Migraine is a chronic headache that is common, disabling and preferentially affects women.
The attacks are often preceded by visual phenomena (Aura) which means that the Ophthalmologist is often consulted although it is not really an eye disease.
Migraine disease most often begins between the ages of 10 and 40, and in 70% of cases there is a family history of migraine. It is estimated that 10% of the French population suffers from migraine attacks.
Common causes of ophthalmic migraines:
Migraine is a hereditary disease, starting before the age of 40 and subject to many environmental factors that intervene in the triggering of attacks:
Menstrual cycle: Before the onset of menstruation, there is a drop in estrogen levels which frequently induces a migraine attack.
Individual factors: worries, annoyances, overwork leading to stress which can provoke a crisis, great physical or intellectual efforts.
Weather conditions: wind, cold or sudden temperature changes.
Strong odors of certain plants or perfumes.
Dietary factors: food allergies (eggs, chocolate, strawberries, seafood, alcohol, ice cream, cold meats, etc.), meals that are too rich, mixing alcoholic drinks, long-term fasting.
Circadian rhythm disruptions (excess or lack of sleep, shift patterns, etc.).
Diagnosis of ophthalmic migraines:
The migraine attack most often begins upon waking, sometimes preceded by warning signs that patients often know well, allowing them to anticipate the attack (very early treatment can considerably shorten and alleviate the attack).
Seizures last between 4 hours and 72 hours.
The pain gradually increases over a few hours before reaching a plateau. It is most often located on one half of the skull, alternating between the left and right from one attack to another.
The pain is disabling, throbbing and aggravated by physical exertion.
Migraine is accompanied by at least two of the following signs: photophobia (intolerance to light), phonophobia (intolerance to noise), nausea, vomiting. The fatigue (asthenia) induced by migraine and the intolerance to external stimuli often force the patient to remain lying down in the dark until the attack subsides (24 hours on average). The end of the attack is rapid, with a discreet note of liberating euphoria.
To confirm the diagnosis, two conditions are essential:
– Occurrence of at least 5 crises meeting these criteria,
– And absolute normality of all other examinations, essentially neurological examination.
Migraine aura
Migraines can often, in some patients, be accompanied by sensory phenomena grouped under the name of "aura". We then speak of accompanied migraines (approximately 20% of cases). These auras precede the attack and generally last less than an hour. Migraine pain follows, sometimes after a delay of a few minutes.
The most frequent auras are ophthalmic auras: the visual field is filled with phenomena such as scintillating points (phosphenes), flies appearing to cross the visual field (myodesopsias) or broken luminous lines, which can form complex compositions.
Visual aura may also consist of homonymous lateral hemianopia (loss of the same half of the visual field in each eye), transient monocular blindness, etc.
Sensory auras can manifest as sensitivity disorders such as paresthesia (tingling, prickling) in one side of the body.
Other auras are rarer and can pose diagnostic problems: transient hemiplegia, diplopia due to oculomotor paralysis, psychological disorders, auditory hallucinations, language disorders.
In all cases, the signs must regress quickly and without sequelae. The neurological examination is always normal in migraine (apart from very rare complications, see below). In some cases, the aura is not followed by migraine.
Role of the brain scanner:
A migraine does not require any further investigation provided that the attack meets the usual criteria for a typical migraine, and that the clinical and neurological examination is normal. A brain scan will be performed in the following cases:
Migraine always affecting the same half of the skull,
Aura of unusual duration (more than an hour),
Aura with sudden onset (the aura sets in within a few minutes: this is called “aura progression”),
Very atypical aura (diplopia, abnormalities reported to the brain stem, psychological disorders, auditory/gustatory hallucinations),
First migraine attack before age 10 or after age 40,
Major and recent change in symptomatology.
The scanner looks for an intracranial arteriovenous malformation, a transient ischemic attack, a cerebral infarction.
Treatment of ophthalmic migraine :
Prevention of certain factors known to cause seizures is effective for those whose seizures are caused by an external factor. These factors include alcohol, tobacco, caffeine, chocolate, certain cheeses, psychological stress, strong odors, light and sound aggression.
Crisis treatment :
In any case, resting in a quiet place, in the dark, far from any noise or light aggression, helps to avoid making the crisis worse.
To be effective, the treatment must be taken as early as possible and ideally during the prodromes of the migraine attack, but after the end of any aura for triptans.
Indeed, the aura would correspond to a phase of vasoconstriction prior to migraine vasodilation. Therefore, the too early absorption of vasoconstrictor triptans could lead to ergotism phenomena. Initially, the drugs proposed are paracetamol, non-steroidal anti-inflammatories, aspirin, to which we can associate Primperan (anti-vomiting) which improves digestive absorption and helps reduce nausea.
Painkillers should only be taken in the event of an attack and never on a daily basis.
If these molecules fail, ergot derivatives or triptans can be introduced. Their efficacy is very good, at the cost of side effects and contraindications that must be carefully weighed against their therapeutic effect. In case of ultimate necessity, morphine remains a last resort.
Background treatment:
The aim of basic treatment is to effectively reduce the frequency and intensity of migraine attacks. It is proposed when attacks are frequent (from three per month) and/or disabling (with a significant impact on activities due to their intensity or duration). The most commonly used drugs are dihydroergotamine, propranolol (beta-blocker), methysergide, flunarizine, sodium valproate and amitriptyline (tricyclic antidepressant, particularly effective if there is an anxio-depressive component associated with the disease). It should be noted that all these products were created for indications other than migraine initially (anti-epileptic, antidepressant, etc.).
Indoramine (alpha-blocker) can also be mentioned as a specific background treatment.
The chosen molecule must be taken regularly for 3 months, with a self-monitoring schedule where the attacks are recorded with a rating of their intensity and duration, medication intake, possible side effects, and above all the effectiveness. If effective, the treatment is taken for another 6 months, before being gradually stopped in the hope of a more or less complete and lasting remission of the attacks.
Today, some of these treatments are sometimes combined with certain classes of anti-epileptic drugs whose anti-migraine action has now been demonstrated.
