Retinal Migraine: The Essentials

Despite the existence of clear diagnostic criteria, confusion still exists about Retinal Migraine. When a Migraine patient is given a diagnosis that isn’t an “official” type of Migraine, but is really more of a description, difficulties can be encountered. Although the descriptive terms may be used fairly frequently, the fall short of a diagnosis, and can mean entirely different things, depending upon who’s using them.

In any field of medicine, standardized diagnoses are used to ensure the best of care as well as accuracy in discussing various diseases and conditions. For Migraine and other Headache disorders, the gold standard for those diagnoses is the International Headache Society’s International Classification of Headache Disorders, 3rd Edition (ICHD-3).

Forms of Migraine that present with visual symptoms seem to be an area where there is a great amount of confusion, use of descriptions rather than formal diagnoses, and misdiagnosis. Both Migraine with Aura and Retinal Migraine are standard diagnoses that tend to be misused by assigning them to any form of Migraine with visual symptoms. Ocular Migraine, optical Migraine, visual Migraine, eye Migraine, and ophthalmic Migraine are not standard diagnoses, but are also often assigned to any form of Migraine with visual symptoms.

Retinal Migraine, is a standard ICHD-3 diagnosis with a specified set of symptoms and diagnostic criteria.

Retinal Migraine Symptoms:

Retinal Migraine is Migraine during which there are repeated attacks of visual disturbances preceding the headache phase of the Migraine attacks.

A retinal Migraine attack begins with monocular (in one eye) visual symptoms that can include:

1. scintillations (seeing twinkling lights)
2. scotoma (areas of decreased or lost vision)
3. temporary blindness.

The headache phase of a retinal Migraine begins during or within 60 minutes of the visual symptoms. The headache phase presents symptoms consistent with Migraine without Aura:

1. Headache duration of 4-72 hours
2. At least two of these characteristics:
   1. unilateral (on one side) location
   2. pulsatile quality (pulsing or throbbing)
   3. moderate or severe pain intensity
   4. aggravation by or causing avoidance of routine physical activity such as walking or climbing stairs
3. At least one of these characteristics:
   1. nausea and/or vomiting
   2. photophobia (increased sensitivity to light) and phonophobia (increased sensitivity to sound)

The primary differentiating factors between retinal Migraine and Migraine with aura are:

1. The visual symptoms of Retinal Migraine are monocular.
2. Total, but temporary, monocular blindness may occur in Retinal Migraine.

Diagnosing Retinal Migraine:

As with other forms of Migraine, there are no diagnostic tests to confirm Retinal Migraine. Diagnosis is accomplished by reviewing the patient’s personal and family medical history, studying their symptoms, and conducting an examination. Retinal Migraine is then diagnosed by ruling out other causes for the symptoms. With Retinal Migraine, it is essential that other causes of transient blindness be fully investigated and ruled out.

Retinal Migraine Treatment:

For infrequent attacks, medications used for other forms of Migraine are often employed to relieve the other symptoms. These medications can include NSAIDs, antinausea medications, ergotamines the triptans. The choice of medications is somewhat affected by the age of the patient. When Migraines are frequent, the same preventive therapies used for other forms of Migraine can be explored.

ICHD Comparison of Retinal Migraine and Migraine Without Aura

Retinal Migraine Description:

Repeated attacks of monocular visual disturbance, including scintillations, scotomata or blindness, associated with Migraine headache.

Retinal Migraine Diagnostic Criteria:

1. At least two attacks fulfilling criteria B and C
2. Aura consisting of fully reversible monocular positive and/or negative visual phenomena (e.g. scintillations, scotomata or blindness) confirmed during an attack by either or both of the following:
   1. clinical visual field examination
   2. the patient’s drawing (made after clear instruction) of a monocular field defect
3. At least two of the following three characteristics:
   1. the aura spreads gradually over 5 or more minutes
   2. aura symptoms last 5-60 minutes
   3. the aura is accompanied, or followed within 60 minutes, by headache
4. Not better accounted for by another ICHD-3 diagnosis, and other causes of amaurosis fugax have been excluded.

Migraine Without Aura Diagnostic Criteria:

1. Headache attacks lasting 4-72 hours (untreated or unsuccessfully treated)
2. Headache has at least two of the following characteristics:
   1. unilateral location
   2. pulsating quality
   3. moderate or severe pain intensity
   4. aggravation by or causing avoidance of routine physical activity (e.g., walking or climbing stairs)
3. During headache at least one of the following:
   1. nausea and/or vomiting
   2. photophobia and phonophobia

Sources:

1. Headache Classification Committee of the International Headache Society. “The International Classification of Headache Disorders, 3rd Edition (ICHD-3).” Cephalalgia, Volume: 38 issue: 1, page(s): 1-211.
2. Randolph W. Evans, Nina T. Mathew. Handbook of Headache, Second Edition. Philadelphia: Lipincott Williams & Wilkins. 2005.