What is the role of migraine in the etiology of transient vision loss (TVL)?

Updated: May 21, 2019
  • Author: Andrew J Tatham, MD, MBA, FRCOphth, FEBO, FRCS(Ed); Chief Editor: Andrew G Lee, MD  more...
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Answer

Migraine with aura is a common cause of transient visual disturbance at any age. Migraine is probably the most common organic cause of organic transient visual loss in children. [3] In a study of 83 patients younger than 45 years with episodic visual loss, migraine was the most likely cause in the majority of cases. [14] In children, 3.5-5% suffer from recurrent migraine headaches; however, only 18% of those have migraine with aura, and only 5% have aura without headache.

Migrainous visual disturbances are also common in the elderly. Visual aura occurs in 1-2% of elderly patients, and in 58%, aura is not associated with a headache. [15]

Migraine auras are typically bright and shimmering with a dynamic quality, whereas ischemia tends to produce dark and static defects. These differences notwithstanding, it may be difficult to distinguish between migraine with aura and amaurosis fugax. The International Headache Society (IHS) defines a migraine aura as a recurrent disorder that develops over 5-29 minutes and lasts for less than 1 hour. [16]

Migraine with visual aura is thought to be due to dysfunction of the striate cortex arising from a reduction in cerebral blood flow from the terminal branches of the basilar artery. Visual symptoms include photopsia, teichopsia (fortification spectra), scotoma, hemianopia, and diplopia and are usually homonymous. [17] There may also be other associated neurologic symptoms, such as paresthesia, weakness of limbs, speech disturbance, and vertigo.

Unilateral symptoms are rare but may occur in retinal or ocular migraine. Retinal migraine is presumed to result from retinal vasospasm causing isolated hypoperfusion of the retina or the optic nerve. [17, 18] This condition is defined as a fully reversible monocular visual disturbance associated with migraine headache and a normal neuro-ophthalmic examination between attacks. Retinal migraine is not as common as was once thought; one literature review found only 5 cases meeting the IHS criteria for diagnosis. [19]

Intravitreal injection of ocriplasmin, used to treat symptomatic vitreomacular adhesion, has been reported to cause transient vision loss due to presumed direct retinal side effects but with unknown molecular mechanism. [20] Vision loss has also been reported after surgical procedures involving the eye, such as a trabeculectomy. One study showed that more than 50% of patients experienced transient vision loss after trabeculectomy. [21]

There is no test to disprove a patient report of transient vision loss. In addition, eye examination findings may be normal in patients with transient vision loss of both organic and nonorganic etiologies. Patients with medically unexplained symptoms are frequent attenders. In primary care, 1 of every 5 new consultations involves a patient with symptoms for which no organic cause is found. [22] Despite the frequency of unexplained symptoms, there has been little research in this area.

Studies in adults suggest that childhood experiences, including illness in family members and previous medical consultations, are contributing factors to unexplained symptoms in later life. A series by Taich et al found that 26.7% of patients with medically unexplained visual loss had a previous diagnosis of depression, anxiety, or attention deficit hyperactivity disorder, and 31% had significant stress at school or at home. [23] Many patients have been seen by other specialties with unexplained symptoms.

If no medical explanation is found for visual loss in a child, parents may be anxious and keen for further investigations. A supportive approach is required, and the need for investigations must be balanced against the risks of exacerbating fears of disease. [24] It is important to establish a good rapport with the parents and the child with transient vision loss.


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