treatment plan

Identifying and Managing Vascular Headache

BY BRUCE E. ONOFREY, RPH, OD
March 2000

Migraine is the most common type of vascular headache. Head pain develops during a reduction in regional blood flow and appears to be responsible for the initial aura associated with ocular migraines. Subsequent inflammation secondary to reduced blood flow can trigger and produce the pain associated with this form of headache.

The Four Forms of Migraine

1. Migraine without aura occurs in 80 percent of migraine sufferers. The headache is idiopathic, recurring and must have at least two of the following characteristics: unilateral, pulsating, moderate to severe in intensity and aggravated by routine activity. Additionally, the headache must be associated with at least one of the following symptoms: nausea, vomiting, photophobia or phonophobia. The most common causes of this form of migraine are menstruation, environmental factors, emotional stress and psychological factors.

2. Migraine with aura occurs in 10 percent of migraine patients. This form is also idiopathic and recurring, but also includes neurological symptoms that are localized to the cerebral cortex and brain stem. The symptoms include: aura developing over at least four minutes and lasting no longer than 60 minutes, and aura including or followed by a headache. The aural symptoms may include homonymous visual disturbance, unilateral paresthesia or numbness, unilateral weakness or aphasia. The most common form of aura is visual and occurs in 80 percent of patients with this type of migraine. If the aura occurs without subsequent development of headache, then the condition is called acephalgic or abortive migraine. Acephalgic and classic migraines with aura can occur in the same individual.

3. Ophthalmoplegic migraine occurs in two to 17 percent of migraine patients, and is most common in children and adolescents. The headache is associated with ophthalmolplegia of one or more of cranial nerves III, IV and VI, with both the pain and paresis on the same side. The pain precedes the paresis and originates behind or above the eye and may spread to the cheek, temple or forehead.

4. Retinal migraine is characterized by fully reversible monocular blindness that lasts less than 60 minutes, followed by a headache. Retinal migraines are generally seen in patients under the age of 40. Repeated episodes can result in permanent visual field loss. Older patients must be assessed for nonmigraine-related vascular disease.

Migraine Management Tactics

There are three categories of migraine treatment: education, nonpharmacologic treatment and abortive versus preventive pharmacologic therapy. Biofeedback techniques have also been used to reduce stress-induced migraines. Recognizing and avoiding the causes of migraine is essential.

Cluster Headache

Cluster headache is another form of vascular headache, characterized by severe, unilateral orbital, supraorbital or temporal pain lasting up to three hours and occurring as often as eight times a day. The headache must be associated with at least one of the following symptoms on the same side as the pain: conjunctival injection, lacrimation, nasal congestion, rhinorrhea, forehead and facial sweating, miosis, ptosis or eyelid edema. This headache is believed to be aggravated by hypoxia. Studies have shown that administration of oxygen can rapidly abort this form of extremely debilitating headache.

The role of practitioners depends on the diagnosis of the disease. Proper examination, lab testing and referral are necessary to ensure that these patients are appropriately managed. 

Dr. Onofrey, editor and author of various ophthalmic texts, practices in Albuquerque, NM.