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Neuro-Ophthalmic Symptoms of Primary Headache Disorders

Why the Patient With Headache May Present to Neuro-Ophthalmology

Smith, Stacy V., MD

Section Editor(s): Digre, Kathleen B. MD; Friedman, Deborah I. MD, MPH

Journal of Neuro-Ophthalmology: June 2019 - Volume 39 - Issue 2 - p 200–207
doi: 10.1097/WNO.0000000000000790
Disease of the Year: Migraine

Background: Primary headache disorders can cause many ophthalmic symptoms that lead many patients to present for neuro-ophthalmic evaluation. Neuro-ophthalmologists frequently encounter these patients in clinical practice.

Evidence Acquisition: A literature review was completed in PubMed using the following terms paired with “migraine” and “headache:” dry eye, eye pain, monocular diplopia, binocular diplopia, photophobia, visual field defect, tunnel vision, floaters, amaurosis fugax, transient visual obscuration, autonomic symptoms, anisocoria, visual snow, Alice in Wonderland syndrome, and palinopsia.

Results: Patients with migraine experience a wide range of visual disturbances including aura and more complex perceptual abnormalities such as Alice in Wonderland syndrome and visual snow. Visual disturbances may consist of positive and/or negative phenomena and may be binocular or monocular. Migraine and other primary headache disorders can be associated with photophobia, eye pain, dry eye, autonomic features, and anisocoria.

Conclusions: Patients with primary headache disorders may experience a wide range of visual and ophthalmic symptoms. An understanding of the typical features of these disorders allows providers to help patients find appropriate treatment without unnecessary testing and to recognize when atypical presentations require additional evaluation.

Department of Neurology, Houston Methodist Neurological Institute, Houston, Texas; and Blanton Eye Institute, Houston Methodist Hospital, Houston, Texas.

Address correspondence to Stacy V. Smith, MD, Houston Methodist Institute of Academic Medicine and Weill Cornell Medicine, Houston Methodist Neurological Institute, Houston Methodist The Woodlands Hospital, 17183 I-45 South, Suite 690, The Woodlands, TX 77385; E-mail:

S.V. Smith is a member of the speaker bureaus for Teva Pharmaceutics and Lilly USA, and a neurology consultant for concussion with the AMR NASCAR Safety team.

© 2019 by North American Neuro-Ophthalmology Society