Good Hope, Heartlands, and Solihull Eye Clinics

Headache from the ophthalmologists view for professionals & eyestrain & visual symptoms

David Kinshuck, from lectures

Healthy diet

Headache in A/E

  • Headaches in the emergency department –a survey of patients’ characteristics, facts and needs JHP 19


4 simple features in the patient's history can accurately diagnose migraine, and therefore neuro-imaging is not needed. Migraine causes a POUNDING headache:


  • pulsating, ache throbbing, pressure
  • duration 4-72 hours (96 hours)
  • Unilateral, occasionally bilateral
  • Nausea
  • Disabling

  • Accompanying symptoms, sit still, draw curtain, feels ill then gets better
  • Aura... One third, recurring, evolves, during attack; versus Tia...full onset at start
  • Migraine..visual change evolves 
  • Premonitory symptoms may last days
  • Chronic migraine ..pattern changes,
  • Neck pain...facial pain...autonomic symptoms 

CNS lesion a possibility

MRI needed

  • cluster type headache
  • abnormal CNS examination
  • ill-defined headache
  • headache with aura
  • headache aggravated by valsalva-like manoeuvre
  • headache with vomiting


  • Right, scotoma, spreads across vision, 20 minutes, more frequent, followed by headache lasting hours = episodic migraine with aura, confirm normal ocular examination 

Case 34y

  • 10 y once a week now twice last all day nausea Episodic migraine


  • Premonitory/episode
    Triptan nsai or paracetamol and antiemetic Sumitriptan oral or subcutaneous Ibuprofen 600-800 high dose anti antiemetic eg metachlorpropamide 10 mg
  • Prevention Beta locker topiramate then second line Amitriptyline
  • Botox etc
  • Use preventative dose


  • Vision
  • sensory
  • speech
  • fully reversible
  • unilateral,
  • headache follows
  • Spreads
  • Tia sudden aura positive
  • Moh medication overuse headache

Case 76y

Severe pain sharp spikes red eye many times a day.. Autonomic Cluster paroxysmal hemicrania sunct..... Cluster 15-180m, rapid, restless.. migraine want rest...

  • Hemicrania.. indomethacin
  • Cluster tryptan subcutaneous oxygen steroids Gon block, preventative verapramil etc


  • migrainetrust  
  • 4-72 h, freq vary, uni, bilateral, throbbing, n,v, aggravated by activity, photphonophobia
  • Aura: Before peak pain...not always progressive over minutes, positive or negative phenomenon, aura visual most speech hemiplegia
  • Tension featureless, 30-120 m, any frequency, pressure heavy, tightening pain
  • Chronic migraine, 15 d a month  , 8 d a month migraine features
  • Crystal clear normal days
    How many days severe
  • Headache diary
    Headache overuse..analgesics > 3m
    15 d a month, less with tryptans
    Increase headache 50%
  • Patient concern, long history, family history, ineffective treatment etc...NOT worrying
  • Red flags:  Fever, posture, personality change, 
  • Retinal changes see 19
  • a healthy diet will reduce attacks considerably BMJ 21. Essentially, such a diet includes fish, vegetables, grains (like oats), beans  and pulses (eg lentils), and DOES NOT CONTAIN fast foods, microprocessed foods (biscuits, sugar, cakes, butter), much red meat (beaf, lamb), no pork, little white meat such as chicken, no proessed meat, fried foods (eg chips) . Oils that healthy include olive oil when cold and sunflower oil for cooking.
  • vitamin D levels low NS19
  • healthy diet affects bowel flora and headaches  MN 19
  • keeping thin JOHP 20  ..less migraine
  • acute developing into chronic migraine
  • see treatment if severe Galcanezumab see 20
  • retinal blood vessels close during retinal migraine EJO 20

Treatment of migraine headache NEJM 20

  • NSAID (e.g. ibuprofen), (or Paracetamol in UK if NSAID contraindicated )


  • antiemetic if lots of nausea or sickness
  • Triptan
  • try several different oral Triptans, but if these don't work, subcutaneous triptan
  • may need NSAID in addition
poor response with repeated attacks, new drugs available from a migraine specialist


Prevention of migraine

  • NEJM 20
  • no smoking or too much alcohol (migraine is worse with smoking)
  • heathy lifestyle helps (avoiding obesity: migraine is worse with obesity), physical exercise, reducing stress, going out with friends, hobbies, joining clubs, Yoga, tai chi etc; )
  • a healthy diet

    migraine episodes are less severe 

    1. with regular exercise and physical activity  
    2. loss obesity (big difference) 
    3. headache and exercise 
    4. low fat dairy food 
    5. reducing internet addiction 
    "We identified that most patients with a migraine diagnosis do not get the minimum level of exercise recommended by the WHO. For patients achieving 150 minutes or more of moderate exercise per week, rates of depression, anxiety, and sleep problems are lower. . exercise can have a significant impact on the headache itself and comorbidities. 
  • headaches are related to daytime sleepiness 
  • more than 2 migraine days a month
  • certain antihypertensives, such as Propanalol or Candasartan
if those don't work, often a migraine specialist consultation will help, and other drugs may help such as
  • Amitriptyline
  • calcium channel blockers
  • Topiramate
poor response with repeated attacks, new drugs available from a migraine specialist, eg fremanezumab


Medication overuse headache

DTB 2010 Suspect this if the headache

  • occurs >15 days/month
  • after 3 months of anti-migraine drugs, analgesics, caffeine, Paracetamol or ibuprofen
  • they is often a primary headache such as migraine or tension headache
  • after use of these drugs for >9 days/month
  • after 37 doses/month (ergots), 114 (analgesics), Paracetamol more than 15 days a month
  • days medication taken is more indicative than the actual number of doses
  • after months of use (ergots), more than a year (analgesics)
  • gets better after stopping the drugs after 1-4/weeks in 50% of patients
  • if the headache continues after stopping for 4 weeks then investigations are required


  • thunderclap headache
  • particularly age>40
  • neck pain or stiffness
  • raised blood pressure
  • loss of consciousness
  • vomiting
  • BMJ 2010   editorial    article

Other thunderclap headaches

  • Lots of causes or thunderclap headache, including no identifiable problem.
  • CT within 3 hours, if possible,
  • if normal scan within 6 hours not subarachnoid
  • ?reversible vasoconstriction syndrome 
  • Thunderclap headache takes 1 minute to max, migraine.. 5 minutes 


  • City Hospital...headache nurse Julie Edwards
  • IIH...Miss Susie Mollan, QE


Chronic ha

  • > 3months
  • headache: 1/2000 neoplasms 

Cluster headaches

Tac trigeminal autonomic cephalgia

  • Restless, rocking, (migraine rest)
  • Mild ptosis, miosis
  • Sunct...tearing : 30m -4 h worst pain ever, responds to oxygen and sumitrapn

Trigeminal neuralgia 

Frequent headaches longer than 3 hours

  • >3 hours may be migraine, no autonomic features (these are cluster)
  • want to lie still ...migraine.


  • does not need to lie down, unlike migraine (dark room, lies down)

A case

  • Case 76y, tender temporal artery, high crp 17, treated
  • But pain was like an electric shock..hundreds of times a day, and pain came with red eye and watering...autonomic headaches..
  • Cause in this case Superior cerebellar artery loop, lamotrigine treatment

Aute headache and ptosis

Acute headache and ptosis: carotid artery discection , 3rd, gca, etc


Treatment can be complicated

  • Expert help may be needed, from a headache nurse/specialist/neurologist
  • As an example of how complicated treatment may be: A 30y lady presented with many headaches, worse at times, and was told
    • The headache itself is a chronic migraine with medication overuse headache and it does have a vertiginous element to it.
    • To improve this initially we need to exclude the medication overuse headache.  Therefore reduce your painkillers to no more than 2 days a week and when you develop a bad headache. (Most painkillers are only effective if used 2 days a week or less.)
    • To treat a severe migraine episode,
      • use Sumatriptan at 100 mg with
      • two Paracetamol
      • and the anti sickness tablet.  The goal is to consistently shut the headache down in 2-4 hours. If necessary your anti sickness tablet could be used particularly during the  first few months when you are cutting your painkillers down but to no more than 2 days a week.
    • In terms of prevention
      • I suggest we stop the Amitriptyline and Pizotifen.  The doses are too low and are not reducing the headache. (These can be used but were not ideal for this patient at this stage.)
      • Start Topiramate (NOT IF PREGNANT or trying to get pregnant), starting at 25 mg at tea time, increasing every 2 weeks aiming for 100 mg for next 4-6 months with a goal to reduce headaches overall by 50%.
    • I will then review your progress again in 4-5 

Rarely multiple problems

  • Case 75y cauc, Abrupt headache lasting seconds left sided ha
  • but later
  • Then got visual disturbances, unilateral tranient monocular visual loss, complete, lasts 5 minutes, full recovery, one cws...gca

Headache and loss of sight

  • Case 37y
  • 10s bilateral loss episodic, built up  over 1 week headache increasing over -a week.
  • Visit 2....blurred vision 2d
  • Acute neuromyelitis optica, Plasma exchange 

Headache and worse bending

  • Case 25y
  • Vision worse when bends, reduced vision, reduced colour, swollen discs, severe anaemia...., icp very very high

Headache and diplopia

  • Case 76y
  • 2 w headache, unwell, diplopia, vertical, 
  • Esr a little up,  Got worse sight, left 3rd, 
  • Swollen temporary arteries, gca

Types of headache

  • Migraine, tension, tac, secondary,
  • Primary .. Tension migraine tac
  • Secondary 
  • Chronic >15 d month
  • Ichd3 bible open in clinic here

Visual symptoms using a computer screen