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8 Articles in this Series
Introduction
Are Botox Injections Safe for Younger Patients?
Chronic Daily Headache Prevalent Among Younger Patients
Depression and Disability, Problems for Children with Migraine
Dropping Caffeine May Enhance Acute Migraine Treatment
Migraine with Aura More Common at Higher Altitudes
New Insights Into Botox for Preventive Migraine Treatment
Triptans Worsen Visual Snow in Migraine Patient
Vitamin Deficiency Common in Migraine Patients

Triptans Worsen Visual Snow in Migraine Patient

It is not uncommon for patients with migraine to report visual disturbances. Typically, these patients can be diagnosed as having migraine with aura (MA). But some patients may experience visual snow (VS), a kind of static haze akin to snowy dots of an analog TV screen.

Visual snow often is compared to static appearing on a analog television.It is a syndrome often confused with MA, but doctors are now beginning to understand more about its characteristics and phenotype. For instance, VS can be experienced very early in a patient’s life, and migraine attacks are not the only reason they’re triggered. In fact, cases of VS may be aggravated by taking certain migraine prophylactics as well, including triptans.

A study presented at this year‘s annual meeting of the American Headache Society (AHS) detailed a case of a 25-year-old chronic migraine patient who began noticing instances of VS that became more “prominent and dense” after taking a triptan.1 This is the first known instance of a migraine therapy potentially worsening a patient’s visual disturbances.

“Although effective as a migraine abortive, in this patient triptans induce VS. This adds evidence to the distinction between VS and typical aura, a phenomenon not influenced by triptans,” the authors wrote.

What is Visual Snow?

The flickering, distracting dots of VS are commonly associated with other phenomena, including:

  • After images
  • Trailing floaters
  • Blue field entoptic phenomenon
  • Photopsia
  • Photophobia
  • Nyctalopia (impaired night vision)
  • Tinnitus

“(Visual snow) is commonly accompanied by migraine and often misdiagnosed as persistent migraine with aura (MA),” wrote Julio R. Vieira, MD, and Richard B. Lipton, MD, of the Montefiore Medical Center, Albert Einstein College of Medicine in Bronx, New York. The condition can be misdiagnosed with psychiatric disorders, post-hallucinogen flashbacks, and even malingering.2

But how exactly VS occurs—and how it may be related to migraine—continue to be relevant, unanswered questions. According to Drs. Vieira and Lipton, VS has been associated with hypermetabolism in the lingual gyrus, which means it is likely independent of either MA or migraine without aura (MoA).

VS may be considered a subjective experience, varying in characteristics from patient to patient. But it does appear to have a biological basis, given the hypermetabolism in the supplementary visual cortex overlaps similarly with occurrences of photophobia in migraine,3 the authors noted.

VS largely has been ignored for several years in migraine research, though—a significant disparity considering, like MA, attacks of VS can disable a migraine patient. What’s more, patients can report instances of VS persisting for years with continuous frequency, unresponsive to typical migraine treatments.4 Those treatments actually may be affecting the VS, according to the case study.

Case Report

A 25-year-old female patient presented with a 2-year history of chronic migraine (CM) and VS. Since adolescence, she had suffered from episodic migraine progressing into CM at age 23. Her symptoms included:

  • Throbbing pain
  • Photophobia
  • Phonophobia
  • Osmophobia
  • Brain fog
  • Poor concentration
  • Fatigue

Two months after her presentation, she reported having episodes of VS, which became continuous. Here symptoms werecharacteristics with other patient-reported cases of VS.4 However, the patient did not report any signs of anxiety or depression, which are also commonly associated with VS, noted the authors.

An extensive workup was conducted, including magnetic resonance imaging (MRI) on the brain, magnetic resonance angiogram/venography (MRA/MRV) on the head, a computed tomography of the sinus, gallium scan, lumbar puncture, as well as ENT, ophthalmology, and dental evaluations—all of which were unremarkable.

Migraine frequency, severity, and VS symptoms did improve when the patient was placed on a regimen of onabotulinum toxin A (Botox), nadolol (Corgard), riboflavin, magnesium, melatonin, diazepam, isdexamfetamine, and an FDA-approved external trigeminal nerve simulator (e-TNS, Celafy) for migraine prevention. For acute treatment of severe headache attacks, the patient was prescribed the anti-inflammatory agents diclofenac potassium for oral solution or nabumetone, and the triptans eletriptan or zolmitriptan as backup.

However, every time the patient took a triptan, the VS episodes became more prominent and dense. “This occurred on at least 30 occasions starting approximately 2 hours after taking triptans, lasting for about 1 day with worsening photophobia, as well as frequent yawning,” the authors wrote.

The Cefaly device also appeared to trigger VS episodes. The patient reported only being able to use the device for 6 minutes at a time because her symptoms would worsen during sessions. While a relatively small percentage of Cefaly device users may report local pain, headache, or arousal changes (sleepiness, sometimes insomnia), this does appear to be the first documented case of the Cefaly device worsening VS symptoms.4

Visual Snow:  A Distinct Syndrome from Migraine with Aura

This latest case study presents novel characteristics of VS, suggesting that trusted prophylactics and popular nondrug treatments could aggravate VS disturbances. Clinicians are beginning to understand how VS typically develops independent of migraine, even though migraine is the most common comorbidity of the syndrome.

Many misrepresentations of the syndrome also are being dispelled. In the past, some have concluded the condition is triggered by anxiety, depression, or usage of illicit substances, particularly Lysergic acid diethylamide or LSD – assumptions that now appear to be erroneous.5-6

VS is also present in pediatric patients.7 According to researchers, this should be something pediatricians are more aware of when treating migraine in young patients, regardless of the fact that only a few recent large studies have contributed any knowledge to this field.8

References

  1. Vieira JR, Lipton RB. Visual Snow Induced by Triptans. Poster presented as part of the 58th annual meeting of the American Headache Society, San Diego, CA: June, 2016.
  2. Lauschke JL, Plant GT, Fraser CL. Visual snow: A thalamocortical dysrhythmia of the visual pathway? J Clin Neurosci. 2016;28:123-127.
  3. Schankin CJ, Goadsby PA. Visual snow – persistent positive visual phenomenon distinct from migraine aura. Curr Pain Headache Rep. 2015;19(6):23.
  4. Magis D, Sava S, d’Elia TS, et al. Safety and patients' satisfaction of transcutaneous supraorbital neurostimulation (tSNS) with the Cefaly device in headache treatment: A survey of 2,313 headache sufferers in the general population. J Headache Pain. 2013;14:95.
  5. Schankin CJ, Maniyar FH, Digre KB, et al. ‘Visual snow’ – a disorder distinct from persistent migraine aura. Brain. 2014;137(Pt5):1419-1428.
  6. Jager HR, Giffin NJ, Goadsby PJ. Diffusion- and perfusion-weighted MR imaging in persistent migrainous visual disturbances. Cephalalgia. 2005;25:323-32.
  7. Schankin CJ, Maniyar FH, Digre KB, et al. ‘Visual snow’—a disorder distinct from persistent migraine aura. Brain. 2014;137:1419-1428.
  8. Rastogi RG, VanderPluym J, Lewis KS. Migrainous aura, visual snow, and ‘Alice in Wonderland’ syndrome in childhood. Seminars in Pediatric Neurology. 2016;23(1):14-17.
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