Persistent and Repetitive Visual Disturbances in Migraine: A Review

Abstract

Visual disturbances in migraineurs, such as visual aura, are typically episodic, that is, associated with the headache attack, and overlaid by head pain and other symptoms that impact the patient. In some patients, however, visual symptoms are dominant due to frequency (migraine aura status), duration (persistent migraine aura and other persistent positive visual phenomena), or complexity (visual snow syndrome). These syndromes are more rare and challenging to classify in clinical practice resulting in a lack of systematic studies on pathophysiology and treatment. We aim at describing clinical features and pathophysiological concepts of typical migraine aura with a focus on cortical spreading depression and differentiation from non‐typical migraine aura. Additionally, we discuss nomenclature and the specifics of migraine aura status, persistent migraine aura, persistent positive visual phenomena, visual snow, and other migrainous visual disturbances. The term migraine with prolonged aura might be a useful bridge between typical aura and persistent aura. Further studies would be necessary to assess whether a return of the classification category eventually helps diagnosing or treating patients more effectively. A practical approach is presented to help the treating physician to assign the correct diagnosis and to choose a medication for treatment that has been successful in case reports of these rare but disabling conditions.

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

“…3 Auras occur in up to one-third of migraineurs, 4 and 90% of auras are visual in nature. 7,8 Prolonged auras and other migrainous persistent positive visual phenomenon have been described, 9 and transient vision loss associated with severe attacks or retinal vasopasm. 6 Most practitioners treating migraine are familiar with photophobia and visual aura, but migraine sufferers may have a number of other, less wellrecognized vision-related symptoms.…”

“…Visual snow, characterized by a persistent, static-like disturbance of the entire visual field, is commonly associated with a history of migraine (59%) and may begin with a headache, with or without a visual aura. 7,8 Prolonged auras and other migrainous persistent positive visual phenomenon have been described, 9 and transient vision loss associated with severe attacks or retinal vasopasm. 10,11 Finally, there is evidence to suggest that chronic migraine is associated with increased symptoms of dry eye, in addition to structural changes in the trigeminal corneal nerve endings.…”

“…Furthermore, recent published literature has suggested that visual symptoms may represent a minor nuisance to patients compared to other manifestations of migraine. 9 The purpose of this investigation was to use validated vision-related QOL instruments to determine the effect of migraine on VQOL.…”

When Can We, Really, Talk About Status Migrainosus in Migraine With Aura?

“…4 While in the ICHD-II, 5 we read: "at least 2 auras per day for 5 or more consecutive days," in ICHD-III is reported "at least three auras occur over a period of 3 days." 6,7 Regarding this topic, in my clinical experience it is not infrequent that some patients reported attacks in succession, but only if specifically questioned: the majority reported 2 episodes or, more rarely, 3 or even more. 6,7 Regarding this topic, in my clinical experience it is not infrequent that some patients reported attacks in succession, but only if specifically questioned: the majority reported 2 episodes or, more rarely, 3 or even more.…”

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

“…Although most patients report photophobia during an attack, some report that certain kinds of light may provoke an attack; and a subset of patients report photophobia between attacks ("interictal photophobia"). 7 Because of the direct effect of aura on vision, this was an obvious candidate for a symptom that could reduce visual quality of life. 5 Approximately one third of migraineurs experience auras, and the majority of these auras are visual.…”