Migraine: The Disease of the Year

Editorial Migraine: The Disease of the Year Deborah I. Friedman, MD, MPH, Kathleen B. Digre, MD W hy would we propose that migraine be the "Disease of the Year" for the Journal of Neuroophthalmology? First, migraine is so common and disabling-it affects almost 20% of women and 6%-8% of men (1,2). We all see it in our neuro-ophthalmology clinics every day, sometimes masquerading as another disorder. Migraine is listed by the World Health Organization as the fifth most disabling disease of the world (3,4). This means many of our neuro-ophthalmology patients will be disabled by this condition. Migraine also is a costly disease-estimated to cost around 27 billion dollars in direct and indirect costs in the United States alone (4,5). Given the burden of migraine and its prevalence in society and in our practices, we are pleased to have assembled some of the world's experts in the field to contribute to our current understanding of migraine from the bench to the clinic. The pathophysiology of migraine is fascinating, and should be understood by all neuroophthalmologists (6). Not only does the entire trigeminal system (ganglia and nuclei) peripherally and centrally participate in the migraine process, but other parts of the brain that we revere and study (the visual pathway) have everything to do with migraine. Peter Goadsby, MD, PhD, will enlighten us on the pathophysiology of migraine. The clinical overlap of migraine and neuro-ophthalmology is "HUGE!" This will be addressed by Dr. Stacy Smith. Aura and other migrainous symptoms present to neuro-ophthalmologists almost daily. Binocular migraine aura symptoms likely arise from cortical spreading depression, giving rise to symptoms originating from the occipital lobe (7). These include positive and negative visual phenomena such as scintillating scotomata with fortification spectra, visual field constriction, cortical blindness, and homonymous hemianopia. Although aura occurs in only 25%-30% of patients with migraine, the migraine headache itself is accompanied by many ophthalmic symptoms, including ocular pain and blurred vision. Transient monocular visual loss or diplopia may be manifestations of migraine. Photophobia, occurring either episodically or chronically, is another common presentation and will be discussed by Rami Burstein, PhD. Individuals with chronic photophobia are highly likely to also have migraine (8). Vertigo, another symptom we commonly treat, often has migraine underpinnings. Approximately one-third of patients with migraine have vertiginous symptoms, either with or without an accompanying headache. Inner ear disease may mimic migraine, and migraine may mimic inner ear disease. Sometimes, an individual has both-this is what makes vertigo and migraine so difficult to sort out (9). Our neuro-otology colleagues see this combination daily and so do we, as long as we recognize it! We will explore this challenging syndrome in an upcoming review by Shin (Josh) Beh, MD. Autonomic features of migraine affect the pupil and other aspects of the eye. In fact, an entire branch of headache features prominent autonomic symptoms-namely the trigeminal autonomic cephalalgias. Here, the typical headache is unilateral with prominent lacrimation, conjunctival injection, eyelid edema, ptosis, miosis, and Horner or partial Horner syndrome. However, even migraine has symptoms of both parasympathetic and sympathetic dysfunction (10). Neuro-ophthalmologists are consulted for benign episodic mydriasis, which is most often a manifestation of migraine (11). Understanding the autonomic contribution to migraine is integral to our understanding of the disease. This will be discussed by Melissa Cortez, DO. Many of the conditions we treat have either migraine as a comorbid condition or migraine features. One of the most common conditions seen in a neuro-ophthalmology practice is idiopathic intracranial hypertension (IIH) (12). In the Idiopathic Intracranial Hypertension Treatment Trial, 41% of enrollees had a history of migraine. Over half of patients that had headaches at baseline described their IIH-related headache phenotype as a migraine or probable migraine; of those, 50% had a history of The authors report no conflicts of interest. Friedman and Digre: J Neuro-Ophthalmol 2019; 39: 1-2 1 Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited. Editorial migraine (13). After IIH is successfully treated, approximately two-thirds of patients continue to experience headaches that are migrainous and that respond to migraine therapy (14). In addition, we frequently consult on patients with eye pain and unusual pain symptoms-these occur with and without autonomic accompaniment. Nonophthalmic eye pain in neurology clinics is most often a manifestation of migraine (15). We are in a new era of treatment for migraine. Every neuro-ophthalmologist should be well aware of evidence-based treatments for migraine, even if we refer our patients to a neurologist or headache specialist for treatment. Some of the very conditions we diagnose may be amendable to treatment with new medications and neuromodulation devices. Drs. Alan Rapoport, David Dodick, and Mia Minen will highlight acute, preventive, and behavioral/complementary therapies, respectively. In this issue, the management of headaches associated with IIH is featured. Finally, there may be a personal benefit to your own migraine therapy from this series. Medical professionals seem to have a higher prevalence of migraine than is seen in the general population (16). Among medical professionals, neurologists, headache specialists, and neuro-ophthalmologists top the list of specialists with migraine (17). In an informal poll at a previous NANOS meeting, nearly every attendee in the room raised their hand when queried whether they had migraine. Thus, there is a high likelihood that you have migraine or will develop it the future. We cannot imagine practicing in the specialty of migraine without a thorough understanding of neuro-ophthalmology; equally, we cannot practice neuro-ophthalmology without a full understanding of migraine. We hope that, with the help of our selected authors, you will share our enthusiasm for migraine in neuro-ophthalmology over the next year and going forward. REFERENCES 1. Lipton RB, Bigal ME, Diamond M, Freitag F, Reed ML, Stewart WF. Migraine prevalence, disease burden, and the need for preventive therapy. Neurology. 2007;68:343-349. 2 2. Lipton RB, Stewart WF, Diamond S, Diamond ML, Reed M. Prevalence and burden of migraine in the United States: data from the American Migraine Study II. Headache. 2001;41:646- 657. 3. World Health Organization. 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