Ocular Migraine – Bringing Facts Into Focus

Migraine aura can be a visual symptom that accompanies a migraine attack. Maybe you have heard of scintillating scotoma? Perhaps you heard of this term for migraine aura while you were browsing a website, or maybe your doctor mentioned it to you. What is it? What does it look like? Can it cause permanent vision loss? Is it an ocular migraine? If you are looking for answers to questions like these, you have come to the right place. Let’s dive into it. 

** While Migraine Strong writes about the latest in migraine treatments, this is not medical advice. We are patient educators and all information you read should be discussed with your doctor.

What Is Visual Aura?

There are three different types of visual aura that present with migraine. They are:

• Scintillations – These appear as twinkling or shimmering lights in the vision.
• Scotoma – Areas of decreased or lost vision.
• Blindness – Complete lack of vision

In short, a scintillating scotoma is defined as a blind spot in the vision that is bordered by a shimmering or flashing light that can be seen in both eyes (even if not equally) and precedes a migraine attack. The video linked below, from the Mayo Clinic, shows a very typical scintillating scotoma…how it starts and how it resolves. There are other auras that people experience that are often described as squiggly lines in your vision, black spots, flashing lights, zig zag patterns or shimmering spots. 

Though visual aura with migraine occurs in about 20% of those that have migraine, it became very apparent in my anecdotal poll of friends and family members that we all experience it just a bit differently. Even in those of us who are siblings or parent and child. Below are some of the explanations that I received from my family members and friends about what their aura looks like and how it progresses.

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What Aura Looks Like

Melynda – Her aura appears as a wavy kaleidoscope of lines that grows and eventually fills her vision in her right eye, she can just barely see it in her left eye as well.

Jon – His aura is a sparkly kaleidoscopic crescent just off center in his field of vision in both eyes, sometimes it will take on a twisty snake like shape. Occasionally, he will get a less distinct foggy aura in his peripheral vision that slowly moves towards the center. 

Emily – Her aura starts as a speck and grows across her field of vision. It looks to her like parts of reality have been replaced with a bronze kaleidoscope-like effect, as if there is a tear in space that the aura is behind. Usually it forms a diagonal line across her vision, but sometimes it is circular. 

Mike – He is almost always triggered by lack of sleep and dehydration. Typically his aura begins with a hole in his vision or the disappearance of the bottom or a person’s face or a car in front of him and to the left while driving (Scary!!). The hole in the vision will transition to something like a jagged zipper structure of lights in his lower vision. 

Caitlin – Her aura is like an oil spill of shimmering colors, a black spot or small spinning dots. It’s usually on the left side of her visual field. 

Danielle – Her scintillating scotoma is first noticed when it looks like half of a person’s face has disappeared. After a few minutes a sparkly spiral appears. Both of those effects usually fade within a half an hour. Head pain may or may not follow.

Eileen – My aura is in my left eye mostly with just a tiny bit leaking over into the corner of my right eye. It is shaped like a half moon that is mostly a shimmering rainbow of colored lights. It starts small and usually is just a dot, like I have looked at a bright light and it’s remnant is showing up in my vision. 

Why Does the Scintillating Scotoma Occur?

The cause of visual aura with migraine isn’t really well understood. The part of the brain that processes visual signals (the visual cortex) might receive a chemical or electrical wave that causes the odd, changing scintillating scotoma we see. This is an area of migraine that is still being studied. The same triggers that will trigger an attack can also trigger aura. Common ones are bright lights, stress, too little sleep, hormones, weather, foods and medications. 

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Ocular Migraine Defined

Because this symptom affects vision it is sometimes called ocular migraine. The term ocular migraine is quite often used as a way to refer to migraine aura, with or without head pain and sometimes incorrectly to refer to retinal migraine. Part of the reason these terms get confused is that they get updated every few years through the academic institutions. They update the terms as a way to clarify the conditions and sometimes the old terms continue to hang around. We will clarify the current terms below. To read about the medications used for the treatment of ‘ocular migraine’, these articles review the preventive medications and acute medications currently available.

Long Term Effects Of Aura

Visual aura, like scintillating scotoma, that occurs with migraine with aura is completely reversible and does not leave any lasting side effects or cause permanent damage. It can be very disconcerting and cause anxiety when we know we are in for an attack. This article has some great tips for how to manage anxiety if you find yourself trying to manage when your migraine aura strikes. 

Does Pain Always Follow the Scintillating Scotoma?

There is a type of migraine attack that has the scintillating scotoma, but no head pain. This is sometimes referred to as silent migraine, but is more accurately called typical aura without head pain. Here is a quick review of what that type of migraine looks like. (If you would like to read about other types on migraine, this article offers all the details.)

Silent Migraine or Typical Aura Without Headache

• Occurs without head pain. 
• People experiencing silent migraine can have all of the symptoms of migraine listed above. 
• Will experience the prodrome, aura and postdrome phases and skip the headache phase.
• Even without the head pain, silent migraine can be very debilitating.  

Retinal Migraine – When Aura Comes From The Eye Not The Brain

Ocular migraine is frequently described as any visual symptom that accompanies a migraine attack. Whether it is scintillating scotoma, squiggly lines in your vision, flashes of lights, blind spots, zig zag patterns, shimmering spots or any other manifestation of aura talked about above. Retinal migraine, is a very specific type of migraine and has some very specific telltale signs that separates it from other types of migraine with aura. 

What To Look For When You Have Scintillating Scotoma

Retinal migraine is a fairly rare condition. Most often, diagnosed with a thorough medical history and a description given by the patient. There is no definitive test. The international Headache Society has retinal migraine strictly defined as at least two attacks fulfilling the following criteria:

• Fully reversible visual phenomena: scintillations (twinkling lights), scotoma (areas of decreased or lost vision) or blindness that occurs in only one eye, and lasts between 5-60 minutes. It’s unusual for the vision loss to last more than an hour. And, in most cases, the same eye is affected every time. 

With

• Headache, beginning during the visual symptoms or within 60 minutes of onset and having the criteria of migraine without aura.

Consisting of:

• Headache lasting 4-72 hours (either untreated or unsuccessfully treated), one sided, pulsating, moderate to severe in intensity, physical activity makes it worse.

And

• Having either nausea/vomiting or light/sound sensitivity.

Diagnostic Distinction

The distinction of the visual aura being present in only one eye is diagnostic in this case. Typical migraine with aura is seen in both eyes because the vision symptoms come from the brain. With retinal migraine, the symptoms are being generated from the eye and therefore are only visible when one eye is open and the other eye is closed. Irreversible vision loss is a potential complication of retinal migraine but is not a complication with migraine with aura.

It is important to note that a normal ophthalmologic exam is necessary to rule out other possible conditions. If your eyesight suddenly diminishes, especially if it’s the first time it has happened, make an appointment immediately with an ophthalmologist, optometrist or a medical doctor. 

Since the scintillating scotoma will likely not happen during your office visit, try to remember to cover one eye and then the other to determine if the visual aura is present in both eyes or just one eye.

Retinal Migraine Triggers

As with all types of migraine, retinal migraine comes with its own set of triggers. Some common triggers are listed below. 

• Stress
• Dehydration
• Wine
• High blood pressure
• Exercise
• Dehydration
• Low blood sugar
• Smoking
• Lack of sleep
• Strong odors
• Food additives like monosodium glutamate (MSG)
• Excessive Heat
• Caffeine

Who Typically Gets Retinal Migraine

• Females
• Those under 40 years old
• People with a personal or family history of migraine or headache disorders
• People with other underlying conditions such as lupus, sickle cell disease, epilepsy, hardening of the arteries, antiphospholipid syndrome (increased risk of blood clots) and giant cell arteritis (inflammatory disease affecting the large blood vessels of the scalp neck and arms)

Retinal Migraine Treatments

The treatments for retinal migraine are very similar to many of the treatments available for other types of migraine. Historically, the effective treatments have included:

Acute

• NSAIDs
• Anti-nausea medications
• Avoidance of triptans and ergotamines

Preventives

• Calcium channel blockers
• Anti-Epileptic medications
• Tricyclic medications
• Daily aspirin therapy is considered
• Discontinuation of smoking or oral contraceptives should be discussed

Takeaways

At Migraine Strong, we always stress the importance of the language that surrounds migraine. We have a neurological disease that is called migraine, of which we experience attacks, not migraines. This is another instance where knowing the difference between retinal migraine, typical aura without headache (silent migraine) and migraine with aura is important. If you’d like to talk about your aura with others, join our private Migraine Strong Facebook group for more discussion options.