 I'm Kathleen Diggree and we're very excited that we get to talk about migraine today, but we're going to talk about things that are not part of the headache, but actually the visual aspects of migraine. And the objectives here are to review the clinical aspects of migraine with aura and differentiate aura from stroke and talk about auras and unusual auras and other visual phenomenon that are associated with migraine. With all headache, you know, we do histories and one of the hardest things about aura is trying to figure out if the aura is in one eye or both eyes, because patients will frequently think that it is in one eye. And they'll say my right eye becomes blurred. And what really is going on is that their right visual field becomes blurred. And many times they don't cover each eye while they're looking at a page to even know whether it's one eye or both eyes. So that's kind of a key question. And you'll see when we talk about other kinds of aura, like retinal aura, how important it is to figure out whether it's one eye or both eyes. Then we want to really try to understand how it starts. Is it a slow onset? Is there a march to it? Or is it fast? And we'll see that if something happens bang right at the beginning, we're going to be thinking more of something vascular going on. And then some things that I really want you to remember are could light cause visual blurring in one eye. And there is a thing called light claudication in older people where light comes into their eye and then their retina can't handle that. Or because they've got some ischemic changes to their visual system that light could be causing trouble. Now light often will trigger migraines, aura, and migraine in individuals that are very susceptible. And then of course, positional changes, any kind of visual phenomenon when they move their eyes. I always want to know if it happened before. And then I want to know how long the aura lasted. Is it more than five minutes or is it less than five minutes? Are there negative phenomenon? And that would be a scatoma. That would be something like a blank spot or positive phenomenon, which means like scintillations. And this positive negative phenomenon is actually an important historical thing to be thinking about. And then I always ask about other things, weakness, numbness, speech, because you're going to see that those types of auras can also accompany visual auras. And then of course, do they have a headache? And then of course, a bold neuro exam, checking acuity, checking visual fields, and checking the fundus. So the one eye or two is extremely important. If they report that it's in both eyes, migraine is by far the most likely diagnosis. Less likely is something ischemic, seizure, or something like optic discadema, giving them visual obscurations. Now, if they have visual loss plus scintillations, of course this can be migraine, it can be seizure, but you have to be thinking about other things as well. And especially if the visual loss goes beyond the time of the headache, then you really are going to be looking for something like stroke. Now, let's just take an anatomy of migraine with aura. Just going to the life history, every all of you know about, I like a structured history of family history, life history, attack history, and then medical history, a medication history. But this is an individual whose father had migraine. This individual was karsic as a kid, stomach aches early on, then started having migraines in college. They got worse when they got married. They got worse when they had children. And then the migraines got better as they got older. This is sort of a life history of somebody with migraine with aura. And the attack, there's a prodrome phase, but the aura comes before the headache in most cases. And we're going to talk more about this. And then of course you get the headache associated with light and sound sensitivity, nausea and or vomiting, and then you have a post-drome. So this is the prodrome that can happen before the headache. The aura usually comes before the onset of the pain. Sometimes the pain will come on with the aura and then all the accompaniments, the dizziness, blurry vision, fuzzy thinking, light and sound sensitivity during the headache phase. And then the post-drome is sort of this fatigue phase, if you will. So this is Mike. He's a 30 year old teacher. He has a family history of migraines and his mother. He first has blurring of his vision then a bright spot goes off to the right side slowly, then the spot goes away and then he has a throbbing headache all over his head with light and sound sensitivity, nausea. And so what I'm going to try to do is show you this video if I can make this work. So let me see if I can get this to work. I'm going to stop sharing that and start sharing this. Let me know if you, can you hear that? We can't hear it, but we can see it. It's a little laggy. Okay, let's see. Now we can hear it. The main thing here is you can see how the spot develops and then there's these scintillations that are occurring. Do you see that? And she's trying to talk to him and he's getting this aura and of course it's disrupting their family life. And now she goes, are you having another migraine? And then as kids are going, do you have a migraine again dad? Oh no, are you okay dad? You're sure acting weird. Okay, now let's go to back to the slides. So you can look at this video yourself if you weren't able to hear it. But I think that is a really nice demonstration of the aura. Oh dear, hold on here. I'm gonna get rid of this and go back to sharing my screen. There we go. Can you see my screen now? Yep. Okay, good. All right, so let's see if we can get this to advance. So the ICHD3, and I hope all of you download the ICHD3, it's a PDF that you can download onto your phone, your iPad, your computer. But it's kind of the Bible of migraine. And to make this diagnosis, you have to have one or more of the following fully reversible auras. And visual auras are the most common, followed by sensory auras, speech and language, motor, brainstem and retinal. And we'll talk about these as well. A typical aura is usually visual and it can be sensory or speech. And there's usually no motor, brainstem or retinal. But that's a typical migraine with aura. And then the aura develops over five minutes. And sometimes you can have two or more auras in succession. So many people will first have the visual aura and then maybe they can't speak right. The aura rarely lasts more than an hour. So it's usually five to 60 minutes. At least one symptom, the aura is usually unilateral or and positive. And you could see from that video that scintillation that was going on during the aura. And it's usually followed by a headache. So that's what the ICHD3 criteria for migraine with aura. It's present in about 20% of people with migraine, most are visual. We used to use the terms classic migraine to indicate migraine with aura and then common migraine to be migraine without aura. We don't use that terminology anymore. Another terminology you hear people using is ocular migraine. There's no such thing as an ocular migraine. Ophthalmic migraine, complicated migraine. These are terms that are not used. Auras can be triggered by light. They can be triggered by flickering. A complex pattern because a lot of these people are extremely visually sensitive. And it's very difficult to stop the aura itself. For example, studies have been done where people get Sumitriptan and it does not stop the aura where it does stop the headache. Now, most of the auras, as I said, are visual. They're often wavy lines. You could see how there was a waviness to it. And then fortification spectra. You could see the little zigzaggy lines that were colored. Rarely there are hallucinations and we'll talk about Alice in Wonderland effect. Aphasia can accompany these visual auras and so can sensory symptoms and occasionally motor symptoms. Brainstem aura is a kind of a different animal. It has numerous brainstem symptoms like vertigo, chiroaural numbness, diplopia, dysarthria, tinnitus, hyperacusis, ataxia, and decreased consciousness. That's a brainstem aura and I'm not really talking about that today. Now, there have been studies that have looked at what kind of phenomenon really occur with individuals by using diaries and things like that. Flashes of bright light are seen anywhere between 16 and 38% of the aura, time of the aura, foggy blurred vision. Blurring seems to be a very common symptom and blurring alone is not an aura. Zigzaggy, jagged lines are pathodynamic, usually of migraine with aura. Skatomas can occur from other things but skatomas are very common in migraine. So are black dots, flickering lights, a sort of feeling like there's a fan in your peripheral vision. Very common symptom in a lot of people. Another common aura is like a heat wave if you've ever driven along a highway and you see kind of a shimmering of the highway in the light, that is somewhat what people describe in their auras. White spots occur in about half. Hemianopia is usually not a very common type of aura. Tunnel vision can occur and then colored dots can occur and then people can get this corona phenomenon where everything has a halo. So when we talk about fortification spectra, this is a medieval fort in Europe and before World War II but anyway, you can see these zigzaggy type lines and that's where fortification spectra actually came from. This aura was actually drawn by a family medicine resident that rotated through headache clinic many years ago but you can see it was just very like that aura I showed you of Mike where it was colored zigzaggy lines. Usually starts in the center, slowly moves out to the side along with a cortical spreading depression that we think is what is going on with aura. And then you can see by 25 minutes, it's way over to the right side. So this aura was in his left hemisphere. It was, he would have sworn and many of you who've ever had an aura will swear that it's in one eye but if you cover one eye or the other eye you'll still see it on a page so you know it's in both eyes. And I always tell people if you have trouble defining it, have a person look at a text and then cover each eye and see if they can read the text. In the center will be a blank spot where nothing is. Sometimes it's kind of dark but then you'll have this fortification spectra along it. If you can get somebody to draw out zigzaggy lines as part of the visual phenomenon they have, this is a typical really visual aura that comes in the occipital lobe. You can't get zigzaggy lines except in the occipital lobe. So you know that is going to be in the occipital lobe. Now, as I said, we think that aura is a cortical spreading depression phenomenon and I believe this week Dr. Brennan will be talking to you about CSD and pathophysiology and migraine. But the neurophysiology of people with migraine is different in the way they integrate sensory phenomenon. There's a wonderful video on Novel. I'm not gonna play it here because it takes too much time but Shirley Ray has this lovely video of a person with an aura, the beginning of an aura and then they did PET studies during the aura to see a change in blood flow. And I know Dr. Brennan will cover that when he speaks to you about pathophysiology of migraine. So what about this woman, a 41 year old woman who started having visual disturbances about age 33? Her, she has these gray waves in the vision. It's in both eyes. It lasts anywhere between five and 30 minutes. It moves off to the right and she has three, she could, these can occur up to three to five times each day and then she gets a very slight headache. And sometimes when she has the aura, she has a sweet speech disturbance with it along with the visual phenomenon. And this is migraine aura without headache. So this usually is a typical aura, but no headache follows. And it used to be called migraine accompaniments or asephelgic migraine, but we know the proper terminology is migraine aura without headache. These are tricky and the differential diagnosis, you have to be really careful is to be sure it's not a TIA. We'll talk about how to differentiate an aura from a TIA. A seizure, and these I'll show you how to differentiate a seizure, an occipital lobe seizure. They're usually stereotypic last seconds. They're a little bit more complicated. Often pinwheels, circles, balls, I'll show you a couple examples. And people who have a aura without headache, a lot of them can have underlying tumors. This can be a symptom of reversible cerebral vasoconstriction syndrome. Can be a symptom of amyloid, AVMs, dissection, vasculitis, autoimmune disease, and even severe preeclampsia and eclampsia. So aura without headache, most of the time this is migraine aura without headache and not due to a secondary cause, but these you have to be a little bit more careful about and especially someone who's having these disturbances several times a day. And then this is a lovely demonstration again of a typical aura with the progression of the aura going off to the left side. So let's talk about this one. This was an 84 year old physician, family history of migraine, migraine with aura since the 20s, always intermittent and never debilitating. In his 40s, he began having aura without headache and he has visual scintillations and sometimes with fortification, meaning the zigzaggy lines. And every once in a while, when the aura's off to the right side, he can't speak. He has word finding difficulty. He has occasionally a mild headache with it, but never a severe one. The speech problem started to last 30 minutes or so, but it was never, ever severe. But one day he was sitting in a board room. He had an aura off to the right. He couldn't understand the slides he was seeing. He got up to leave. He couldn't get his words out. And this aura lasted about three to four hours. He had no headache. About a week later, he had another one that went over three to four days. He was hospitalized and MR was negative for a stroke. He did have some slowing on his EEG and he does have some vascular risk factors. So the diagnosis on this one is again migraine aura without headache. And we put him on aspirin and verapamil and that combination usually stops the attacks and that really worked well for him. So typical aura without headache is a typical aura not followed by a headache. Sometimes it's a teeny weenie headache, but not a major headache. And it has to fulfill the criteria for migraine with typical aura and no headache following the aura. Now these migraine accompaniments, and I'll call them that even though they're auras, mostly are visual. Sometimes it can be blindness. This was a review of study of all these people who had aura without headache. Some had hamonomous hemianopia. Some had parasthesias with their visual phenomenon and some had speech disturbance with the visual phenomenon. And some had weakness and speech and parasthesia and vision changes. And then some people just had the parasthesias speech disturbance and parasthes. So these are these migraine accompaniments or these auras that came on without a headache. There is an entity and that's what this physician had was late onset migraine accompaniments or we sometimes call it Loma. These are usually after age 40 and typically it's people with aura and then as they get older, the headache piece goes away or it gets markedly, markedly better and they're left with the aura. And while visual aura is the most frequent sensory aura, speech auras, motor auras, auras can occur. And the big problem and look at the physician was a vascular path. We had to determine could this be a TIA where he had a march of one symptom followed by another one, but he had no evidence of any ischemia on his imaging whatsoever and it all went away with aspirin and verapimil. So let's just, this is really important for neurologists, okay? So migraine with aura is usually positive visual phenomenon whereas in TIA it's usually loss of vision, okay? Usually visual field is involved. It can be unilateral, it can be both visual fields. In TIA it's gonna be a homonymous hemianopia. This to me is the most important one. It starts in the center, slowly moves across the visual field and in TIA it's usually pretty fast and onset. It comes on and stays and then it leaves. And the duration for a typical aura for migraine is 15 to 60 minutes whereas in a TIA it's usually three to 10 minutes. And this buildup, I can't stress that enough is so critical because everything else in TIA is usually unilateral, abrupt onset, et cetera. And usually there's a vascular territory that's involved. Now, as I said, you really can't treat the aura itself but you can prevent migraine with aura. And I do like baby aspirin. I use it a lot in people with aura as long as they don't have any contraindication and I love calcium channel blockers. However, there's great evidence for to pyramid, amitriptyline, CGRP monoclonal antibodies and many other preventatives such as other anticonvulsants have been used. The acute treatment of the headache portion can be with triptans, midren, ergatomines, G-pans, dytans and of course treat the nausea if a person has nausea. Now, here's a 43-year-old woman who has no previous migraine and she begins to have a visual disturbance of pinwheels off to the left side of her vision. She'd have these 10 to 12 per day, they're short, 10 seconds to four minutes and she never got a headache afterwards. And she was diagnosed with aura without headache. But unfortunately, this was a presentation of her metastatic colon cancer. So, you know, migraine with aura, especially when it's new in somebody 40 years old, I would image these people and pinwheels, if you start hearing pinwheels in the vision, start thinking seizures, occipital load seizures. And these are some lovely colorful drawings of people's visual auras that are associated with seizures. They're usually multicolored, circular, spherical and in seizures, they'll last seconds, maybe up to one to three minutes and then they're really frequent versus a typical migraine aura, they're rarely daily. And they're not the zigzaggy lines, mostly the circular types of things. And so that's how to differentiate a seizure from an aura. Okay, we're gonna go to this woman, she's 74 years old. She has a history of migraine with aura. So she has eight weeks of squiggles in her left visual field. And when she closes her eyes, she has kaleidoscopic letters with her eyes closed. These symptoms are constant. She's had an MR and MRA negative. So what do you think about a diagnosis for this woman? Well, she has persistent aura without infarction. Now, this is not a common diagnosis, but neurologists should know about this. It's a typical migraine with aura except that it's gonna go on for more than a week. If it's less than a week, we just call it prolonged aura and probable migraine with aura. Amazingly, people can have these symptoms for months or years. Now, the ones I've seen have not been this dramatic. Mostly they are like a little rice kernel that just stays there and they see it forever or for many months or years. There have been studies, however, with people who had persistent aura without infarction of the auras lasting 11 days to 28 years. And the age of people that present with this can be young to older. And it's very hard to treat. People have tried Divell Pro-X, Ferrosimide, Vrapamil, Lomotrogene, Gabapen, Teperamid, Acetazolamide, Magnesium, and Aspirin and various other things. And this aura is very, very difficult to treat. But you should be aware of persistent aura without infarction. It absolutely requires an MR scan. And sometimes you may even need to repeat it again because the MR may be negative at the beginning. And then there is migraine aura status. So this is not in the regular part of the ICHD3. It's in what we call the appendix. And these are headache types and migraine types that are waiting to be put into the ICHD, the regular ICHD. These are people who have migraines fulfilling, migraine with aura. And these are people who have three auras occurring over a period of three days. Now that woman that I talked about at the beginning of this aura without headache, having three to five in a day, she would qualify for migraine aura status. Now these also are not common. They're very rare. And you've absolutely got to think about other conditions that could be causing it like RCVS, press, dissection, some structural lesion. And you really do need to image these people who have migraine aura status. Well, a very interesting phenomenon is Allison Wonderland syndrome. I think Dr. Pasodin did a grand rounds on this. This is a perceptual disorder. And it causes people to see things in different shapes and sizes. So you can have macro-semato-agnosia or micro-semato-agnosia. That means that your body looks, it has places that are bigger than normal or smaller than normal, or that you feel like you're bigger than you should be or smaller than you should be, or things are far away. So that's teleopsia or pelliopsia. Let's see, there's some chat here. Metamorphopsia. So metamorphopsia is where things are gonna look wavy. So if you were to take an Amzler grid and cover each eye individually, things could look wavy or the page could look wavy. And there are many causes of metamorphopsia. For example, edema in the macula. So metamorphopsia is a symptom that is not typical of migraine, but it can be associated with Alice in Wonderland syndrome. Is migraine aura status differentiated from persistent aura without infarction based on three discrete events or one prolonged event? So that's a good question, but persistent aura means that it's going on continuously, okay? Whereas migraine aura status is episodes of aura occurring multiple times a day or multiple times within a week, but persistent aura is continuous. It's all the time. Thank you for your questions. Anytime you have questions, it's fine. Try to raise your hand so I, or shout at me or something, so if I don't see it in the chat. Anyway, back to Alice in Wonderland. Dr. Jigri, can I interject with a question? Sure. Can you hear me? I can. So if somebody has a history of migraine with aura, can they go on to develop different auras through time? Is that something that's expected or is it always going to be the same? You know, don't ever expect migraine to be the same always, okay? So here was that physician who started out with just typical migraine visual aura. Then he developed aura with speech things, okay? Then he developed aura with speech and paracetias. So do you see what I mean? And people's auras can change over time. And then some people's auras are the same for their whole life. Like they get visual aura and that's all they ever get, okay? So it's a very variable, which makes migraine so interesting that I can't imagine, I mean, isn't it cool that we as neurologists get to deal with this condition? Because nobody's the same and everybody's is a little bit different. So they can change over time, they can stay the same. It really is an individual phenomenon. For sure it can change as you get older. And typically I see people who had migraine with aura, meaning they had terrible headache and migraine with their auras and then as they got older, they had a kind of piece went away and the aura persisted. Seamiller Fisher really popularized this late onset migraine accompaniments and actually wrote about his own auras throughout his life. If you want some really good bedtime reading, I won't put you to sleep because it's really interesting. You can read Seamiller Fisher's articles on this. I've got them, if anybody's interested, send me an email and I can send them to you. So any other question about migraine with aura before we go into these more complex types of things? I have one question, one more question. Sometimes people ascribe like a stereotypic something that always happens with their migraine that aren't the actual like migranist characteristics and they aren't actually what would fit is what we consider an aura. Is there a specific way that we should call these sort of things or just describe what happens? Okay, so now you said stereotypic before their headache. That? Well, that happens with their headache, maybe not before it, and it may last longer. Okay, like blurred vision with a migraine. So blurring a vision is, I mean, very, very common with migraines and often it occurs during the whole migraine. Where is that coming from? It's probably not the occipital lobe. I'm not, nobody, I mean, neuro-ophthalmologists that like headache and migraine, we talk about this all the time. Is this something in the midbrain going on, affecting focusing? Is it just, is it something on the occipital lobe? It's just a non-specific finding. It is not an aura. Okay, because it's going on with the headache, but they get the blurring. I don't call that an aura. An aura is a discrete neurologic event and it's usually stereotypic, meaning it occurs the same each time they have a migraine with the aura. It's the same, or mostly the same, okay? And that is an aura. It has to be kind of a discrete neurologic thing that happens usually before. Sometimes it can go into the headache phase a little bit, but it usually happens before, sometimes with it. And I guess my question isn't differentiating those two as what do we call this other non-specific findings? Is there an actual term that we should be calling them or should we just be describing that that's part of what happens while they have their migraine? I would describe it as part of what's happening with their migraine, that they have visual blurring during the migraine phase, the headache phase, yeah. Okay. These are hard. It's splitting hairs a little bit, but I think it's important that we kind of, for neurologists to kind of understand this a little bit more because we're the ones that are dealing with the brain function that's going along with migraine. Any other questions about migraine with aura or aura without headache? Okay, so this Alice in Wonderland syndrome is not common, but it's really interesting. And it's been, it's actually, it's been a diagnosis over the last 60, 70 years. It comes from Lewis Carroll, Lewis Carroll had migraine and he did have auras and many people believe that some of the things that happened to Alice were part of what he had with an aura and nobody really understands the pathophysiology of this and it is not specific to migraine. It can happen with seizure, it can happen with autoimmune disorders and even infections. It's been associated even with Jacob Kreitzfeld disease. So this is where she feels like she's too big for the situation. Here is her distorted neck and elongation and then this third one is when she looks like she's too small. So mycropsy and macropsy and then this body distortion. Any questions about Alice in Wonderland? Okay, I wanna talk about retinal migraine and I wanna talk about this because it's important to differentiate retinal migraine from transient, monocular blindness associated with carotid artery disease, okay? Retinal migraine, first of all, is rare. It is repeated, monocular visual attacks, usually scintillations, blindness in one eye. And it's usually associated with the headache and you can have positive phenomenon, you can have negative phenomenon during the attack either or both and patients need, they really need to draw out their defect after instruction. Most people who have an aura, a typical aura will feel like it's in one eye and that's where it really becomes important for people to draw out their field and really test their vision each eye individually. And then it's so hard to make this diagnosis because you have to have a clinical visual field exam or the patient has to draw this out. And the spread is usually over five minutes and the symptoms last five to 60 minutes and it usually comes with a headache and it's very rare and I haven't seen this very frequently, if at all. Maybe I've seen it. Now what I want you to notice is that these field defects, altitudinal and hemianopic are usually what, or this sort of gray to black vision, this is more likely to be vascular transient monocular blindness. Occasionally it can be a constricting blindness, but rarely and spots and all these little dots and things are more likely to be sort of this migranous phenomenon. And monocular visual loss can be from dry eyes and blurriness in one eye or both eyes. This is a benign condition. Migraine, of course, we've been talking about that. I'm gonna show you vasospasm, that's usually benign and many people believe, neuro-ophthalmologists in particular believe that most of the retinal migraine that's in the literature is actually this vasospasm. The one I really don't want you to miss is transient monocular blindness in the elderly because that can be deadly or lead to blindness. And of course, we're always looking for anabolic phenomenon. And then the only other things that can cause this monocular blindness are intermittent glaucoma and intermittent red cells or white cells in the anterior chamber. Now, for many years, people thought, well, people thought that this vasospasm was retinal migraine, but we think retinal migraine may actually be CSD that's occurring in the retina. So it has a very slow progression. It's not fast, whereas vasospasm is usually pretty fast. Vasospasm will result in a pale nerve and then afterwards you'll see kind of a hyperemia that's occurring and it can respond to a calcium channel blocker. Now, I do have a vasospasm. Let's see if I can see. Tell me if you can see my video coming up here. Can you see the video? Yes. Okay, good. So this is a person who has intermittent vasospasm and one eye, it's a right eye and it's just intermittent. But I want you to notice how fast this occurs. We're photographing him because he got several episodes in a day of transient monocular blindness and boom, this occurs. This is not a slow, gradual phenomenon. This was a boom, sudden vasospasm. And this went on for quite some time and you can see that his red cells are starting to go flow the opposite direction. If you want to look at this yourself, it's on novel, Neuroophthalmology, virtual educational library, novel.utah.edu. And you can watch this. I've got it in the Moran Eye Center. And here again, you can kind of see the red cells actually going into the disc, not out. You can also notice that he's got some silioratinal vessels that are still supplying parts of the retina, whereas the rest of the retina, see how pale it's getting and the vitreous is getting a little milky looking. So this guy needs to work up obviously, but he had vasospasm and it was not a retinal artery occlusion, but it was a vasospasm. He had a mass in his orbit that was intermittently causing an occlusion, kind of an occlusion of his central retinal artery. We took out the mass and the vasospastic episodes completely went away. So, but he did not have any emboli coming from the crottids. He had a big crotted workup multiple times. He had echocardiogram, all kinds of stuff until we diagnosed this vasospasm. But this is what a lot of people think of when they think of retinal migraine, it's more likely to be vasospasm and not retinal migraine. Now, any questions about retinal migraine that's not common if you think you've diagnosed it, send the patient to us so we can take a look at them, because it's really rare and very uncommon. But it's important to know about it because not only is it in the ICHD3, but it's also important to note it because it's in the differential diagnosis of transient monocular blindness. Any other questions on that? All right, next I wanna talk about other migraine phenomenon that can occur and these are not auras, okay? So, well, they could be auras if they occur stereotypically before a headache, but most of the time these are not. So, some people can get persistent positive phenomenon and I'm gonna talk about what these persistent positive phenomenon are. And these can just occur with or without a headache and some people are more visually sensitive who have migraine than other people. They see millions of dots, they see crack lines, blobs of white and gray, blue squares, bubbles, carpet patterns, circles, clouds, comets, greeny vision, heat waves, light flashing, flickering, lines of ants, photopsias. Photopsias are little white spots, rain-like patterns, snows, squiggles, TV static. So, these phenomenon can occur in people and they can see through these, okay? So, they're not an aura because it's not a discreet neurologic event usually before a headache, but these are visual symptoms that people who have migraine can have. So, persistent positive phenomenon. It's, they're not common either but it's not rare. You're gonna hear people talk about this. Oh, I get migraine with aura but in between I can see little spots and dots or I look at carpet and it looks like it's moving or I look at bathroom tile squares and it gives me the sense it's moving. Other people have what they call stripe-induced discomfort. They can't look at Venetian blinds without closing their eyes. Remember I talked about this flickering and their periphery of their vision that can be occurring. That can occur with their eyes closed and then this palenopsia can occur too as some people can get palenopsia just because they've got sensitive brains and palenopsia is two kinds of palenopsia. One is where an object moves across space like your hand moves across and you can see the hand moving. You can see the hand kind of making a movement along the way. And another one is looking at something and then looking away and still seeing that object. That's another form of palenopsia. Palenopsia can come from migraine. It can come from medications like people who get put on clomaphen for trying to induce pregnancy. That drug and many others can give you palenopsia. Even some of the anticonvulsants can give people palenopsia. This isn't migraine per se but it can't accompany it. It's just these migraine phenomenon that can occur in some people. So now I'm gonna take you through somebody who's got something like that and then we'll make their diagnosis. This is a 17 year old. He's a high school student and he got sent with the question from the neurologist is this persistent migraine aura? Is this persistent migraine aura? He has a family history of migraine. He's had typical migraine without aura and he's had a migraine with aura maybe every three to six months. He's a good student. And of course, the phenomenon that's going on his mother's worried about him driving and he insists that he can still drive. But he has these silvery lines that are present when he concentrates on them. Then he gets kind of floaters or squiggly lines especially if he looks at the sky or at snow when he goes skiing. And he's had grainy vision all the time as long as he can remember. And these symptoms go on all the time without or with a headache. And he sees through him. He says, mom, I can drive because I can see perfectly normally. I'm 2015. And so this is somewhat of what he's describing. Here's this grainy vision. And then these are the floaters that he can see in the blue sky. This is one form of palinopsia where you see the trailing image of the hand. And then little dots, this is harder to see but there are little white dots throughout in the sky. And this is another form of palinopsia where you look at an object, then look away and you still see the same object. And he endorsed these three, the grainy vision, the floaters and then the little dots in the blue sky. And so this is actually visual snow. This is not rare, but it's not common either. I see a lot of kids come in with this and they have these continuous dots in their visual field for at least the last three months. And then you have to have two other phenomenon, either palinopsia or the enhanced and topic phenomenon meaning excessive floaters or self-light of the eye. So self-light of the eye is when you close your eyes and many people with migraine may see waves of purple or light and their vision with their eyes closed in the complete darkness or photopsias which are these little bright spots, photophobia or nictalobia meaning night vision problems. And it's not consistent with typical migraine aura and these symptoms are not explained by any other disorder. It's seen in both men and women, many people have migraine but some people have headaches as well. And there may be a continuous from the beginning and there's a high prevalence of tinnitus or ringing in the ears and there's altered signals that occur in the parietal occipital region and also in the cerebellum, interestingly enough. Okay, Shay says sounds like, almost like Van Gogh. Do you know Van Gogh had migraine? He had migraine with aura. So many, some people believe that a lot of his paintings are somewhat of the kinds of visual phenomenon he had. And he had migraine and he had frequent migraine and he had terrible migraine. So interesting people that have migraine. So treatment of visual snow, I think the most important thing is that if you hear this story, reassure the person that they aren't crazy and then medications don't always work, people try different medicines all the time but they don't always work. And sometimes we try FL 41 tint. I wanna say a caveat about visual snow. Visual snow should be typical and it should be typically starting at a young age. When you start hearing visual snow in an older person for the first time, you've gotta work it up. We had a patient who got misdiagnosed with visual snow. She was in her 60s and she actually had multifocal coreiditis. So a retinal disorder that can cause similar phenomenon with sparkles and flashes in the vision and different things like that. She had night vision trouble, but it was a retinal disorder. So Jacob Kreuzfeld can sometimes be, have people think that visual snow. So please be careful in anybody older that gets this first diagnosis. You might wanna send them to neuro ophthalmology and have a good retinal exam and consider other diagnoses. I do wanna just mention photophobia. We did a big grand rounds on eye pain and photophobia so I'm not gonna talk about that but it's an extremely common symptom in migraine. 80 to 90% of everybody with migraine has ectophotophobia, meaning photophobia during their headache. And some people get migraine with and without aura with continuous photophobia. And these people can get very disabled. Don't forget that there are many causes of photophobia and many of these are neurologic like meningitis, pituitary tumors. The most common ones are usually migraine, however, and post-traumatic headaches. So individuals often report photophobia as the most bothersome symptom in migraine. In fact, many of the migraine trials now ask for what is your most bothersome symptom to treat and photophobia is right up there. If an individual has constant photophobia and you've ruled out other things, it could be, it is most likely migraine. And if you see continuous photophobia, always think about depression and anxiety because those things do come together. And the pathway for photophobia is in the posterior thalamus connecting to the trigeminal pathway. So I hope that I wanted to save a few minutes for questions. I hope you understand that migraine is more than a headache that visual symptoms are frequent. I really want a neurologist to always be able to recognize aura versus other visual phenomenon and differentiate aura from a TIA or a stroke. You can direct your patients to the American Migraine Foundation. Lots of great information. There's information about migraine with auras and aura in general. And then I don't know if anybody knows who the patron saint of migraine is, but this is St. Dimfna, the patron saint of migraine. And she's applying this very old sage rabbit on the side of this lady's head. She's taking vapors to try to treat the migraine. So with that, I'm gonna stop sharing my screen, but I wanna open it up. We've got about three minutes here for questions. So anybody with questions? No questions. Well, I hope that