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Mar 06 2012

Visual Migraine Questions

Cos I know I have some knowledgeable readers.

So right now I am sitting in a darkened office, with brilliant jagged geometric shapes floating in my right visual hemisphere. Having just taken my Maxalt, I am hopeful that they will disappear soon, and that they will not be replaced by an exploding horrific headache.

But the questions…

This time, the colors are different from earlier visual migraines. Less bright colors, sometimes appearing to be a palate of grays. It also appears more melty than usual. Oh, and this one is confined to my right visual hemisphere.

So, does that mean vascular activity in left occipital lobe? Or could it be elsewhere in the various visual pathways? More generally, could one conceivably map the location in the brain where the migraine activity is happening by attending to the visual phenomena? (Has this been done?)

The NYTimes had (has?) a blog on migraine art; there is quite a lot of variation. I tend to get the current effect (location varies, as does color scheme now), and occasionally a different sort where it looks like I am viewing the world through a cracked stained-glass window. Would different sorts of visual experiences imply different, and specifiable, brain areas of vascular weirdness.

Signing off now–my right eye is beginning to throb, which is not a good sign.

24 comments

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  1. 1
    Phledge

    I am not a neuroophthalmologist, but IIRC the phenomenon of unilateral hemianopsia is caused by a lesion at the optic chiasm right above the pituitary. So that’s where I’d put my money on the vascular changes for this migraine.

    All medical curiosity aside, I hope you feel better soon. Migraines are assholes.

  2. 2
    Stephanie Zvan

    You may actually be experiencing a retinal migraine, where the activity is in the eye itself. Those…tend to suck. Sorry.

  3. 3
    Rebecca Rose

    All those pretty colors and interesting geometric shapes… sound absolutely awful. May this be the last one you ever get!

    *virtual hug*

  4. 4
    timberwoof

    I recall reading about some guy who experienced an aura like that and happened to be in front of an ophthalmologist’s office. The doctor examined his eyes and saw vascular disturbances in his retina that matched the location of the symptoms, leading to a lot of new research into the subject.

    I occasionally get such migraines, brought on by stress and certain preserved foods. (Damn. I like pickled herring!) If I take Exedrin (Extra Strength or Migraine (the difference is a few dollars per bottle)) at first symptoms, then I just get a headache.

    In any case, I ride them out: I hide in a dark and quiet room for the rest of the day. Keep well hydrated.

    Health and good luck to you…

  5. 5
    Cuttlefish

    Thanks, all! An hour in a dark room, some food and water, and a miracle of modern medicine later, I appear to have dodged the pain.

    Re: retinal migraine–I was told by a vision researcher that the way to eliminate that possibility is to check whether the image goes away (or changes) when you shut one eye or the other. Mine does not, so I’m assuming (and could be wrong, of course) that it’s further back in the system. But I don’t know, and wouldn’t have even thought to examine the possibility without my brilliant readers!

  6. 6
    Anonymous Atheist

    Variations in migraine weirdness (including some far weirder than yours) still seem to generally fall into the unfortunately-populous category of medical phenomena that aren’t well-understood.

    In brief:
    http://www.allaboutvision.com/conditions/ocular-migraine.htm

    It appears migraines are triggered by activation of a mechanism deep in the brain, which releases inflammatory substances around the nerves and blood vessels of the head and brain. But why this happens and what brings about the spontaneous resolution of an ocular migraine remain unknown.

    Imaging studies also have revealed that changes in blood flow to the brain occur during ocular migraines and visual auras, but the underlying cause for these changes is not known.

    In depth:
    http://www.sibelium.com.cn/sibelium/WX/fulltext_WX_2/038.pdf (2007)

    Migraine is a disorder that may manifest as a myriad of neurological symptoms named aura, usually – but not always – preceding the typical headache phase. The most frequent aura (from Greek ‘breeze’) type is visual, characterized mostly by flashes of light, or bright zigzag, horseshoe-shaped expanding visual perceptions. Some patients may experience diverse visual, as well as sensory, motor or language disturbances, indicating that other areas of the cortex distinct from the occipital lobes must be affected.

    The exact mechanism of aura is not known. The remarkable progressive nature of the aura symptoms fits with the pace of spreading depression (SD), a neurophysiological phenomenon present in grey matter of various species. … Existing evidence indicates that SD underlies migraine aura. However, SD may also occur in migraine without aura. … The occipital cortex is considered the area where most migraine-related SD would start.

    Four individuals had prosopagnosia [impaired face recognition] immediately before a migraine attack, and three mentioned suffering difficulties in physiognomy recognition irrespectively of migraine attacks. Two MWA [migraine with aura] patients reported dyschromatopsia [disorder of color vision]. One of them also suffers from sleep-related seizures. She did not present typical visual aura symptoms, but colours ‘get mixed up’. Although she easily recognizes faces, it is particularly difficult to remember peoples’ names during the aura phase. The second patient, who also has prosopagnosia, reports that ‘the colours get mixed’. Migraine-related brighter colours were noticed by 20 patients. This sensation was sometimes very marked (‘colours get so bright that I feel they will attack me’). Brighter colours were much more common than the opposite, as only five patients (MWA, 4; MwoA, 1) reported AR [attack-related] colour paleness or a tendency to a colourless, black-and-white vision. Three out of these five subjects also had prosopagnosia.

    Six (AR, 5; OA [outside attack], 1) individuals claimed object recognition was defective in association with attacks, such as not recognizing familiar products in the supermarket. …

    A feeling of general strangeness (‘I feel my bed and pillow differently, as if I had changed to another body’), including a non-explainable sensation of imminent attack, was reported by some patients. The following reports were given each by a different subject: feeling of reduced speed of events as in a slow-motion movie; diplopia; visual perception of objects turning more ‘fluid’ and mixing one to each other.

    Data show that neurological symptoms in both MWA and MWoA [migraine without aura] other than the classic visual aura may be underestimated. Bizarre perceptions in migraine may be more frequent than commonly supposed. Data show that symptoms are frequently present not only during attack, but also interictally in both types of migraine. This is in accordance with the fact that brain structural changes are present in migraine and may account for interictal dysfunction in various areas of the brain.

    The most common form of migraine aura is visual. Fortification spectra are present in 20% of the cases. These typical migraine visual abnormalities are probably related to ‘early’ visual corti-cal areas. Spreading fMRI BOLD [blood-oxygen-level-dependent] signals have been shown during visual aura initiating at the visual cortex, suggesting SD as the underlying pathophysiological process in migraine aura. Other relatively rare complex visual abnormalities may occur in migraine. Lilliputian hallucinations, characterized by the vision of either people or objects as miniatures or small fantastic little animals or creatures, have been described, as well as splitting or misinterpretations of the body image, macro- and microsomatoagnosia. In the so-called ‘Alice in Wonderland syndrome’, which may be associated with migraine or epilepsy, patients experience bizarre perceptual sensations.

    Several lines of evidence support the possibility of SD underlying migraine aura pathophysiology. First, the typical zigzag patterns as described by Lashley are compatible with SD propagatingon the primary visual cortex, based on the organization of orientation preference maps in V1. Secondly, the multitude of successive cortical dysfunctions in migraine aura fits with a propagating type of disorder. Our aura cases have first occipital symptomatology, progressing afterwards in a geographically compatible pattern to successive cortical areas, as suggested by the building-up symptomatology. Although irrefutable human documentation of SD propagating beyond the central sulcus is not available, this phenomenon remains as the most suitable expla-nation for the complex symptoms in our cases. Moreover, the timing, as suggested by Lashley, is compatible with the known SD propagation velocity considering the cortical function maps and their relative positions. Thirdly, fMRI data obtained during human aura show a BOLD signal changes propagating at velocity of 3.51.1mm/min, again within the same range.

    The analysis of the present cases and general experience indicate that aura symptoms, regardless of their form, vary to a great extent in duration and severity from patient to patient, and also within the same individual. Positive visual phenomena may present as tiny, mild light spots of short duration, as well as vision impairing impressive fortification spectra. There are patients who recurrently present one type of aura for many years, and change to a new pattern without obvious reasons. Aphasia is sometimes so marked that patients cannot communicate, but in other cases, there is but a mild language dysfunction. This variability accounts for all aura phenomena, including motor, sensory, and even our prosopagnosia findings. It is noteworthy that SD is not a multigradient, progressive phenomenon, but rather an all-or-nothing sort of event. Provided SD produces aura symptoms in migraine, clinical expression does vary in intensity while the underlying pathophysiological process does not.

    In conclusion, MWA and MWoA are symptom-rich neurological conditions marked by overlooked abnormalities that may predominate during attacks but also occur at interictal phases. This may indicate that MWA and MWoA are closer to each other if comprehensively appraised. Today’s knowledge on cortical function mapping, previous neuroimaging studies, the aura time course, and the add-on pattern of different symptoms’ progression during aura, support SD as the most probable pathophysiological aura underlying the phenomenon. Doubt remains as to why SD, an all-or-nothing type of cortical event, expresses at different degrees from the clinical point of view. The pathophysiology of migraine will not be understood before the mechanisms behind the clinical expression of SD become apparent.

    (Noteworthy quote for your situation: “There are patients who recurrently present one type of aura for many years, and change to a new pattern without obvious reasons.”)

  7. 7
    Cuttlefish

    Sweet!

    (And I must say, it is nice that I have my vision back to read it! A few years ago I had a real scare, when following one of my visual migraines, I couldn’t read–I knew there were letters there, but there were no functional words.)

  8. 8
    tac

    I’m a headache neurologist (university based) and your idea that the visual aura is in your cortex is correct. Right visual field (both eyes) is represented by the left occipital cortex.

    The activity in the brain from migraine visual aura has been imaged in PET and functional MRI scan. Research suggests it is due to a metabolic or functional change, not actually due to ischemic or vasoconstriction. Couple of references if you are interested:

    Cephalalgia. 1997 Aug;17(5):570-9.
    Regional cerebral blood flow and oxygen metabolism during migraine with and without aura. Andersson JL, Muhr C, Lilja A, Valind S, Lundberg PO, Långström B.

    Ann Neurol. 1990 Dec;28(6):791-8. Timing and topography of cerebral blood flow, aura, and headache during migraine
    attacks. Olesen J, Friberg L, Olsen TS, Iversen HK, Lassen NA, Andersen AR, Karle A.

  9. 9
    Cuttlefish

    Unrelated question, tac–I have made plans to donate my brain to Cuttlefish U. (well, after I’m done with it); I plan to do some videos about my brain to show along with it to bio, psych, or whatever classes…because students all ask questions about “whose brain is it?”. Anyway, I would love to do a series of videos with various researchers, using whatever methods they use (PET, FMRI, etc.) to include with this. Hell, I’d love to do it as a series for PBS. Anyway, any advice? What sorts of methods should I be looking to include? Got any connections? Wanna look at my brain?

    eta–oh, and thanks for the references!

  10. 10
    jdguil

    I used to have ocular migraines. They were caused by my eyes not properly focusing. After 30 minutes of reading the print would go out of focus and I would often get the ocular migraines. I told two different optomologists about the problem and they just brushed me off, saying I was getting old.
    The third one I talked to checked my eyes and found that one eye was focusing higher than the other. She prescribed prisms in my reading glasses to level the view from both eyes. It solved the problem completely; no more migraines and no more reading focus problems. Hope that helps.

  11. 11
    otrame

    I’ve had visual migraines occasionally for many years. I’m one of the lucky ones and I seldom get the headache or nausea (though about once in ten years I do).

    But last year I woke up one morning and was seeing double. Completely split vision, two of everything. It did not go away after a couple of minutes. Since I was 60 years old and so forth, I thought it might be a stroke (double vision is a possible symptom).

    By the time I got to the ER I just had very blurred vision. About an hour later, I realized that the “thick” feeling in my head (not quite a headache, but definitely something) was familiar. Then I realized that what I had experienced was a migraine of a type I had never even heard of before. They CAT scanned me, of course, just to be sure, but by the time I left the hospital, it was all over.

    Cuttlefish, migraines do change sometimes and that is not necessarily a sign of something worse, but if you are at all concerned, I would go to the doc.

  12. 12
    tac

    Cuttlefish—I don’t know if I can help with the video+brain imaging questions—I’m mainly clinical, and don’t interact with the imaging research people at my institution. Depending on where you live, you could contact the PET scan department and ask for a research “Fellow” and see if they are looking for volunteers.

    One of the leading migraine imaging people recently joined UCSF Neurology (where I trained, maybe before dinosaurs became oil): Peter Goadsby, M.D., Ph.D.

    If you want to discuss this further you could email me at colli037 at yahoo dot com

  13. 13
    Trebuchet

    Glad you’re feeling better, Cuttlefish! Even gladder that I don’t experience migraines.

    Completely off topic: May I assume you’re still following Sailor Twain? I followed your link to it a long time ago and was instantly hooked. Things are getting intense. I can’t stand the wait for Mondays, Wednesdays, and Fridays.

  14. 14
    Cuttlefish

    Oh, absolutely, Treb! Makes me wish I could draw… or manipulate time, so that I can read the rest of it NOW! What gets me is, all of it has now been uploaded! Not available to everyone, but the story is done–that freaks me out for some reason.

    For those reading who missed the earlier bit, start here: http://sailortwain.com/blog/2010/01/15/sailortwain-001/ and be prepared to spend a lot of time.

  15. 15
    Trebuchet

    I’m already looking forward to spending some rainy day reading the whole Twain saga at one sitting. And then going through again, more slowly, reading the comments. I’ll probably buy the book when available as well, just to thank him for the story.

  16. 16
    Cuttlefish

    You caught me–I’m re-reading the whole thing now! And yes, will do so again with comments, and will likely buy a copy. Something that brings that much pleasure is worth paying for.

  17. 17
    Tigger_the_Wing, Back home =^_^=

    I have a related question for the kind people on here; is my Prinzmetal’s angina related to the migraines? The migraines started becoming more frequent fiteen years ago, at around the time that the angina was becoming troublesome (obvious heart pain instead of something mild enough to be dismissed as indigestion).

    Some history: I have congenital prosopagnosia, so I wouldn’t notice that as a migraine symptom. But I often have aura-without-headache (sometimes by noticing the very early changes and getting the meds into myself quickly). The aura can be olfactory and auditory hallucinations as well as/instead of visual ones. Also aphasia, hemiplegia and, occasionally, total paralysis. One time I even forgot that my right hand side existed (which was weird…). After I had gone to bed with a hemiplegic migraine and woke up feeling better, my husband brought me a meal on a tray. After a while, he pointed out that I was having difficulty eating with just the fork in my left hand and I wondered what the problem was.

    For the last couple of years I have been taking one Dolased tablet (codeine phosphate 10mg/paracetamol 500mg/doxylamine succinate 5mg) twice a day (with my morning and evening meds) and that has helped largely prevent the head pain and reduce the frequency of other neurological symptoms to around weekly and mostly mild (e.g. stammering and minor vocabulary loss instead of total aphasia; balance problems instead of paralysis; everything being bright and sparkly instead of vision loss). The safe dose is up to eight tablets in 24 hours, so by taking two a day I am well within the limits and can take more if the symptoms break through.

  18. 18
    helenkrummenacker

    The cracked window effect is classic visual migraine.

  19. 19
    Tsu Dho Nimh

    I used to get what were diagnosed as migraines … the most common visual effect was a depression in the ground in front of me, as if there were a dip in the grass or even sidewalks.

    It made walking difficult, because I never could tell if it was real or not.

  20. 20
    Cuttlefish

    Aren’t y’all glad we live in an age where this is not seen as a symptom of possession, and where cures are more than prayer and/or exorcism?

  21. 21
    Rebecca Rose

    Amen, brother! ;-)

  22. 22
    Keith O'Connor

    After 40 years of cluster headaches, one day I had a visual migraine instead and it wasn’t followed by pain. No pain at all. I still have visual migraines but I’m almost happy to see them, since they’re SO much better than crushing pain. Is this a new phenomenon for you? If so, perhaps it signifies the start of a change for the better.

  23. 23
    den1s

    As a child, my migraines were intense and started with a visual lack of a focal point…. in fact I couldn’t see the point of focus, it was blanked out. Together with the electrical zig-zag flashes running across the top of my vision they provided the impetus to learn to get to a completely dark and quiet room. If I could actually get to sleep, the searing white hot pain wouldn’t hit, but on awakening I would feel like my brain was physically bruised and would hurt if I shook my head from side to side.

    Thankfully I don’t seem to get the headaches anymore, but I do get the aural displays sometimes which are still worrisome but they only seem to last ten minutes and just disappear.

    Nasty business… I understand/share your pain

  24. 24
    chris

    I am so sorry. I come from the position of being the person who does not get migraines who married into a family that does.

    First I learned how to deal when spouse got a migraine, which was to make him comfortable, put a damp cloth over his eyes, make sure the room dark and remove the children. Now I have two out of three children who get migraines, and the same routine applies.

    My youngest got her first migraine just a couple of weeks ago. She was freaked out by the aura, and I had to explain to her that the majority of her brain is devoted to vision. So if there is any abnormality in function, she will see it first. This did seem to comfort her. It also helped her to tell her that her oldest brother’s aura was that everything turned purple.

    What did not help was that her oldest brother recently had a complex migraine that sent him to a hospital. This is a migraine that mimics a stroke. A person literally loses use of any language, and their limbs become numb. And if the person has a severe genetic heart anomaly, this means he is automatically suspected of having a stroke, even though he is only twenty three years old. Not a stroke, but a very bad migraine.

    I’ve only had sinus headaches due to allergies. Once I found out what caused them I was able to get rid of them with antihistamines and Sudafed. I have never had a real migraine.

    Now I am all too familiar with them. I have nursed more migraines than I care to count. My husband used to get them regularly, but that stopped almost twenty years ago. Now it is two of my children. One has a severe genetic heart condition that prohibits the use of most of the most popular medication. Rats!

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