Headache

While headaches are common and usually not related to eye problems, certain types of headaches have important connections to neuro-ophthalmology. Some headaches cause visual symptoms, some are caused by eye conditions, and some indicate serious underlying problems.

Headache Types Relevant to Neuro-Ophthalmology

Migraine

Migraine commonly involves the visual system:

Visual aura

• Occurs before or during headache in ~25% of migraineurs
• Scintillating zigzag lines
• Expanding blind spots (scotoma)
• Shimmering or kaleidoscope effects
• Usually lasts 20-60 minutes

During the headache

• Photophobia (light sensitivity)—very common
• Blurred vision
• Eye pain
• May have visual snow or afterimages

Raised Intracranial Pressure

Idiopathic intracranial hypertension (IIH)

• Headache, often daily and throbbing
• Worse with straining, coughing, bending
• Visual symptoms: transient dimming, double vision
• Pulsatile tinnitus (whooshing in ears)
• Papilledema on exam

Other causes of elevated pressure

• Brain tumors
• Venous sinus thrombosis
• Meningitis

Giant Cell Arteritis

• New headache in patients over 50
• Temple tenderness
• Scalp pain (hurts to brush hair)
• Jaw claudication (pain with chewing)
• Vision loss risk—medical emergency
• See giant cell arteritis

Cluster Headache

• Severe, stabbing pain around eye
• Same side every time
• Eye tearing, redness, nasal congestion
• Droopy eyelid during attack
• Occurs in clusters over weeks/months

Eye-Related Headaches

Acute angle-closure glaucoma

• Severe eye pain with headache
• Nausea, vomiting
• Blurred vision, halos
• Medical emergency

Eye strain

• Frontal headache or around eyes
• Related to prolonged visual tasks
• See eye strain

Uncorrected refractive error

• Need for glasses causing strain headaches
• Usually frontal or around eyes
• Related to visual effort

Warning Signs (Red Flags)

When Headache Needs Eye Evaluation

Evaluation of Concerning Headaches

Eye Examination

• Visual acuity—checking for vision loss
• Pupil examination—nerve function
• Visual field testing—may show blind spot enlargement
• Dilated fundus exam—checking for papilledema

Neurological Examination

• Cranial nerve testing
• Motor and sensory exam
• Balance and coordination

Imaging

• MRI brain—looking for tumors, structural problems
• MRV (venous imaging)—checking for venous sinus thrombosis
• CT scan—for acute headache, ruling out bleeding

Other Tests

• Lumbar puncture—measuring pressure, checking for infection
• Blood tests—ESR, CRP for giant cell arteritis

Treatment Approaches

Treatment depends on the underlying cause:

For Migraine

• Acute treatment—triptans, NSAIDs, gepants
• Preventive medication—if frequent
• Lifestyle modifications—sleep, triggers, stress

For Idiopathic Intracranial Hypertension

• Weight loss—if overweight
• Acetazolamide—reduces CSF production
• Shunt surgery—if medical management fails
• Focus on protecting vision

For Giant Cell Arteritis

• Immediate high-dose steroids
• Long-term steroid-sparing treatment
• Vision protection is priority

For Eye Strain Headaches

• Correct refractive error
• Ergonomic adjustments
• 20-20-20 rule
• See eye strain

Frequently Asked Questions

Can eye problems cause headaches?

Yes, though less often than commonly believed. Eye strain from uncorrected refractive error, acute glaucoma, and eye inflammation can cause headaches. However, most headaches aren't due to eye problems.

Do I need my eyes checked for my headaches?

If your headaches are typical tension-type or migraine without unusual features, an eye exam may help if you have eye strain but isn't always necessary. However, if you have visual symptoms with headaches, new or unusual headache patterns, or red flag symptoms, an eye evaluation is important.

Is migraine aura dangerous?

Typical migraine aura (lasting 20-60 minutes, visual positive phenomena like zigzag lines) is generally not dangerous, though migraine with aura does carry slightly increased vascular risk. Atypical aura (longer duration, motor symptoms, unusual features) needs evaluation.

Can migraine cause permanent vision damage?

Rarely. Most migraine visual symptoms are temporary. However, retinal migraine (rare) involves actual vascular changes in the eye and can potentially cause lasting damage. Persistent visual changes warrant evaluation.

Why do my headaches cause light sensitivity?

Photophobia is very common with migraine and involves both peripheral (eye) and central (brain) mechanisms. Light activates pain pathways during migraine. Some migraineurs have baseline light sensitivity even between attacks.

References