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Often Implicated, the Eye Rarely
Causes Headache |
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BY DON SCHRADER
Contributing Writer |
SCOTTSDALE, ARIZ. (ECCC)—
Despite multiple associations with headache, the eye rarely
causes headache or other types of pain, said Dr. Robert B.
Daroff on February 21 at a headache course sponsored by the
Diamond Headache Clinic Research and Education Foundation.
“Many primary care physicians think the eye is a major cause of
headache,” said Dr. Daroff, professor of neurology at Case
Western Reserve University and University Hospitals in
Cleveland. “There seems to be almost a reflex response to send
patients to the ophthalmologist, even though eye disease is a
very infrequent cause of monosymptomatic eye or head pain.”
Dr. Daroff defined monosymptomatic eye pain as a
normal-appearing and normal-functioning eye, with pain as the
only symptom. Conditions that cause such pain are relatively few
and extremely rare. Pain arises from what ophthalmologists call
a “red eye.” A normal-appearing “white eye” usually is just
that: normal. Non-ophthalmologists are unlikely to see patients
with these conditions.
“If the gonioscopy is normal, look behind the eye for the cause
of a monosymptomatic painful white eye,” said Dr. Daroff.
The widespread belief that the eye is a common cause of headache
is understandable, given the multiple associations between the
eye and headache:
• Certain types of eye disease may cause headache.
• The eye and periocular area are often the epicenter of pain in
primary headaches, such as migraine, tension-type, and cluster
headache.
• Photophobia frequently occurs concomitantly with primary and
secondary headaches.
• Primary and secondary headache syndromes often have ophthalmic
manifestations, and ocular disorders can arise secondarily to
treatment for migraine.
Among non-ocular causes of eye pain, headache ranks at or near
the top, according to Dr. Daroff. Migraine, cluster headache,
and tension-type headache all can have eye pain as part of the
symptom constellation. However, a multitude of other conditions
also can cause eye pain, including ophthalmic division
trigeminal neuralgia, herpes zoster, sinusitis, and dental
abscess.
Photophobia can occur with any type of headache that involves
the front of the head. The differential workup for a patient
with headache and photophobia is the same as for a patient with
headache alone, explained Dr. Daroff.
In addition to photophobia, phonophobia and osmophobia (or
olfactophobia) are not uncommon among migraine patients.
“It seems that migraine patients have a lower sensory
threshold,” said Dr. Daroff. “These sensory sensitivities can
occur during migraine, or they can induce headache.”
Migraine with aura represents another link between headache and
the eye. More than 90% of migraine auras are visual and involve
homonymous positive visual phenomena, such as scintillations,
bright spots, and zig-zag lines. Though typically hemifield or
quadrant in localization, the visual aura can expand and
ultimately involve the entire visual field, according to Dr.
Daroff.
Migrainous vertigo has presented a challenge to the
International Headache Society’s (IHS) classification system.
When vertigo precedes or accompanies migraine, the eye movement
should be regarded as an aura. However, the aura would be
atypical because the IHS headache classification system defines
a “typical” aura as being somatosensory, visual, or aphasic. The
IHS system does not have a category of migraine with atypical
aura, Dr. Daroff noted.
Migraine-associated vertigo does not respond to the medications
commonly used to treat migraine. Some headache specialists
believe vertigo will respond to prophylactic treatments for
migraine, but the scientific proof is lacking, said Dr. Daroff.
Still another association between headache and the eyes comes in
the form of ophthalmoplegic migraine. The condition typically
has onset during childhood and involves the third cranial nerve,
or less frequently, the fourth or sixth nerve. The headache
usually lasts for several days, and migraine-associated symptoms
are uncommon. As the headache resolves, diplopia begins and may
progress and persist for weeks after the headache has resolved.
The ophthalmoplegic migraine is rare, particularly in adults,
said Dr. Daroff. An MRI scan of patients with the condition may
exhibit contrast enhancement and thickening of the subarachnoid
portion of the nerve. However, the imaging abnormality may not
appear until after a patient has had several episodes of
ophthalmoplegic migraine, Dr. Daroff pointed out.
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