Headache and the Eye

Ula Jurkunas, MD; John W. Gittinger, JR, MD

Disclosures

Compr Ophthalmol Update. 2004;5(4) 

In This Article

Ocular Causes of Headache

The eye is a transparent, superficial organ, and routine examination techniques readily identify ocular causes of headache. There has been ongoing debate whether uncorrected refractive error causes asthenopia or eye strain. Although there is little evidence that refractive error or strabismus directly causes headaches, appropriate correction may improve symptoms.[66,67] Untreated hyperopia can result in persistent attempts to accommodate, thus relaxing accommodation with hyperopic prescription may lessen the eye discomfort. Accommodative spasm usually occurs in young patients and presents with eye pain, myopia, and miosis when doing near work. Management is reassurance and general relaxation techniques.

Any ocular surface disease should be treated. Uveal and scleral inflammation should be addressed with anti-inflammatory therapy and work-up for underlying systemic causes.[67]

Acute elevation in intraocular pressure is usually associated with pain, while an eye with a similar pressure of gradual onset may be asymptomatic.[67] While acute angle-closure glaucoma is the most common painful glaucoma, some for ms of secondary open- and closed-angle glaucoma are associated with acute pressure spikes and pain ( Table 7 ).

Retrobulbar optic neuritis presents with subacute loss of vision and pain on eye movement with nor mal-appearing optic nerves initially.[68] In papillitis there is disk swelling. Patients are usually women between 15 and 45 years of age. Magnetic resonance imaging should be performed to look for evidence of demyelination elsewhere, as treatment with high-dose corticosteroids may delay the onset of clinically definite multiple sclerosis (MS). Immunomodulatory therapies used in relapsing/remitting MS, such as beta-interferons, may be appropriate early therapy in these patients with optic neuritis and evidence of brain demyelination (i.e., those patients therefore at higher risk for the subsequent development of MS).[69,70]

Temporal headache in an elderly person should alert one to a possibility of giant cell arteritis, which is an emergency ( Table 8 ).[71] Appropriate clinical assessment and evaluation with sedimentation rate and C-reactive protein should be targeted at this group of patients. If there is already visual loss in one eye from anterior ischemic optic neuropathy or central retinal artery occlusion and this diagnosis is suspected, corticosteroid therapy should be initiated immediately and followed by temporal artery biopsy. The main goal is prevention of contralateral eye involvement.

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