Retinal migraine (ocular migraine)
A retinal migraine is an attack in which the sight of one eye goes dark, clouds over or starts to shimmer: usually for ten to twenty minutes, occasionally for…
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Medicines commonly prescribed for Retinal migraine (ocular migraine)
For informational purposes only. Always consult a doctor before using any medicine.
Dosage form: INJECTABLE, 6 mgActive substance: sumatriptanManufacturer: Glaxosmithkline S.A.Prescription requiredDosage form: NULL, 27 mgActive substance: sumatriptanManufacturer: Klaria AbPrescription requiredDosage form: NASAL PRODUCT, 10 mgActive substance: sumatriptanManufacturer: Glaxosmithkline S.A.Prescription required
A retinal migraine is an attack in which the sight of one eye goes dark, clouds over or starts to shimmer: usually for ten to twenty minutes, occasionally for close to an hour. Then vision comes back in full, and a headache tends to follow. The condition itself is uncommon and destroys nothing. The danger lies elsewhere: several situations begin in exactly the same way, and in those the clock runs in hours, sometimes in minutes. You cannot tell them apart by eye.
That is why this is a diagnosis made last, once everything else has been checked and ruled out. If you are reading this page after the first such episode of your life, the most useful thing here is not to make that diagnosis yourself.
What an attack looks like
It starts abruptly, in the middle of an ordinary day, with no warning. People describe it differently: for some, one eye simply switches off and everything goes black or grey; for others, a dark patch spreads out from the centre or creeps in from one side; for others again, sparks, zigzags or a shimmering arc tremble over the picture.
Most often it lasts ten to twenty minutes and settles on its own. Vision returns to exactly what it was, with nothing left behind. Over the following hour a headache usually starts, typically on the same side, throbbing, with dislike of light and nausea. But there may be no headache at all: in roughly a third of people the attacks consist of the visual symptoms alone, and that does not make it a different condition.
Between attacks the eye sees normally and an ophthalmologist finds nothing. The frequency varies enormously, from once or twice a year to several times a month.
One eye or both: how to check, and why it matters
This is the most important practical distinction on the whole page, and almost nobody gets it right first time.
In ordinary migraine with aura the shimmer is not "in the eye" but in the visual field: the same half of the picture drops out or trembles in both eyes at once. It feels as though one eye is the problem — the one on the side that darkens. In retinal migraine it really is one eye, while the other sees perfectly well at the same time.
The check has to be done during the attack, by covering each eye in turn with your palm. Close one eye and look with the other, then swap. If, with the "good" eye covered, the remaining eye sees normally, then the trouble is in the visual field and this is the aura of an ordinary migraine. If the darkness or shimmer stays with the same eye while the other is covered, the problem is monocular.
This can only be established in those few minutes while the attack is running; afterwards all you have is the memory, and memory misleads. A great deal follows from the answer: an aura filling the same half of the field in both eyes points to the brain, while blindness in one eye points to the eye and to the vessels feeding it, and the two are investigated in completely different ways.
When waiting is not an option
A first-ever loss of vision in one eye means being seen by a doctor the same day, even if it passed in ten minutes, your sight came back completely and you feel entirely well. This is not over-caution: in most such episodes the cause is not migraine.
An ambulance is needed straight away (in Spain, Italy, Portugal, Poland and Ukraine, dial 112) if:
- vision in the eye has not returned within an hour, or has come back only partly;
- along with the vision there is weakness in an arm or a leg, one side of the face has dropped, speech has become slurred, or a savage headache has come on of a kind you have never had;
- the eye has suddenly become painful and red, coloured haloes have appeared around lights, and you feel sick or are vomiting.
Same-day medical assessment, ideally straight to an ophthalmologist, if:
- you are over fifty and this has happened for the first time. At that age, brief blindness in one eye points away from migraine before it points towards it;
- your temple aches, the scalp has become tender when you comb your hair, your jaw tires and hurts while chewing, your shoulders and hips feel stiff, and there is weakness, weight loss or an unexplained temperature. This is the picture of giant cell arteritis, an inflammation of the artery walls. In that condition a brief blindness that comes and goes often gives days of warning before one that does not go, and treatment is started at once, without waiting for results;
- a dark curtain comes down or a shadow creeps across the eye, preceded by flashes and a shower of new floaters — that is how a detaching retina behaves;
- the attacks have become more frequent or longer, or have changed in character;
- you are pregnant, have recently given birth, or have high blood pressure.
Do not drive yourself in these situations: the attack may repeat on the way.
What else looks exactly the same
The list below is not for diagnosing yourself. It is there to explain why a doctor will not settle for the word "migraine".
- Transient blindness from a narrowed carotid artery. A fragment of plaque briefly blocks the artery supplying the retina. This is the very mechanism of a stroke and a warning that one may follow: the carotid arteries and the heart need looking at quickly, and treatment cuts the risk substantially.
- Blockage of the retinal artery. The same thing, except the blood flow never came back. Sight is lost irreversibly within a few hours, and help only counts if it is very early.
- Retinal vein thrombosis. Here vision falls over hours or days rather than in an instant, and does not return by itself.
- Giant cell arteritis in older people — the most galling cause of the lot, because it responds beautifully to treatment started in time.
- Retinal detachment or tear — the curtain, the flashes, the floaters, the loss of part of the field.
- Acute angle-closure glaucoma — severe pain, a red eye, haloes around lights.
- Inflammation of the optic nerve. Vision in one eye drops over hours or days, colours look washed out, and the eye hurts when you move it.
How it gets sorted out
What helps a doctor most is a detailed account, so work it out beforehand: which eye it was and whether you checked by covering the other; how many minutes it lasted; what it actually looked like — darkness, a patch or a shimmer; what happened afterwards; how many such episodes there have been and whether they are all alike.
Next comes examination of the back of the eye through a dilated pupil, along with eye pressure and blood pressure. If a vascular cause is suspected, an ultrasound scan of the carotid arteries, an electrocardiogram and sometimes a twenty-four-hour heart rhythm recording go looking for the source of a clot. At the slightest suspicion of arteritis, blood is taken urgently for the erythrocyte sedimentation rate and C-reactive protein. Glucose and blood lipids are checked. If the picture is unusual, or there were neurological symptoms, a brain MRI scan is added.
The diagnosis of retinal migraine is built from repeated, closely similar attacks in one eye, full recovery of vision, a normal retina between attacks, an accompanying headache, and the absence of everything listed above. A single episode is never enough.
What is done about the attacks
During an attack the simple things help: stop what you are doing, lie down in a quiet darkened room, and wait for vision to return. For the headache that follows, paracetamol or an anti-inflammatory painkiller is usually enough; if nausea is marked, a doctor may add something for it.
A word on triptans and ergot preparations. These are the medicines many people take "for migraine", and they work by narrowing blood vessels. That is precisely why they are not usually prescribed in retinal migraine. If you already have such tablets at home, do not take them during an eye attack unless a doctor who knows about your one-eyed episodes has expressly told you to.
If attacks are frequent, preventive treatment is discussed. It is taken every day rather than at the moment of an attack, and the options include calcium channel blockers, beta blockers, some anti-epileptic medicines and tricyclic antidepressants. The choice depends on age, blood pressure, other conditions and any plans for pregnancy: several of these are not given to women who could become pregnant.
There is one more subject worth raising yourself. Combined hormonal contraception is generally avoided in migraine with aura and in retinal migraine, because the combination raises the risk of ischaemic stroke, particularly in smokers. That is no reason to be left without contraception: progestogen-only and non-hormonal methods exist. Discuss the switch with a doctor rather than simply stopping the pills.
What you can do yourself
The single most useful thing is a diary. For each attack write down the date and time, which eye, how long it lasted, what it looked like, whether a headache followed, and what the day before was like: how much you slept, when you ate, how the day went, what medicines you took, where in your cycle it fell. After a few months a pattern emerges from those notes that is invisible any other way, and to a doctor that list says more than an hour of questions.
Then come the dull things that work: going to bed and getting up at roughly the same time, not skipping meals, drinking enough water. Caffeine and alcohol trigger attacks in some people but by no means in everyone, so test them against the diary instead of giving up everything blindly. Keep your blood pressure under control. And if you smoke, this is one of the cases where stopping genuinely changes the outlook rather than merely being good for you.
Online consultation
A remote appointment is strong in this subject because almost everything here is decided by talking: which eye, how long, what it looked like, what came before. Those are exactly the details that separate migraine from a vascular cause.
An online consultation is well suited to going through an episode that has already happened and working out what it might have been; deciding whether you need to be seen urgently or can book in the ordinary way; drawing up the list of tests that makes sense in your particular case; reviewing the treatment you have been given and checking that it contains nothing unsuitable for you; talking about contraception if you get aura; and learning to keep an attack diary and then reading it through together.
Have ready for the appointment: a description of the last attack in full detail, your diary if you keep one, a list of your medicines including contraception and supplements, your blood pressure readings, and the results of previous blood tests and eye examinations. If an attack happens before the consultation, cover each eye in turn there and then and write down what you saw — that one sentence is worth more than everything else.
This material is for information only and does not replace medical advice.
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