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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]. ...
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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]. ...
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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.
... 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. ...
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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). ...
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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.
Article
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.
Article
To investigate the association between uncorrected or miscorrected refractive errors in children and headache, and to determine whether correction of refractive errors contributes to headache resolution. Results of ophthalmic examination, including refractive error, were recorded at initial visit for headache. If resolution of headache on subsequent visits was not documented, a telephone call was placed to their caregivers to inquire whether headache had resolved. Of the 158 patients, 75.3% had normal or unchanged eye examinations, including refractions. Follow-up data were available for 110 patients. Among those, 32 received new or changed spectacle correction and 78 did not require a change in refraction. Headaches improved in 76.4% of all patients, whether with (71.9%) or without (78.2%) a change in refractive correction. The difference between these two groups was not statistically significant (P = .38). Headaches in children usually do not appear to be caused by ophthalmic disease, including refractive error. The prognosis for improvement is favorable, regardless of whether refractive correction is required. [J Pediatr Ophthalmol Strabismus 20XX;XX(X):XX-XX.].
Article
Pain in and around the eye with or without an associated headache is a common presenting complaint to the neurologist. Although the main causes for eye pain are easily diagnosed by simple examination techniques that are readily available to a neurologist, sometimes the etiology is not as obvious and may require a referral to an ophthalmologist. This article summarizes and updates our prior review in Neurologic Clinics on this topic and includes (1) ocular and orbital disorders that produce eye pain with a normal examination, (2) neurologic syndromes with predominantly ophthalmologic presentations, and (3) ophthalmologic presentations of selected headache syndromes.
Article
Orbital and retro-orbital pain are relatively common clinical conditions that are associated with such disorders as trigeminal, lacrimal, and ciliary neuralgia, cluster headaches, paroxysmal hemicrania, inflammatory orbital pseudotumor, trochleitis, and herpetic neuralgia ophthalmicus, thus making the nerves supplying the orbit of great clinical importance. Surprisingly, how pain from this region reaches conscious levels is enigmatic. Classically, it has been assumed that pain reaches the ophthalmic division of the trigeminal nerve (V1 ) and travels to the descending spinal trigeminal nucleus. However, exactly where the receptors for orbital pain are located and how impulses reach V1 is speculative. In this project, we reviewed all of the reported connections between the orbital nerves and V1 in order to understand how pain from this region is transmitted to the brain. We found reported neural connections to exist between cranial nerve (CN) V1 and CNs III, IV, and VI within the orbit, as well as direct neural branches to extra-ocular muscles from the nasociliary, frontal, and supraorbital nerves. We also found reported neural connections to exist between the presumed carotid plexus and CN VI and CN V1 , CN VI and CN V1 and V2 , and between CN V1 and CN III, all within the cavernous sinus. Whether or not these connections are sympathetic or sensory or some combination of both connections remains unclear. An understanding of the variability and frequency of these neural connections could lead to safer surgical procedures of the orbit and effective treatments for patients with orbital pain. Clin. Anat., 2014. © 2014 Wiley Periodicals, Inc.
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Headache is an extraordinarily common complaint presenting to medical practitioners in all arenas and specialties, particularly primary care physicians, neurologists, and ophthalmologists. A wide variety of headache disorders may manifest with a myriad of neuro-ophthalmologic symptoms, including orbital pain, disturbances of vision, aura, photophobia, lacrimation, conjunctival injection, ptosis, and other manifestations. The differential diagnosis in these patients is broad and includes both secondary, or symptomatic, and primary headache disorders. Awareness of the headache patterns and associated symptoms of these various dis-orders is essential to achieve the correct diagnosis. This paper reviews the primary headache disorders that prominently feature neuro-ophthalmologic manifestations, including migraine, the trigeminal autonomic cephalalgias, and hemicrania continua. Migraine variants with prominent neuro-ophthalmologic symptoms including aura without headache, basilar-type migraine, retinal migraine, and ophthalmoplegic migraine are also reviewed. This paper focuses particularly on the symptomatology of these primary headache disorders, but also discusses their epidemiology, clinical features, and treatment.
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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.
Article
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.
Article
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.
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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.
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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.
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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.
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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.
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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.