Ocular Migraine Treatment: What You Need to Know

If you’ve experienced the pain of a migraine, you know how debilitating the condition can be. According to the American Migraine Foundation, migraine is the third most common disease that affects people worldwide. It is such a common condition that one in four people in American households experience migraine. Migraine is different from a regular headache or tension headache. They typically involve intense or pulsing pain in the head that is often accompanied by nausea or vomiting and sensitivity to sound or light. 

In about one-third of people who experience migraine, the condition is preceded by visual disturbances that are described as an ‘aura’, flashing lights, or stars. This type of migraine is called an ocular migraine. Ocular migraine is not always followed by the typical pain of a classic migraine, but in most cases they are. The first time you experience an ocular migraine can be very alarming as it interferes with the ability to go about normal daily activities like driving, working, reading or writing. Some people report having blind spots in their vision or even seeing psychedelic images during an ocular migraine. Although these symptoms are alarming, they are a normal part of ocular migraine. Visual auras are chemical or electrical waves that spread over the region of the brain that is responsible for vision. Symptoms are thought to start out slowly and last for an average of 15 to 30 minutes. Visual auras can last for an up to an hour. 

Symptoms of an ocular migraine

Searching for whether what you have is an ocular migraine can be confusing. Ocular migraine is a term that is often used interchangeably to describe migraines that have accompanying visual changes. 

There are two types of ocular migraine. One type is migraine with aura, which is usually not a serious medical condition. The other is a retinal migraine that can have serious complications or other underlying health reasons for their occurrence. 

 Typically, ocular migraine are characterized by the following symptoms:

• Tingling or numbness of the hands or feet
• Difficulty finding words to speak
• Motor weakness
• Altered sense of touch or taste
• Mental fogginess or lack of clarity

Visual symptoms that include the following:

• Seeing flashing lights or stars
• Zig zag lines
• Blurry or foggy vision
• Seeing small blind spots or jagged lines with edges

Difference between retinal migraines and migraine with aura

Retinal migraines are different than migraine with aura. According to the American Migraine Foundation, retinal migraines affect only one eye and occur during the headache phase of the migraine. It can be difficult to tell whether the visual disturbances affect only one eye, so you can cover one eye to check. Retinal migraines can cause temporary blindness, decreased vision and or seeing twinkling lights. Since it is hard to distinguish between a retinal migraine and ocular migraine, it is important to consult a doctor if you suspect that you may be experiencing retinal migraines. This type of migraine can irreversibly affect vision, unlike ocular migraine. 

Causes of ocular migraine 

The exact cause of ocular migraine is not known. Genetic factors play a major role in whether you will experience migraines. Having a family history of migraines increases the chance that you may get them too. The changes in vision that cause the appearance of an aura are caused by electrical activity in certain regions of the brain that move across the cortex slowly. The vision of an aura lasts for the entire time it takes for the electrical activity to move across the cortex. In retinal migraines, the electrical activity either occurs at the back of the retina in the eye, or it can be caused by reduced blood flow to the retina. 

Triggers of ocular migraine

Certain triggers can cause the onset of an ocular migraine attack. Triggers will be different for every person and recognizing what these triggers are can reduce the frequency of their occurrence, or help prevent them from occurring at all. Some common triggers include:

• Bright or harsh lights
• Staring at electronic screens for prolonged periods of time
• Strong odors
• Driving long distances
• Extreme weather conditions 
• High altitude
• Dehydration
• Stress or anxiety
• Alcohol
• Certain foods that contain the following: 

-Excess caffeine or withdrawal of caffeine

-Monosodium glutamate (MSG) 

-Some artificial sweeteners

-Nitrate containing food 

-Tyramine containing foods like soy products, certain cheeses or sausages

Treatment of ocular migraine 

Treatment of ocular migraine involves both prevention and management of pain. If you experience more than four migraines per month, you will most likely need prescription drugs for treatment. 

The best way to prevent ocular migraine is to avoid things that trigger them. Since an ocular migraine attack usually lasts for an average of 30 minutes and maximum of one hour, you should rest immediately until it passes and avoid activities that will be unsafe without clear vision. You should also avoid other triggers during an ocular migraine. 

Ocular migraine can be treated with both over-the-counter (OTC) medications and prescription medications. OTC medications can be purchased without a prescription, but you will need a valid prescription from a doctor to get prescription medications to treat migraine. 

OTC drugs for ocular migraine treatment

OTC drugs will help reduce the pain of migraine. Popular choices for painkillers include 

• Ibuprofen
• Naproxen
• Acetaminophen
• Combination of acetaminophen and caffeine
• Excedrin Migraine 

If nausea also occurs with an ocular migraine, anti-nausea medications are taken as well. 

Prescription medications for ocular migraine treatment 

• Blood pressure medication

Beta-blockers are the first line treatment to prevent the occurrence of ocular migraine. These drugs were originally developed for the treatment of high blood pressure. They are thought to be effective in preventing migraine by restricting the blood flow to the brain and by inhibiting the waves of electric current that move across the brain to form the auras that accompany ocular migraine or migraine with aura. 

Two beta-blockers are FDA- approved for the treatment of migraines. These are propranolol (Inderal and Inderal LA) and timolol (Blocadren). Propranolol has been reported to reduce migraine occurrence by up to 50 percent and it is considered to be the most effective. 

The most common side effects of beta-blockers are feeling dizzy, fatigue, tingling or cold hands and feet, weight gain or sexual dysfunction. Beta-blockers can interact with other medications like anti-depressants, insulin and cholesterol lowering drugs, so if you are already taking one of these medications, be sure to inform your doctor. 

Calcium channel blockers like verapamil (Calan or Verelan) are another class of prescription blood-pressure medications that are commonly used to treat ocular migraine. These prevent blood vessels from becoming constricted by restricting the movement of calcium ions across cells that are important for muscle contractions of the artery walls. Recently in 2018, the American Headache Society announced that there is not evidence to conclude whether calcium channel blockers are actually effective in preventing migraines. Additionally, they can lose their effectiveness if used over a long period of time.

Some side effects of calcium channel blockers include dizziness, feeling drowsy, nausea, rash, constipation or low blood pressure. This class of medication can be a good choice for migraine treatment for patients who are not able to take beta- blockers due to other health reasons. 

CGRP inhibitors 

Calcium gene related peptide (CGRP) inhibitors prevent the action of CGRP, a substance within the body that causes migraines. This class of drugs is relatively new to the treatment of ocular migraine and most CGRP inhibitors are in the form of a prefilled syringe or pen that are used by injection under the skin on a monthly or quarterly basis. Examples of some CGRP inhibitors include eptinezumab (Vyepti), erenumab (Aimovig), fremanezumab (Ajovy) and galcanezumab (Emgality). One oral CGRP inhibitor is also available as ubrogepant. Taking CGRP inhibitors can prevent ocular migraine attacks from occurring. The most common side effect is redness or itching at the site of injection. 

Tricyclic Anti-depressants

Migraines are thought to be caused by a drop in serotonin levels. Tricyclic antidepressants, like amitriptyline (Elavil) or nortriptyline (Pamelor), help migraine by stabilizing serotonin and norepiphrenine levels. Taking tricyclic anti-depressants for migraine is one of the most common ways to treat them, but this is an ‘off-label’ use of anti-depressants. There are also more side effects associated with taking them such as dry mouth, nausea, nervousness, insomnia and sexual problems. Amytryptiline has additional side effects like blurred vision, constipation, urinary retention or a sudden decrease in blood pressure when standing. 

If you have tried other OTC migraine medications and found that they don’t work for you, then your doctor may have you try anti-depressants.

Anti-seizure medications (epilepsy medication)

Less commonly, anti-seizure or medications used to treat epilepsy are used as preventative treatment of migraines. These include valproic acid or topiramate. 

Devices used to treat ocular migraine

A newer method to treat or prevent ocular migraine is through a device that can be self-administered to provide electrical stimulation to regions of the forehead or the back of the head. Cefaly is a portable headband that was the first device approved to treat migraine. It is used for 20 minutes a day. Spring TMS is held at the back of the head and stimulates a part of the brain with a magnetic pulse. The gammaCore is a non-invasive vagus nerve stimulator that sends electrical stimulation to the vagus nerve to relieve migraine pain. 

Treatment of Migraine with Aura

Treatment methods for migraine with aura are similar to the treatment of retinal migraine, but not exactly the same. The same OTC painkillers are recommended, but prescription medications used to treat migraine with aura vary slightly. They include:

• Blood pressure medication
• Antidepressants
• Anti seizure drugs
• Triptans
• Ergotamines

Your doctor can help recommend the right treatment for your ocular migraine. Diagnosis will include going through your history of headaches and tests like eye exams, CT scan, or MRI. Ocular migraine can be a symptom of a more serious underlying condition like stroke, seizures, head injury, brain tumor, or abnormalities to the head, neck or spine. Therefore, if you are concerned about the cause of your ocular migraine and if you experience them more frequently than normal, it is important to consult a doctor.