S2:Ep16 – Symptoms in the Eye: Is it migraine?



Voice-over: Welcome to Spotlight on Migraine, hosted by the Association of Migraine Disorders. Join us for fresh perspectives by medical experts and advocates as we explore the spectrum of migraine and dig deeper into this complex disease. This episode is brought to you by our generous sponsor, Teva Pharmaceuticals.


Learn why many of us get symptoms in our eyes with a migraine attack, and how to differentiate them from ocular migraine. In this episode, Dr. Rani Banik discusses various eye-related migraine symptoms including visual aura, pain, light sensitivity, visual snow, and more.


Teva is committed to providing innovative medicines to enable people, including those living with migraine, to live better days. Teva applies a holistic approach to the development of new treatments that focus on the needs of patients. Visit TevaPharm.com to learn more.


Molly O’Brien: Hello, and welcome to Spotlight on Migraine. I’m your host, Molly O’Brien. Today we’re talking all about migraine and the eye. What is aura? Why do some people have it? And what about other symptoms that manifest in the eye? We’re going to cover it all.


I’d like to introduce our guest, Dr. Rani Banik. She’s a board-certified ophthalmologist and a fellowship-trained neuro-ophthalmologist. Dr. Banik, thanks so much for joining us today.


Dr. Rani Banik: Thank you so much for having me on your podcast.


Molly: Just to kind of get a baseline and to start the conversation, Dr. Banik, can you help us understand the relationship between migraine and the eye?


Dr. Banik: Absolutely. So a lot of people don’t realize that they are very closely connected, and the reason is because migraine, we think, is mainly mediated by the trigeminal nerve. So it’s a very important nerve that lies deep within the brain, but it sends many different branches to the covering of the brain, to the face, to the eye socket as well. And so small little branches of the trigeminal nerve innervate the eye socket, the surface of the eye, the cornea. So anything that causes migraine or triggers a migraine can potentially cause visual symptoms as well.


Molly: It’s fascinating because some people do get these symptoms manifesting in the eye, and some people don’t. So we have a lot to talk about today. I’m very interested. Can you talk to us a little bit about migraine and the eye in terms of what types there are?


Dr. Banik: There are many different visual symptoms of migraine, and oftentimes the terms get confused. So I just wanted to clarify that a little bit, because it really is important to use the proper terminology and also for your doctor to use the proper terminology, because depending on the type of symptom, different types of workup may or may not be necessary. 


So we’ll first start with the most common manifestation of migraine, which is visual aura. And many people have probably experienced this. I know I have myself. It’s quite frightening when it happens. But basically, it’s a disturbance in vision. It may start off as a small gray or dark spot in your vision, but then it begins to shimmer, and it starts to enlarge. It almost looks like a C shape or semicircle, and it can take up the entire half of your vision. And it grows and grows, it expands, and then eventually it kind of drifts off. 


And inside it can be — different people experience different variations, but it’s usually geometric figures. It can look like a kaleidoscope. Sometimes it’s multicolored, sometimes it’s white and black, but it has a movement quality to it. 


And afterwards, after the visual disturbance resolves — usually it lasts about anywhere from 15 to 30 minutes. After it resolves, oftentimes people will then experience a headache afterwards. And it’s interesting, so the visual aura is on one side of your vision, so half of your vision, whether it’s your right half of your vision or your left half, but the headache tends to be on the opposite side. So for example, if you start to see these flashing lights over here on your right, you’ll experience a headache on the opposite side. 


And this happens because what causes the visual aura is actually not an eye issue; it’s actually in the brain. And initially, what happens is that there are blood vessels in the visual cortex back here, which is the area that processes our vision. Those blood vessels can go into spasm, and when they go into spasm, that’s when people have this strange disturbance. And then after the spasm, the blood vessels dilate, and the dilation is what causes the headache. So that’s one visual manifestation of migraine.


Now, there are many others, but I just want to say in terms of terminology, so we call that visual aura or migraine with aura. If you just get the visual disturbance but no headache, you can just call it aura without headache or acephalgic migraine. But that is different than ocular migraine. A lot of people use them interchangeably, but they’re actually two distinct phenomena.


So ocular migraine is actually a one-eye phenomenon where what happens is — let’s say it’s the right eye that gets affected — the vision may go completely out or partially out in one eye only. So it may be gray or black or white. So people may lose, for example, the top half of their vision or the bottom half of their vision. And that symptom can last a few minutes, even up to half an hour, even an hour at the most. And then slowly the vision starts to come back. It comes back kind of pixelated, and afterwards people may develop a pain behind the eye or kind of in the eye socket, like a dull pain. 


So two very distinct things — aura versus ocular migraine. And some people call ocular migraine “retinal migraine,” and that’s okay. And the way you can think about it is that the spasm is actually in the retina. It’s actually in a blood vessel in the eye. So those are just two of the many, many visual symptoms of migraine.


Molly: So much to take in, and interesting because some people might get aura and some people might experience aura not within the eye. So I find it fascinating how our migraine brains work.


Dr. Banik: Yeah, and people may experience different types of aura. It doesn’t have to be visual. Some people experience olfactory or smell aura or some other disturbance like numbness or tingling or weakness. So there are many different types of aura, but visual aura I think is probably the most common.


Molly: And as we continue on, can you tell us a little bit about other migraine symptoms that might manifest in the eye?


Dr. Banik: Yes. So many people will have a vision disturbance or pain, but sometimes people have other unusual symptoms; for example, their lid may become a little bit droopy. Or if you look very closely at your pupils, which is that dark circle in the middle of the colored part of the eye — that’s called a pupil — sometimes the pupils may be asymmetric. One pupil may be larger than the other, or it may be not circular but kind of like an oval shape, or sometimes we call it a tadpole pupil. These are all other visual manifestations of migraine.


Sometimes people may even have redness of the eye or congestion, so again, many, many different symptoms of migraine. Those types of symptoms, when the lid or the pupil gets affected, it usually affects a different pathway. So I talked before about the trigeminal nerve, but there are other nerves as well that can get involved in migraine.


And you may have heard of the autonomic nervous system, meaning the sympathetic or the parasympathetic nervous system. The parasympathetic nervous system is the part of our nervous system that helps us calm down and relax, and the sympathetic nervous system is kind of more fight or flight, that kind of immediate response or kind of the quick up-regulating response. So if either of those two systems get affected with a migraine, people may experience the eyelid issue or the pupil issue, or sometimes people even have tearing of the eye, and that’s also part of the parasympathetic system.


So migraine is not just a single kind of — I wish it would fit nicely into one category, but it doesn’t. It can affect many different types of nerves, with a variety of symptoms.


Molly: It is fascinating to learn about. It seems like we’re always experiencing something new. I have heard people talk a little bit about visual snow. Can you talk to us a little bit what that is and why that happens or the other symptoms that might manifest in the eye?


Dr. Banik: Yeah, so visual snow is a very unique symptom, and I actually experience it myself, so I’ll describe to you what it’s like. So basically, it’s like you’re seeing an overlay over your entire vision of TV static. Remember back in the day when if the channel wasn’t tuned in to a particular station, you would see this kind of white and gray and black granularity? So people experience that as an overlay in their vision.


And you can still see through it; for example, I can see everything I need to see, but I do notice this overlay. And it’s worse in certain lighting conditions — for example, if there is high contrast. If I’m looking at a bright white wall, I’ll probably notice it more, if I’m looking at the dark night sky. But in situations where you have different types of contrast, you may not notice it as much.


But visual snow is unique in that it is — because part of the brain is almost hyperexcitable, and it’s almost like visual noise going on in our brains that we actually see and experience. And it is much more common in people with migraine. So there was a study done where they looked at all the patients with visual snow, and about 60 percent of them had some form of migraine. It is definitely more common in migraine, but it can happen in people even without migraine. 


And I can tell you that I didn’t experience snow until about five or six years ago. And it was almost like someone turned on a switch, and all of a sudden, I started to experience it and notice it. And it’s pretty much been constant and persistent since. 


So, unfortunately, there is not great treatment for snow. I do recommend a couple of things for my patients. I’ve tried a couple of different supplements, vitamins, even some pharmaceutical agents, but there is no cure yet, meaning there is no one thing that can completely get rid of it. 


But one thing I will tell you, when people first start to experience snow, they get quite frightened. They think, “Oh my goodness, this is happening. I’m going to go blind. I’m going to lose my vision permanently.” But I can reassure you that it does not cause blindness. And just know that it’s there, it’s with you, but it doesn’t actually cause your vision to degrade over time. So keep that in mind.


Molly: And that’s a great point because a lot of times, these symptoms that manifest in the eye are very scary. And so I’m interested, can migraine affect your sight over time? You talked a little bit about visual snow — it can’t cause blindness — but how can migraine impact your sight, if it can?


Dr. Banik: Yeah, so the good news is for most people, these symptoms are transient. So yes, it’s quite disturbing when it happens. Sometimes when people experience an aura, especially for the first time, they think they’re having a stroke. It’s very, very frightening. But luckily, if you wait it out, it will pass. 


And most of the symptoms, again, will usually pass within 15 to 30 minutes, at the most 60 minutes. If it doesn’t resolve within 60 minutes, I would definitely seek the care of a healthcare practitioner because you want to make sure that there’s nothing else going on. And the thing that we worry about most is having a stroke, whether it’s in the brain or in your eye. So definitely, if it’s a prolonged symptom, get it checked out. 


And I can tell you that I’ve been practicing for over 20 years, and I would say about 50 percent of my patients have some form of migraine or some variant of migraine, so I see a lot of that in my practice as a neuro-ophthalmologist. But I have only seen one patient in over 20 years that had permanent vision loss from her migraine symptoms, and that was because she ended up having a type of ocular migraine, which is what we were talking about before, but it ended up transforming into a retinal stroke. So it’s very, very rare that that can happen, but it is one of the manifestations, more serious I would say, that unfortunately can cause permanent loss.


Molly: And kind of as we talk about you treating patients, are there any tests that need to or can be done to diagnose ocular migraine or to help lessen the symptoms?


Dr. Banik: Absolutely. So what I would say first of all is if you have chronic migraine and you have had these symptoms for years and years and years, you probably don’t need any tests because it’s probably very benign and it’s a variant of migraine or migraine with aura. But if it’s your first time having one of these symptoms, at least get an eye exam to make sure that it’s not something more serious, something more neurologic. 


And the one test that I usually do for my patients with, let’s say, new-onset visual aura is a visual field test. And I don’t know if you or your listeners have ever gone through this test. It’s a tricky test to do, but basically, you sit in a machine — it’s almost like a bowl — and the machine shows you these tiny, tiny little white lights, and you click a button when you see the light. So basically, it’s testing your entire peripheral vision.


And in most cases, visual aura will have a normal visual field. But rarely, there are some people who have visual aura, but it’s not really — or who have symptoms of what we think is visual aura, but it’s not really visual aura. It could represent something else, for example, something going on in the brain like seizure activity or a stroke or bleeding in the brain. So that’s why just as a precaution, I always get that visual field test done for the first-timer. Now, again, if someone’s had repeat episodes, you don’t need to get that done, but the first time, yes, get it checked out.


Molly: Let’s move on to talking about light. Sometimes different types of lighting can trigger migraine, and sometimes if you’re on the cusp of an attack or you’re within an attack, light can be bad news, so to speak, so it can be really disturbing. Why do people with migraine have this light sensitivity?


Dr. Banik: Yeah, I love this question. Great question. So it all goes back to those pathways I was talking about before, the trigeminal nerve. So the cornea, which is on the very surface of the eye — it’s the curved part of the eye; it’s transparent — it is very rich in nerve endings, and these nerves are basically branches of the trigeminal nerve. 


So when light hits the cornea, it can activate those trigeminal nerve endings. And if that trigeminal pathway is primed for migraine — it’s almost like, again, you’re hyperexcitable or your nerve endings tend to be hyperexcitable — different wavelengths of light can trigger a migraine attack. 


And based on the research studies that have been done with light and migraine, it’s been shown that light in the shorter wavelengths — so there’s many different types of wavelengths of light — but blue or green wavelengths of light, which are more short-wavelength, high-energy wavelengths of light, tend to trigger migraine. So for example, for many people, if they were out in bright sun, that can trigger a migraine, or if they’re on their screens for a long period of time. 


So all of our screens emit blue light. You’ve probably all heard about blue light in some shape or form. It’s a hot topic now because we’re so attached to our screens, especially during the pandemic. But that light coming from our screens can definitely trigger migraines. And again, it has to do with that wavelength that I was talking about, that blue or green wavelength.


There are some conflicting studies. The earlier studies did show that blue to green wavelengths, which is basically between about 480 to about 550 nanometers or so, could potentially trigger migraine. But now there is more of a shift towards certain wavelengths of light being therapeutic for migraine. There are some studies that show that green light — the longer types of green light, more towards the yellow end of the spectrum, and definitely longer wavelengths — for example, orange and red — have also been proposed as treatment for migraine. So I would say if you’re going to try to limit the amount of light that you’re exposed to, definitely try to limit blue light.


Molly: Good to know as we continue to try to add more tools to our migraine toolbox. And speaking of that, I’m interested — can sunglasses help prevent a migraine attack? Or even the migraine-type glasses — are those beneficial at all for our eye and migraine health?


Dr. Banik: Yeah, so sunglasses — I’ll just kind of make a distinction here — sunglasses typically block at UV wavelengths, so UVA and B wavelengths, which we tend to think not being so much of a trigger for migraine. The migraine glasses you’re talking about, which are mainly types of blue-blocking glasses — again, the shorter wavelength, blue wavelengths, are blocked out. 


For example, there’s a tint out there called an FL-41 tint. You may have heard of it, or your listeners may have heard of it before. FL stands for “fluorescent” 41. And basically, it’s a rose-color tint or kind of a pinkish tint. That actually has been clinically proven to help with the light sensitivity in migraineurs, so it is something I absolutely recommend. If you definitely suffer from light sensitivity, whether it’s indoors or outdoors, I would suggest trying a pair of FL-41 glasses. There are many different manufacturers out there, but that is the type that has been proven. So not just your typical blue blocker, but specifically the FL-41 tint. And that tends to block out the 480 to 520 nanometer range of light.


I love them myself, by the way, so actually I keep a pair in the car. And I have the entire wraparound kind, so not just the typical sunglasses, but they even have the little side panels. I wish I had a pair to show you.


Molly: Another great tool to add to that migraine toolbox. Let’s talk a little bit about other symptoms that might manifest in the eye. We had some viewer comments. They were interested in why your eyes might feel heavy or painful in the middle of an attack or glossed over. You talked a little bit about the pupils changing, the eyelids changing, but what about other symptoms like eye pain or puffiness?


Dr. Banik: Yes, eye pain is actually quite common, especially in the patients that I see. They initially actually may — these patients may see an ophthalmologist before they see a neurologist and realize that it’s a form of migraine. But it all goes back to that trigeminal nerve. 


There are two specific nerves that are right here and here. So there’s a nerve here called supratrochlear nerve, and a nerve here called the supraorbital nerve, and both of these also go deep within the eye socket. So these nerves tend to get affected, so people may have a dull pain in the eye socket, sometimes even a sharp kind of stabbing type of pain. It can be really quite debilitating.


And sometimes for these patients, they may not develop the classic migraine symptoms. We think of the headache, we think of the light sensitivity, sound sensitivity, nausea, vomiting. They may not have that full spectrum of symptoms, that range. They may just have the eye pain. So it’s really, really important first of all to see an eye doctor just to make sure it’s not something else — make sure it’s not something else, another eye pathology. But basically, if the eye exam is normal, in most cases it’s a variant of migraine, again because of those trigeminal branches being triggered.


Now, in terms of that glazed-over look you were talking about, yes, many people can feel a heaviness or kind of like a redness of the eye, and most of those symptoms are mediated by the sympathetic and parasympathetic systems I was talking about earlier. So again, all these nerves are kind of on — their threshold for being triggered is very, very low, so they easily can get triggered by basically anything. And it could be light, it could be stress, it could be dehydration, lack of sleep, too much caffeine. These are oftentimes some of the most common triggers for the visual symptoms of migraine.


Molly: And as you said that, I’m thinking, “Yep, that’s exactly where it hurts, right down through here and right through here, where it’s that feeling where you just want to make it go away.”


Dr. Banik: Exactly. And sometimes even the pain may go to your sinuses, and the reason they may come down here — we have sinuses up here as well and behind the eye sockets. It’s all because of that trigeminal nerve, because there are branches that go to all of our sinuses as well. So if one branch gets triggered, sometimes the pain can even travel. It can migrate because the various branches get — kind of like a domino effect, they get triggered one by one.


Molly: That is so fascinating. And you talked to us a little bit about triggers just a moment ago — light sensitivity, too much caffeine. Can you talk to us and explain a little bit more about these triggers? Can what we see or what we’re doing with our eyes actually trigger migraine? And then we’ll get into what to do to stop it.


Dr. Banik: Yeah, yeah, absolutely. So as I mentioned before, light is perhaps the most common trigger for many people, particularly strong sunlight. Or if the sunlight’s coming in at an angle through the window, a lot of people will get triggered by that. Or if they’re in a car and they’re kind of getting the sunlight through the trees, that can be a trigger. 


Or even fluorescent lights — many people are triggered by overhead fluorescent lights because of the wavelengths that they emit, but also because the fluorescent lights have an internal flicker rate. And a lot of people don’t realize this, is that fluorescents are flickering at a very, very high rate, and the reason they flicker is because they’re trying to save energy. That’s the way the bulb was designed to save energy. So they have this fast on-and-off kind of a rate. And the same thing with all of our devices: they have an internal flicker rate.


Molly: Let’s talk a little bit about how we can prevent or at least try to modify some of our behaviors. Are there any good practices or good eye-health hygiene practices that we can use to help reduce our risk of an attack?


Dr. Banik: Yeah, so this is a great question. There’s so much I could talk about here. So what I would say is many of us are on our screens all the time, hours and hours a day. The average adult, even — this is before the pandemic — was spending about 11 hours a day in front of screen, which is crazy to think of. It’s just mind-boggling to think that we are so attached to our screens for work and entertainment and now for social interactions also. So because of that increased screen time, you really want to mitigate that blue light coming from your screen. 


So one thing I would say is most of our phones have a blue light filter, so there is a night-shift mode that you can put on that will automatically filter out those blue wavelengths depending on the time of day. So we do need blue light for a healthy circadian rhythm, or sleep-wake cycle, so that blue light coming from the sun is useful. But when it comes from our devices, it can trigger migraines, it can affect our sleep, it can cause digital eye strain. So you want to perhaps put on one of those blue filters. You just go to your settings and put on that.


But also there is a couple of apps that I like. I like — it’s called Iris — Iris Tech is actually the full name, so you can download that. I think there’s a free trial, maybe a one- or two-week free trial, and then if you like it, you can purchase it. It’s not very expensive. It’s for a nominal fee. There’s also another app called F.lux — F dot L-U-X — that can also basically filter out those blue wavelengths. That’s one thing you can do.


The second thing you can do is if you’re working for an extended period of time, or if you know you’re going to be at your computer for hours at a time, I like something called the 20/20 Rule. And when we think of 20/20, we think of perfect vision, but this is kind of a variation of that. So the 20/20 Rule is every 20 minutes — set your timer — take a 20-second break, and just close your eyes for 20 seconds. And that way, it eliminates all that light getting to your eyes. It gives your eyes a rest. It gives your brain a rest. And maybe take some deep breaths while you’re doing that 20-second break, and then just resume your work. So it’s very, very effective to use that 20/20 Rule.


Molly: Anything else that you want to share with us as we kind of wrap things up here?


Dr. Banik: Just one other thing. If anyone — now that during the pandemic it may be challenging to go see your doctor, I do offer telemedicine consults, so you can find that information on my website as well. So if you don’t have a local neuro-ophthalmologist in your area — there aren’t that many of us across the country and across the globe — but if you don’t have access to one, you can always sign up for a telemedicine consult with me.


Molly: And that wraps up this episode of Spotlight on Migraine. I’d like to thank our guest today, Dr. Rani Banik. Thank you so much for joining us. It’s been a great conversation.


Dr. Banik: Thank you so much, Molly. I really enjoyed our talk.


Molly: I did as well. And for all of you listening and watching, if you want more information on migraine and the eye, you can follow Dr. Banik on her social media pages or check out her web page. 




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