What are the clinical manifestations of ocular migraines?

Clinical Manifestations of Ocular Migraine

Ocular migraine (retinal migraine) presents with repeated attacks of monocular visual disturbances—including scintillations, scotomas, or transient blindness—that are fully reversible and typically followed by migraine headache within 60 minutes. 1

Visual Aura Characteristics

The visual manifestations are the hallmark of ocular migraine and follow specific patterns:

• Bright scintillating lights or zigzag lines are the most characteristic positive visual phenomena, often appearing as shimmering or flickering patterns 1
• Scotomas (blind spots) that interfere with reading and central vision, representing negative visual phenomena 1
• Visual symptoms typically expand gradually over 5-20 minutes rather than appearing suddenly, which helps differentiate them from vascular events like transient ischemic attacks 1
• Duration of individual visual symptoms ranges from 5-60 minutes, with complete resolution expected 1
• Monocular involvement is essential for true retinal migraine diagnosis, distinguishing it from typical migraine with aura which may affect one hemifield bilaterally 2

Temporal Pattern and Progression

The attack follows a predictable sequence:

• Visual disturbances develop gradually with spreading characteristics over at least 5 minutes 1
• Multiple aura symptoms may occur in succession rather than simultaneously 1
• Headache follows within 60 minutes of the visual symptoms in most cases, though some patients experience visual symptoms without subsequent headache 1

Associated Headache Features

When headache accompanies the visual symptoms, it typically demonstrates:

• Unilateral location affecting one side of the head 1
• Pulsating quality rather than constant pressure 1
• Moderate to severe pain intensity that interferes with daily activities 1
• Aggravation by routine physical activity such as walking or climbing stairs 1

Accompanying Symptoms

Beyond visual and pain manifestations, patients commonly experience:

• Photophobia (light sensitivity) occurring before, during, or after visual symptoms 1
• Phonophobia (sound sensitivity) as a transient bilateral phenomenon 1
• Nausea and/or vomiting during the headache phase 1

Diagnostic Requirements

For definitive diagnosis, specific criteria must be met:

• At least 2 attacks fulfilling the characteristic pattern are required for diagnosis 1
• Complete reversibility of all visual symptoms is mandatory—persistent deficits suggest alternative diagnoses 1, 2
• Exclusion of other causes is essential, as retinal migraine is a diagnosis of exclusion requiring workup to rule out vascular, inflammatory, or compressive etiologies 3, 2

Critical Pitfalls to Avoid

Do not assume migraine if visual symptoms have sudden simultaneous onset—this pattern suggests transient ischemic attack rather than migraine, which characteristically shows gradual spreading over at least 5 minutes 1

Do not diagnose retinal migraine if visual field defects persist beyond 60 minutes without complete resolution—while rare cases may show prolonged recovery beyond 10 days, persistent deficits mandate comprehensive neurologic and ophthalmologic evaluation to exclude stroke, retinal vascular occlusion, or other serious pathology 4, 2

Do not confuse bilateral visual field defects with true retinal migraine—retinal migraine by definition affects only one eye, while typical migraine with aura may cause hemianopic visual loss affecting the same visual field in both eyes 2