Can LASIK (Laser-Assisted In Situ Keratomileusis) surgery cause headaches?

LASIK Surgery and Headaches

While headache is not listed as a recognized complication in the 2023 American Academy of Ophthalmology Refractive Surgery Guidelines, LASIK can indirectly cause headaches through several mechanisms including corneal neuralgia, dry eye-related eye strain, and visual disturbances that trigger headaches. 1

Direct Neurologic Complications

Corneal neuralgia (neuropathic pain projected to the cornea) is a documented post-LASIK complication that can manifest as chronic pain requiring multimodal local and systemic treatment beyond standard dry eye therapies. 1 This nerve damage-related pain syndrome may present as:

• Eye pain that can radiate and potentially trigger headaches 2
• Light sensitivity (photophobia) that commonly accompanies headache disorders 2
• Persistent discomfort beginning within 2 months of surgery 2

The mechanism involves corneal nerve damage from the flap creation and stromal ablation, leading to pathologic neuroplasticity including peripheral sensitization, central sensitization, and altered descending pain modulation—similar to other persistent post-operative pain syndromes. 3

Indirect Mechanisms Leading to Headaches

Dry Eye and Eye Strain

• Post-LASIK dry eye occurs in 20-55% of patients with chronic symptoms persisting 6 months or longer. 4, 3
• Dry eye causes fluctuating vision, foreign-body sensation, and discomfort that can lead to eye strain and secondary headaches. 1, 5
• The neurotrophic effect on the cornea combined with altered tear dynamics creates ocular surface desiccation. 5
• Risk factors include female sex, higher refractive correction, and greater ablation depth. 4

Visual Disturbances

• Quality of vision under low-light conditions is reduced after LASIK, with halos and glare particularly in patients with smaller treatment zones or high refractive corrections. 1
• These visual symptoms can trigger headaches through sustained accommodation effort and visual stress. 1
• However, less than 1% of patients report difficulty performing usual activities due to visual symptoms. 1

Clinical Approach

When evaluating post-LASIK headaches, assess for:

• Timing: Corneal neuralgia typically begins within 2 months of surgery 2
• Character: Differentiate between eye pain/pressure versus true headache
• Associated symptoms: Light sensitivity, eye pain, visual disturbances 2
• Dry eye signs: Tear break-up time, corneal staining, Schirmer testing 4
• Corneal complications: Flap striae, epithelial ingrowth, diffuse lamellar keratitis 1

Treatment algorithm:

1. For dry eye-related symptoms: Supplemental lubrication, topical cyclosporine, punctal occlusion 1, 5
2. For corneal neuralgia: Multimodal treatment including autologous serum tears, systemic agents for neuropathic pain, and potentially PROSE treatment 2
3. For visual disturbances: Ensure refractive stability; consider enhancement only after stable refraction 1

Important Caveats

• In vivo confocal microscopy can help identify neuropathic basis when symptoms are out of proportion to clinical signs. 2
• Early multimodal treatment is warranted to prevent centralization and persistence of pain. 2
• Preoperative optimization of dry eye decreases incidence and severity of postoperative symptoms. 5
• The comprehensive list of LASIK complications in the 2023 AAO guidelines does not explicitly mention headache, suggesting it is not a primary or common direct complication. 1