The Magical Mystery of Migraines

Talking flowers, barking trees, magic mushrooms, people shrinking to tiny sizes and stretching to great heights—not all of these events came purely from Lewis Carroll’s imagination. According to some experts, the creator of Alice in Wonderland drew on his experiences with migraines—a form of severe headache—to help create some of that fantasy world.

Today, many neurologists use the term "Alice in Wonderland syndrome" when referring to the visual disturbances and hallucinations that can be part of migraine aura, the neurologic churning that can occur before migraine onset and affect vision in very odd ways. "Many of the descriptions conjured for Carroll’s stories were based on classic migraine experiences," says Cleveland Clinic neurologist Mary Ann Mays, M.D. "Only a person who had experienced these phenomena would be able to describe them."

A migraine is an intense, throbbing pain that can affect one or both sides of the head. Episodes can last for hours or days and leave people bedridden. Approximately three times as many women as men get migraines; children of migraine suffers are more likely to get them than children whose parents are not affected.

No one knows why migraines occur, but it is known that certain factors can trigger them. These include stress, noise, pollution and odors, and certain medications. Dietary triggers include caffeine, red wine and champagne, NutraSweet and chocolate. Changes in hormone levels can affect the frequency of migraine occurrence.

The aura of migraines
The two main types of migraines are those that occur without aura or those that occur with aura. Aura refers to an array of psychologic or neurologic disturbances that occur shortly before migraine onset. Compared to migraine without aura, migraine with aura is the less common type, but it is perhaps more medically intriguing, and for patients who get them, more unsettling. (Aura also can occur without a subsequent migraine, a factor that can result in mischaracterization of the migraine type. More on this below.)

Auras typically last 5 to 20 minutes and involve symptoms such as vertigo (motion sickness or dizziness), imbalance, confusion or numbness; but most auras consist of visual disturbances such as partial vision loss, the appearance of "special effects" and distortion of objects. Sometimes the visual effects can be dramatic, says Dr. Mays—flashing lights, complex color patterns and shapes (e.g., triangles and dots), and floaters (the perception that some tiny foreign object is floating across the eye). An individual might also see shimmering or zig zag lines in the peripheral vision and blurriness in central vision.

"Children who develop auras prior to migraines may experience visual distortions," says Dr. Mays. "Certain objects may appear larger or smaller than they really are."

The "one-eye" migraine
In a related condition called ocular migraine, which is even less common than migraine with aura, individuals experience the same visual disturbances that occur during an aura, but the symptoms only occur in one eye. The aura that occurs before an ocular migraine is commonly followed by a migraine headache. And the same triggers that can bring on migraine with or without aura also can cause ocular migraine.

Ocular migraine can produce various degrees of vision loss or obstruction. Some patients, says Dr. Mays, report blind spots or "holes," referring to missing sections in the normal visual field, or they may experience a shade of black or gray over the visual field. Some people compare the visual phenomena of ocular migraine to the patterns produced by an old television with faulty reception, says Dr. Mays. "Others say it’s like looking through watery glass."

Ocular migraine symptoms are temporary and do not harm the eye; but they can interfere with daily activities, such as reading and driving and can interrupt the work day.

Fear about vision loss caused by ocular migraine often leads an individual to seek medical care, says Dr. Mays. In some cases, the first stop is the ophthalmologist’s office. That’s fine, says Dr. Mays, but people diagnosed with ocular migraine should also see a neurologist so that conditions such as stroke, which can cause similar visual symptoms, can be ruled out and so that the migraine itself can be effectively managed. Other conditions that produce ocular-migraine like symptoms include retinal artery thrombosis (blood clot in a vein inside the eye) and, as noted, migraine with aura.

Confusing auras
Although ocular migraine and migraine with aura are very similar experiences, one key difference is the source of the vision disturbances. In migraine with aura, the occipital cortex of the brain is the source of vision disturbances. In ocular migraine, it is the retinal blood vessels inside the eye. The retina is the thin lining on the back, inner part of the eye that prepares images for processing by the brain. An individual experiencing the aura of ocular migraine could cover or close one of the eyes and stop the symptoms. Not so for an individual experiencing traditional aura. "The symptoms affect both left- and right-sided vision," says Dr. Mays. "The source of the problem is the brain, not the eyes."

For some reason, says Dr. Mays, auras that occur without a subsequent migraine often get labeled—by patients and physicians—as ocular migraines. She speculates that it’s a combination of a lack of knowledge about migraines and the notion that if there are visual problems but no migraine, it must be an "eye," or ocular, problem.

Frequency is unpredictable
Migraine frequency varies. Some people have them once in a lifetime; others have them twice a month. Some of Dr. Mays’ patients have daily migraines; in most of these cases, the migraine occurs without aura.

Certain foods, such as processed meat, aged cheese and red wine can trigger migraines, but only about 10 percent of Dr. Mays’ patients report being affected by food triggers. Other triggers include changes in schedule, says Dr. Mays.

"I advise my patients to keep to a regular schedule, avoid missing meals and to maintain a consistent sleep and rising schedule," says Dr. Mays. "Too little or too much sleep can trigger migraines."

Weather changes also can trigger migraines, especially a rise or fall of barometric pressure.

Treating migraines
The effectiveness of migraine treatment depends on several factors, including whether a patient has identified likely triggers, how successful the patient is in avoiding identified triggers, how proactive the patient is in using treatments such as relaxation or drugs and how well the patient responds to treatment.

Drugs effective for treating migraine pain include over-the-counter anti-inflammatory agents such as ibuprofen (Advil, Motrin) and naproxen (Alleve) and aspirin (Excedrin Migraine). A newer class of migraine agents, known as triptans, has changed migraine treatment, says Dr. Mays. The seven triptans include sumatriptan (Imitrex), zolmitriptan (Zomig), and naratriptan (Amerge). Unlike traditional migraine medications, which help the body tolerate headache pain, triptans help manage the source of migraine pain by reducing "swelling" of the blood vessels in the brain and reducing inflammation, thus helping alleviate migraine pain.

Triptans are not recommended, however, for ocular migraines, because the constricting affect they have on blood vessels could cause problems in the retinal vessels, resulting in vision loss. The best treatment for ocular migraine, says Dr. Mays, is prevention—avoiding triggers, minimizing stress, maintaining a consistent schedule and getting enough sleep.

© Copyright 1995-2005 The Cleveland Clinic Foundation. All rights reserved

 

This information is provided by the Cleveland Clinic and is not intended to replace the medical advice of your doctor or health care provider. Please consult your health care provider for advice about a specific medical condition. For additional health information, please contact the Center for Consumer Health Information at the Cleveland Clinic (216) 444-3771 or toll-free (800) 223-2273 extension 43771. If you prefer, you may visit www.clevelandclinic.org/health/ or www.clevelandclinicflorida.org. This document was last reviewed on: 9/1/2003

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