Reduced Visual Quality of Life Associated with Migraine is Most Closely Correlated with Symptoms of Dry Eye.

BACKGROUND AND OBJECTIVE: Patients with migraine frequently report ocular or visual symptoms including aura, photophobia, and eye pain. Using validated instruments, our group previously reported that due to these symptoms, patients have marked reductions in visual quality of life. In chronic migraine, these reductions can be as substantial as those reported for other neuro-ophthalmic diseases such as multiple sclerosis with optic neuritis and idiopathic intracranial hypertension. Because the instruments take several different dimensions into account, we were unable to determine which ocular symptom(s) contributed to reduced visual quality of life. The purpose of this investigation was to attempt to determine which ocular symptom(s) were driving the observed reduction in visual quality of life. METHODS: We designed a cross-sectional survey-based study to assess visual quality of life, headache impact, aura, dry eye, and photophobia in migraine patients. Subjects were recruited from the Headache Clinic and General Neurology Clinic at a tertiary teaching hospital. Subjects completed validated questionnaires including: The visual functioning questionnaire-25 (VFQ-25), the headache impact test (HIT-6), the visual aura rating scale (VARS), the ocular surface disease index (OSDI), and the Utah photophobia score (UPSIS-17). Associations between VFQ-25 and OSDI, VFQ-25 and VARS, VFQ-25 and UPSIS-17, HIT-6 and OSDI, HIT-6 and VARS, and HIT-6 and UPSIS-17 were calculated. RESULTS: Of the 62 patients who completed all questionnaires, 17 had episodic migraine and 45 had chronic migraine. Twenty-three patients experienced aura and 39 did not report aura. The most striking correlations were observed between the VFQ-25 and the OSDI (-0.678; P < .001), between the HIT-6 and UPSIS-17 (0.489; P < .001), and between the HIT-6 and OSDI (0.453; P < .001). CONCLUSIONS: Dry eye seems to be the most important symptom that reduces visual quality of life and worsens headache impact. This symptom may be a form of allodynia, a well-known feature of chronic migraine. Photophobia appears to have modest effects on headache impact. In the future, we hope to determine whether treatment of dry eye symptoms can improve visual quality of life and reduce headache impact.

Patients With Migraine Have Substantial Reductions in Measures of Visual Quality of Life.

OBJECTIVE: Migraine is associated with several important visual symptoms, during both acute attacks and headache-free intervals. The purpose of this investigation was to use validated vision-related quality of life instruments to assess the effect of migraine on visual quality of life. BACKGROUND: Many migraineurs experience visual aura, increased photophobia during and between headache attacks, and increased symptoms of dry eye with structural changes in corneal nerve endings. Other visual symptoms associated with migraine include positive persistent visual phenomenon (visual snow) and transient vision changes. Previous research looking at the disability associated with migraine has shown that patient-reported quality of life data can be useful in determining the severity of disease burden. Recent published literature has suggested that visual symptoms related to migraine represent a proportionally minor burden to patients, compared to other manifestations of migraine, but no previous studies have assessed how migraine affects visual quality of life. METHODS: In this cross-sectional quantitative survey, visual quality of life in individuals with chronic and episodic migraine was assessed using the National Eye Institute Visual Function Questionnaire-25, and the 10-item National Eye Institute Visual Function Questionnaire-25 Neuro-Ophthalmic Supplement. Overall headache severity and impact was assessed using the Migraine-specific Quality of Life Questionnaire (Version 2.1) and the Headache Impact Test-6. Participants were recruited from Headache and Neuro-ophthalmology subspecialty clinics. The target sample size was 30 participants per subgroup. The results were compared to those from disease-free controls and to results from other neuro-ophthalmic disease quality of life studies. RESULTS: Among 29 participants with chronic migraine, vision-specific quality of life scores were all statistically significantly decreased compared to disease-free controls. The National Eye Institute Visual Function Questionnaire-25 median composite score was 85 for chronic migraineurs and 96 for controls (P < .001). The 10-item National Eye Institute Visual Function Questionnaire-25 Neuro-Ophthalmic Supplement median score was 72 for chronic migraineurs and 95 for controls (P < .001). Among 37 participants with episodic migraine, vision-specific quality of life scores were also decreased compared to disease-free controls. In the episodic migraine group, decreases in the National Eye Institute Visual Function Questionnaire-25 scores were not statistically significant (median score 91, P = .01 compared to the control group), but decreases in the 10-item National Eye Institute Visual Function Questionnaire-25 Neuro-Ophthalmic Supplement remained statistically significant (median score 85, P = .003 compared to the control group). Chronic migraineurs had decreased visual quality of life scores compared to those with episodic migraines. Participants with chronic migraine had visual quality of life scores that were as poor as those previously published for patients with other neuro-ophthalmic disorders such as multiple sclerosis, myasthenia gravis, and ischemic optic neuropathy. CONCLUSIONS: Visual quality of life is significantly adversely affected in migraine sufferers. In fact, patients with chronic migraine may have visual quality of life impacts that are as significant as those associated with other common neuro-ophthalmic disorders. Future studies of the overall disease burden in patients with migraine should include an evaluation of the effects on visual functioning.

Thin-film optical notch filter spectacle coatings for the treatment of migraine and photophobia.

Previous evidence suggests optical treatments hold promise for treating migraine and photophobia. We designed an optical notch filter, centered at 480nm to reduce direct stimulation of intrinsically photosensitive retinal ganglion cells. We used thin-film technology to integrate the filter into spectacle lenses. Our objective was to determine if an optical notch filter, designed to attenuate activity of intrinsically photosensitive retinal ganglion cells, could reduce headache impact in chronic migraine subjects. For this randomized, double-masked study, our primary endpoint was the Headache Impact Test (HIT-6; GlaxoSmithKline, Brentford, Middlesex, UK). We developed two filters: the therapeutic filter blocked visible light at 480nm; a 620nm filter was designed as a sham. Participants were asked to wear lenses with one of the filters for 2weeks; after 2weeks when no lenses were worn, they wore lenses with the other filter for 2weeks. Of 48 subjects, 37 completed the study. Wearing either the 480 or 620nm lenses resulted in clinically and statistically significant HIT-6 reductions. However, there was no significant difference when comparing overall effect of the 480 and 620nm lenses. Although the 620nm filter was designed as a sham intervention, research published following the trial indicated that melanopsin, the photopigment in intrinsically photosensitive retinal ganglion cells, is bi-stable. This molecular property may explain the unexpected efficacy of the 620nm filter. These preliminary findings indicate that lenses outfitted with a thin-film optical notch filter may be useful in treating chronic migraine.

A comparison of idiopathic intracranial hypertension with and without papilledema.

OBJECTIVE: To compare clinical features, visual characteristics, and treatment of idiopathic intracranial hypertension patients with and without papilledema. BACKGROUND: Idiopathic intracranial hypertension does not often occur without papilledema. This study estimates the prevalence and compares the clinical characteristics of idiopathic intracranial hypertension patients with and without papilledema. METHODS: We performed a cross-sectional analysis of all idiopathic intracranial hypertension patients diagnosed at the University of Utah Neuro-Ophthalmology Unit between 1990 and 2003. Patient records were reviewed for presence of papilledema and other signs, symptoms, and treatment characteristics. Each patient without papilledema was matched to the patient with papilledema who was closest to his/her age and sex. McNemar's and Wilcoxon-signed rank sum tests were used to compare characteristics between matched pairs. RESULTS: Among all patients (n = 353), the prevalence of those without papilledema was 5.7% (n = 20). Patients without papilledema reported photopsias (20%), and were found to have spontaneous venous pulsations (75%) and non-physiologic visual field constriction (20%) more often than did those with papilledema. Mean opening pressure, although above normal, was lower in patients without papilledema (mean = 309 mm cerebrospinal fluid) compared with those with papilledema (mean = 373 mm cerebrospinal fluid, P = .031). Idiopathic intracranial hypertension patients without papilledema had more frequent diagnostic lumbar punctures than did patients with papilledema. Visual acuities and treatment were similar between groups. CONCLUSIONS: The clinical presentation of idiopathic intracranial hypertension without papilledema is only somewhat different from that of idiopathic intracranial hypertension with papilledema. The lower opening pressure in patients without papilledema may explain variations in symptoms and signs between the 2 groups. When there are visual field changes in idiopathic intracranial hypertension without papilledema, non-physiologic visual loss should be considered.

Clinic-based study of family history of vascular risk factors and migraine.

The objective was to evaluate the presence of a positive family history (FH) of vascular risk factors between patients with migraine with aura (MA) and migraine without aura (MO), and in chronic migraine (CM) compared to other headache types. As migraine patients are typically too young to have developed vascular events, studying older relatives of migraine patients may be a practical means of evaluating associations between vascular risk factors and migraine. A cross-sectional study of a clinic-based sample of adults with migraine headache was carried out at the University of Utah. Predictor variables comprised first or second degree relatives with stroke, hypertension, diabetes or hypercholesterolaemia. Outcome measures comprised diagnosis of MA, MO or CM according to the revised International Headache Society criteria. There was no significant difference in FH of vascular risk factors in MA compared to MO (adjusted OR 1.04, 95% CI 0.61-1.78). CM was associated with a decreased risk of FH of stroke (OR=0.11, 95% CI 0.02-0.87, p=0.036). There was no significant difference in FH of vascular risk factors in MA patients compared to MO. CM patients were more likely to have a negative FH of stroke compared to other headache types, suggesting that CM is likely a neuronal disease rather than a vascular one.