Spring 2022 distributed quarterly to 2800 optometric physicians
From the EDITOR For most ODs, headaches are a frequently heard patient complaint. While the majority are benign and nonthreatening, some headaches can represent serious and life-threatening diseases requiring immediate referral, evaluation, and care. In this issue, my colleague (and optometry school classmate) Drew Aldrich reviews characteristics of the more common headaches we encounter, associated eye findings, and red flags that may be helpful.
Ami Halvorson, OD
PCLI—Portland, OR
Headaches are a common complaint in eye care. Patients are also often referred to optometric physicians by their primary care providers to rule out a visual contribution to their headaches. Given the ubiquitous nature of headaches and the large variety of etiologies, they can indeed be a pain—for both patients and doctors.
This article highlights characteristics of the most prevalent headaches in optometry clinics, including those with associated eye findings, and the red flags that require a watchful eye. With a good differential diagnosis in hand, optometric physicians can make appropriate and timely referrals.
Common Primary Headaches
The two most common primary headaches, which by definition are not related to an underlying condition, are tension headache and migraine.
- Tension-type headaches are the most frequently occurring and have a lifetime prevalence of up to 80%. They can be episodic or chronic and are often described as a bilateral mild-moderate pressure or band-like sensation that can last hours to days.
- Migraine is the second most frequently encountered and is often experienced as a disabling, unilateral pulsating pain frequently associated with nausea, vomiting, and phono/photophobia. If preceded by a visual aura, they are referred to as classic migraine. Of note, 80% of migraine sufferers have a positive family history which can aid in the differential diagnosis.
Acephalic Migraine
A relatively common headache-related phenomenon is migraine aura without headache, also known as an acephalic migraine. It is often, albeit incorrectly, referred to as ocular migraine, which is a different entity. Most patients will describe experiencing recurrent positive visual symptoms—such as the classic scintillating or fortification scotoma and small bright spots or stars in their vision. They usually last from 5 to 60 minutes and are fully reversible.
With origination in the brain, symptoms are present in both eyes. However, patients will often misinterpret them as a monocular phenomena (i.e., involving the eye with the temporal field abnormality). It is essential to differentiate these from tractional retinal photopsias, which are usually located in the periphery and last only seconds. Occasionally, patients may experience transient negative visual symptoms such as blurry or foggy vision. In these cases, acephalgic migraine is a diagnosis of exclusion after appropriate evaluation to rule out other vascular diseases such as transient ischemic attack or temporal arteritis. This is especially important in patients over the age of 50.
Trigeminal Autonomic Cephalgias
The trigeminal autonomic cephalgias are a group of primary headaches that have features of both headache and cranial autonomic dysfunction, often involving the eye:
- Cluster headache is characterized by recurrent episodes of excruciating unilateral orbital or temporal pain lasting 15-180 minutes. It more often occurs in males with cyclical phases of 4-16 weeks duration. During an episode, patients may also complain of conjunctival injection, eyelid edema, and a pseudo-Horner’s pupil.
- Paroxysmal hemicrania presents with frequent attacks (5+ per day) of unilateral supraorbital or temporal pain lasting 2-30 minutes. These are often accompanied by conjunctival and nasal congestion, a pseudo-Horner’s pupil, and restlessness or agitation.
- Short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing (aptly referred to as SUNCT headaches) last only seconds to minutes and can occur up to 200 times per day.
Red Flags
Headaches can also herald the presence of more serious, potentially life-threatening illnesses requiring emergent referral and imaging. A thorough history and eye examination can reveal several red flags.
History should include:
- Is the headache new or longstanding
- Location and frequency
- Any associated symptoms
- Family history
- Current medications
- Chronologic features (i.e., AM or PM)
History red flags and concerning features:
- Onset after age 50
- Sudden onset “worst headache of my life”
- An accelerating pattern
- New headache in cancer or HIV patients
- A morning headache associated with nausea or vomiting
A complete eye exam is also a critical part of a headache evaluation. It can reveal clues to an underlying etiology, including several eye conditions patients may misinterpret as a headache.
The exam should include:
- Blood pressure measurement
- Careful pupil testing
- Sensorimotor evaluation (to uncover any extra-ocular muscle deficiency or binocular vision dysfunction)
- Anterior chamber evaluation
- Visual field testing
- Dilated eye exam
Exam red flags and concerning features:
- The presence of an extra-ocular muscle paresis or new-onset (or worsening) strabismus is a significant finding. It could be related to an intracranial mass, temporal arteritis, herpes zoster ophthalmicus, or increased intracranial pressure to name a few.
- Patients should be dilated, and the presence or absence of optic nerve edema or pallor should be documented. This is especially important in the setting of a sixth nerve palsy due to the abducens nerve’s susceptibility to elevated intracranial pressure as it ascends the clivus. A dilated exam may also reveal severe hypertensive retinopathy and disc edema indicative of a hypertensive emergency.
Other Rare Headaches
Retinal or ocular migraine is a relatively rare condition characterized by transient monocular vision loss secondary to retinal vascular vasospasm. This can take the form of dimming vision, scotomas, or complete vision loss. A headache usually follows the visual symptoms. In general, patients are younger (less than 40 years old) and have a personal or family history of migraine. An important differential, especially in older patients, is amaurosis fugax or transient monocular vision loss (TMVL). These cases require prompt evaluation by the emergency department to rule out serious vascular or neurologic disease.
Conclusion
Headaches are one of the most common patient complaints in optometric practices. While they can have a multitude of etiologies, the vast majority are relatively benign. Occasionally, headaches represent potentially life-threatening diseases requiring emergent referral for evaluation and neuro-imaging. As eye care providers, we may be the first to evaluate these patients and can play an essential part in ensuring a timely referral. Our detailed patient history, thorough eye exam, and alertness to red flags are critical.
Sources
Headache. The American Journal of Medicine (2018) 131, 17-24.
Retinal, Ophthalmic, or Ocular Migraine. Current Neurology and Neuroscience Reports (2004) 4, 391-397.
by Jay Haynie, OD FAAO
By Drew Aldrich, OD | PCLI Kennewick, WA
Hypertensive retinopathy
Conditions Presenting with HA Symptoms
Sinus disease
Dental disease with referred pain; TMJ
Ophthalmic problems (i.e. elevated IOP, uveitis, scleritis, orbital disease)
Herpes Zoster ophthalmicus or post-herpetic neuralgia
Trigeminal neuralgia
Requiring Emergent Referral
Intracranial hemorrhage
Carotid artery dissection
Meningitis
Pituitary apoplexy
Giant cell arteritis
Increased intracranial pressure
Hypertensive emergency
Characteristics
Sudden and intense HA
Recent trauma; Ipsilateral Horner’s pupil
HA with nuchal rigidity
Hemorrhage or infarction within pituitary gland; vision loss and CN palsies
HA, scalp tenderness or jaw claudication
Secondary to IIH, mass lesion, or venous sinus thrombosis; presence of papilledema and/or CN 6 palsy
Severely elevated BP with end-organ damage
Requiring Emergent Referral
Intracranial hemorrhage
Carotid artery dissection
Meningitis
Pituitary apoplexy
Giant cell arteritis
Increased intracranial pressure
Hypertensive emergency
Characteristics
Sudden and intense HA
Recent trauma; Ipsilateral Horner’s pupil
HA with nuchal rigidity
Hemorrhage or infarction within pituitary gland; vision loss and CN palsies
HA, scalp tenderness or jaw claudication
Secondary to IIH, mass lesion, or venous sinus thrombosis; presence of papilledema and/or CN 6 palsy
Severely elevated BP with end-organ damage
Secondary Headaches (HAs)
Questions
If you have questions, feel free to contact our optometric physicians. We’re always happy to help.
Evaluating
Headaches
in Optometry
ABOUT THE AUTHOR
Drew Aldrich, OD
PCLI Kennewick, WA
Kind, thoughtful and easygoing, Drew Aldrich has a gentle spirit, is adaptable and blends well with a wide range of personalities. Born in Visalia, California, Drew grew up in this agricultural heart of the central valley. He enjoys hiking, backpacking, camping, reading, exercising, surfing and medical missions. Drew and his wife, Sarah, a teacher and stay-at-home mom, live in the Tri-Cities, Washington. They have a daughter and son – Naomi and Asher.
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