- acetaminophen
- aspirin
- naproxen
Prescription medications that may be used to treat an ocular migraine include many of the same medications used to treat classic or common migraine attacks, such as:
- triptans, such as sumatriptan (Imitrex) or rizatriptan (Maxalt)
- ergotamine derivatives, such as DHE (dihydroergotamine)
- CGRPs – calcitonin gene-related peptide receptor agonists/gepants (Nurtec, Ubrelvy)
- ditans – lasmiditan (Reyvow)
- prescription NSAIDS, such as diclofenac or celecoxib
- anti-nausea medications
- neuromodulation devices, such as Cephaly, Nerivio, or Gammacore
Whether an individual is using over-the-counter or prescription medication, early-onset treatment is more effective than waiting until after the migraine attack has had a chance to build up.
Migraine Prevention
Patients who experience more frequent visual aura symptoms may consider medications designed to prevent classic or common migraine, including:
- antidepressants, such as amitriptyline (Elavil ), nortriptyline (Pamelor), or venlafaxine (Effexor)
- blood pressure medications, such as beta blockers or calcium channel blockers
- anti-seizure drugs, such as valproic acid (Depakene, Depakote) or topiramate (Topamax, Qudexy XR, or Trokendi XR)
- monoclonal antibodies, such as erenumab (Aimovig), galcanezumab (Emgality), fremanezumab (Ajovy), eptinezumab (Vyepti)
- gepants, such as atogepant (Qulipta), rimegepant (Nurtec ODT)
- Botox
Other practices/treatments that may be helpful
- Get regular exercise – any kind – including walking, swimming, bicycling.
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- Eat regularly – try not to skip meals.
- Develop good stress management strategies.
- Consider mindfulness practices, such as meditation, tai chi, yoga, etc.
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- Maintain a regular sleep pattern (7-9 hours per night).
- Consider testing for apnea if sleep is frequently interrupted.
- Ask your healthcare provider if supplements may be helpful.
- Join a migraine support group for tips and fellowship.
- Consider FL-41/tinted lenses, which help block color wavelengths that bother persons with light sensitivity.
Looking forward
Roughly one-third of people with migraine experience some kind of aura, and many of those experience some kind of visual aura. The symptoms can be unsettling, but they are generally benign. It is important to note that effective options are available to treat attacks and help prevent future ones, as discussed above.
While there is no cure for migraine, many new treatment and prevention options are now available – and more are in the pipeline. Work with an experienced healthcare professional to find what management techniques work best for you. And consider joining a migraine support group to help you on your healthcare journey.
