Download Evaluating the Headache Patient in an Ophthalmic Practice

NEURO-OPHTHALMOLOGY
Evaluating the
Headache Patient in
an Ophthalmic Practice
Red flags, office testing, and neuroimaging.
BY JOSHUA PASOL, MD
P
atients may initially present to their eye care
provider with complaints of headaches or transient
visual symptoms. Headaches are most commonly
tension or migraine in type and are not associated
with any ocular disease. Alternatively, headaches may be
caused by more serious disorders with ocular manifestations
such as giant cell arteritis or intracranial processes like
tumors, aneurysms, and strokes. A full evaluation of
patients’ symptoms may require in-office testing, neuroimaging studies, and referrals to other specialists.
Recognizing headaches that are serious in nature can help
identify and prevent sight- or life-threatening diseases.
ASSESSING THE CLINICAL HISTORY
Assessing the clinical history of patients with
headaches is extremely important. Those with new-onset
or worsening symptoms have a more urgent need for
evaluation than patients who have had stable symptoms
for many years. The three symptoms most frequently
found in patients with abnormal neuroimaging studies in
the emergency setting are (1) a headache of new onset or
a change in the type of headache, (2) nausea or vomiting,
(3) and the onset of the worst headache of their lives.1
Patients who have suffered from headaches for many
years or who have stereotypical headaches (ie, tension
and migraine) are less likely to suffer from an intracranial
abnormality. Tension headaches are typically described as
band-like pains around the front of the head extending
posteriorly. Migraine headaches are typically unilateral,
severe, throbbing pains with associated nausea or vomiting and sensitivity to light or sound.
VISUAL SYMPTOMS
ASSOCIATED WITH HEADACHES
Up to 28% of migraine sufferers have associated
visual auras. These typically last about 15 minutes and
usually precede the headache.2 The aura is typically
experienced in the center of both eyes and expands
outward toward one hemifield, leaving a central scotoma. A few patients have migraine aura without a
headache (acephalgic migraine), and others have a
retinal (ocular) migraine, which is a monocular visual
event followed by the typical migraine headache. Still
other migraineurs experience reversible episodes of
monocular visual loss without a headache, which likely
represents retinal artery vasospasm.
Visual symptoms also occur with more serious diseases. Transient blackouts or obscurations of vision are
frequently experienced by patients with papilledema.
Amaurosis fugax can result from temporal arteritis or
other inflammatory vasculitides or carotid artery diseases. Sellar masses with chiasmal compression lead to
a progressive loss of vision, but they can also cause a
sudden loss of vision, as seen with pituitary apoplexy.
All of these conditions can be associated with
headaches.
OCULAR SYMPTOMS ASSOCIATED WITH
HEADACHES
Headache patients may have associated ocular complaints. Ptosis, miosis, conjunctival injection, and tearing can occur with cluster-type headaches and with
short-lasting unilateral neuralgiform headache with
conjunctival injection and tearing, also called SUNCT.
These headaches are generally more common in men
and are due to changes in hypothalamic activity.3
Horner syndrome (ptosis, miosis, conjunctival injection, and at times, anhydrosis) can be present with
carotid artery dissection. These patients usually have
ipsilateral neck pain radiating upward toward the jaw
and occasionally into the affected eye.4
Diplopia with associated headache symptoms can
SEPTEMBER 2011 ADVANCED OCULAR CARE 65
NEURO-OPHTHALMOLOGY
be due to numerous conditions, including orbital
inflammatory disease, ischemic or inflammatory cranial neuropathies, Tolosa-Hunt syndrome, pituitary
apoplexy, aneurysm, meningitis, intracranial hypertension, intracranial tumors, and basilar migraine. A careful history and examination are important when evaluating these patients to determine what type of testing
is needed. Other associated neurological complaints or
examination findings should prompt a neurological
evaluation.
(Cerebral angiogram courtesy of Ali Aziz-Sultan,MD,Neurosurgery at University of Miami Miller School of Medicine.)
OFFICE TESTING CAN BE USEFUL
Visual field testing is probably the most important
in-office test for patients complaining of headaches.
A
B
C
D
Abnormal results may lead to further neuroimaging or
neurological evaluation. It is important to look for
homonymous defects that would suggest a central
nervous system lesion (Figure 1) or bitemporal field
defects suggestive of a chiasmal process. In patients
with eye pain, the visual field may demonstrate asymmetry, which could lead to the diagnosis of optic neuritis or a retro-orbital lesion such as an aneurysm. In
patients with papilledema due to pseudotumor cerebri, visual fields along with the clinical examination
guide treatment. Visual field testing assists in the evaluation of patients with transient visual loss and photopsias with or without associated headaches. In these
cases, the visual fields may reveal homonymous
defects that could be caused by a tumor
or stroke. Rarely, migraines can lead to
cerebral infarction, which could be detected with visual field testing if damage
occurred within the visual pathway.5
Other useful in-office tests include fundus photography (Figure 2), fluorescein
angiography, and ultrasonography.
Photographs can be used to document
papilledema for future comparison in
cases of pseudotumor cerebri. Autofluorescence is useful for documenting
optic nerve head drusen in patients who
may have an unrelated headache syndrome. Fluorescein angiography is useful
in cases of suspected giant cell arteritis to
assess choroidal perfusion as well as retinal and optic nerve involvement. Ultrasonography helps differentiate papilledema from pseudopapilledema due to
buried drusen.6
Figure 1. Humphrey visual fields (Carl Zeiss Meditec, Inc., Dublin, CA),
optic nerve photographs, and magnetic resonance imaging (MRI) of
the brain and cerebral angiogram in a 49-year-old patient. New-onset
headaches and visual loss are caused by a giant left internal carotid
artery aneurysm that is compressing the left optic tract and the left
optic nerve. Note the right homonymous visual field defect and inferior
defect in his left eye due to compression (A). Optic nerve photographs
reveal a normal right optic nerve, whereas the left optic nerve has trace
temporal pallor (B). MRI and a cerebral angiogram reveal a giant left
internal carotid artery aneurysm (C and D).
66 ADVANCED OCULAR CARE SEPTEMBER 2011
WHO NEEDS NEUROIMAGING AND
WHAT TO ORDER
Knowing when and which neuroimaging
studies to order for patients with
headaches is important. Those who have
common migraines without aura and tension headaches with normal neurological
examination are likely to have normal neuroimaging studies and, therefore, likely do
not need them. Neuroimaging is also likely
unnecessary for patients who have typical
migraine aura with or without headaches
and normal visual fields, especially if the
aura is that of positive visual phenomenon
(eg, zigzags, shimmering lights, kaleidoscopes, etc.). Those with a negative visual
NEURO-OPHTHALMOLOGY
with and without contrast can be performed if the
patient is claustrophobic or if MRI cannot be obtained.
Neurological visual field defects also require neuroimaging. Bitemporal defects, especially those that
respect the vertical meridian, require imaging of the
sella. MRI of the sella with and without contrast is preferred, but CT can also be performed. Homonymous
hemianopic defects should be evaluated with CT or
MRI, the latter’s being the test of choice. Contrast is
useful if a tumor is suspected, but these field defects
are usually due to infarct or trauma.
Other types of headaches require more specific neuroimaging. Patients with trigeminal neuralgia require
both MRI, with and without contrast, and MRA of the
brain to evaluate for pathology along the trigeminal
nerve. Practitioners may wish to obtain orbital imaging of patients with eye pain and a normal examination, but the yield in these cases is usually low. Orbital
MRI with and without contrast is beneficial in cases of
eye pain and objective findings such as ocular misalignment or visual loss. If there is pupillary involvement such as from a third nerve palsy, it is important
to obtain MRA of the brain. Carotid artery studies,
such as MRA or CT angiography of the neck, are
required for patients with Horner syndrome and neck
pain to look for carotid artery pathology. The history
and clinical examination should guide eye care specialists on which neuroimaging study to order.
CO N C LU S I O N
In-office testing can be valuable when assessing
patients with headaches or eye pain. Eye care specialists should order neuroimaging studies based on the
clinical history and examination findings, and they
should seek neurological evaluation if they encounter
other symptoms or signs outside the ophthalmic
examination. ■
Figure 2. Optic nerve photographs reveal optic nerve drusen
in the right eye and blurred nasal disc margins in the left eye
due to buried drusen in a patient with tension headaches.
phenomenon (loss of vision) and no headaches generally need vascular studies (magnetic resonance angiography [MRA] or computed tomography [CT] angiography of the neck and brain) to look for arterial
narrowing. They may also need cardiac evaluation
and hematological testing for hypercoaguability.
Patients who have papilledema with or without
headaches always need neuroimaging. Preferred studies
include MRI of the brain with and without contrast and
a magnetic resonance venogram to look at the venous
sinuses for possible obstruction. A CT scan of the brain
Joshua Pasol, MD, is an assistant professor of
ophthalmology at the Bascom Palmer Eye Institute,
University of Miami Miller School of Medicine. He
acknowledged no financial interest in the products
or companies mentioned herein. Dr. Pasol may be
reached at (305) 482-5219; [email protected].
1. Sobri M,Lamont AC,Alias NA,Win MN.Red flags in patients presenting with headache:clinical indications for
neuroimaging. Br J Radiol.2003;76(908):532-535.
2. Stewart WF,Linet MS,Celentano DD,et al.Age- and sex-specific incidence rates of migraine with and without
visual aura. Am J Epidemiol.1991;134(10):1111-1120.
3. May A,Bahra A,Büchel C,et al.Hypothalamic activation in cluster headache attacks. Lancet.
1998;352(9124):275-278.
4. Stapf C,Elkind MS,Mohr JP.Carotid artery dissection. Annu Rev Med.2000;51:329-347.
5. Spector JT,Kahn SR,Jones MR,et al.Migraine headache and ischemic stroke risk:an updated meta-analysis. Am
J Med.2010;123(7):612-624.
6. Kurz-Levin MM,Landau K.A comparison of imaging techniques for diagnosing drusen of the optic nerve head.
Arch Ophthalmol.1999;117(8):1045-1049.
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