Published in Ocular Surface

Investigating the Dry Eye and Migraine Connection

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9 min read

Featuring recent studies, this article outlines the link between dry eye and migraines and offers clinical pearls to optometrists for treating them concurrently.

Investigating the Dry Eye and Migraine Connection
Dry eye is defined by the Tear Film and Ocular Surface Society Dry Eye Workshop II (TFOS DEWS II) as a multifactorial disease of the ocular surface characterized by a loss of homeostasis of the tear film, and accompanied by ocular symptoms, in which tear film instability and hyperosmolarity, ocular surface inflammation and neurosensory abnormalities play etiological roles.1
The International Headache Society (IHS) defines migraine as a recurrent headache disorder manifesting in attacks lasting 4 to 72 hours. Migraine episodes can be classified as chronic or episodic and with or without an aura.2

The link between migraines and dry eye

Both dry eyes and migraines are quite common in the general community. Dry eye prevalence ranges from 5% to 50% in the global population, while migraine is up to 9.5% in males and 25% in females in Western nations.3
Dry eye or migraine symptoms can become bothersome and reduce a patient's quality of life. Recent research has revealed that dry eye and migraine share many symptoms, pathogenesis, and possible therapies and treatments.4

Supporting studies on the link between migraines and dry eye

According to the data, people with migraine have more dry eye symptoms versus dry eye signs than those who do not have migraines, and migraine with aura is more related to dry eye than migraine without aura.5,6

Recent studies on the link between migraines and dry eye:

  • In a study of 31 South Florida veterans compared to 219 controls, individuals with migraine had significantly higher dry eye symptom scores on the ocular surface disease index (OSDI) but similar tear break-up time (TBUT), corneal staining, and tear production compared to controls.5,7
  • A Turkish study comparing 33 migraine patients to 33 controls found that migraine patients had substantially greater dry eye symptoms on the ocular surface disease index (OSDI) and lower TBUT and Schirmer scores than controls.5,6
  • A Turkish study of 58 migraine sufferers discovered that those with migraine plus aura were 5.03 times more likely to develop a dry eye condition than those without aura.5,8
  • Studies have demonstrated that photophobia is a common feature of both dry eye and migraine.9,10
    • A study of 102 South Florida veterans discovered that those with persistent dry eye symptoms were more likely to report photophobia than those without persistent symptoms.9
    • Photophobia was identified as the most irritating symptom by 49.1% of 6,045 respondents in the Migraine in America Symptoms and Treatment (MAST) Study, and 80% of 117 patients with chronic migraine ranked their photophobia as severe.10

The pathophysiological relationship between dry eye and migraines

The overlap of dry eye symptoms with migraine symptoms suggests a pathophysiological relationship between them.11 Migraine is assumed to be caused by activation of the trigeminovascular network, whereas dry eye symptoms are thought to be caused by activation of the sensory trigeminal neurons of the cornea.11,12 Both dry eye symptoms and migraine have abnormal peripheral trigeminal nerve activation with subsequent peripheral and central sensitization.
Although the exact pathophysiology is unknown, one explanation is that dry eye symptoms and migraine are caused by aberrant trigeminal nerve activity, which involves the trigeminal nerve and its neuronal projections to the trigeminovascular system.11,12
The neurons of the trigeminal nerve's first division that compose the corneal nerve plexus travel parallel to the ocular surface, and their axons synapse in the brainstem, where the trigeminovascular system occurs. Because the feeling of dry eye activates the trigeminovascular system, changes in corneal innervation from ocular surface inflammation and refractive surgeries may all contribute to migraine.11,12
In people with persistent migraines, abnormal corneal nerves may cause dry eye symptoms.13 According to studies, migraine sufferers were shown to have abnormalities in their corneal nerve structure, such as branching and tortuosity, and considerably more corneal sensitivities when compared to controls, perhaps inducing dry eye symptoms via activation of the trigeminovascular system.13

Research on co-morbidity

Studies have shown that dry eye and migraine can be considered co-morbid.14,15,16 According to a Korean research study of 14,329 individuals, the prevalence of migraine and dry eye diagnosis was identical, with 24.2% reporting migraine, 22.6% reporting a dry eye diagnosis, and 37.1% reporting dry eye symptoms.15
In a hospital-based study of 72,969 people in North Carolina, individuals with migraine and dry eye were identified using the International Classification of Diseases (ICD-9 and ICD-10) codes, and the prevalence of a migraine or dry eye diagnosis was 7.3% and 13.2%, respectively.16
Additionally, the frequency of a dry eye diagnosis was found to be higher in those with migraine.14,17 The presence of a dry eye diagnosis raised the risks of a migraine diagnosis by 1.76-fold in a large Taiwanese research study utilizing ICD-9 codes.17

Treatments to consider for dry eye and migraines

Anti-inflammatory medications are considered to be a first-line treatment in those patients with dry eye and migraine.18,19 Topical corticosteroids are therapies that will decrease ocular surface inflammation.18 Nonsteroidal anti-inflammatory drugs (NSAIDs) can alleviate acute migraines.19
If patients are not responding to the anti-inflammatory treatments initially, then therapies targeting nerve dysfunction should be considered.14,20,21 Tricyclic antidepressants (TCAs) and serotonin and norepinephrine reuptake inhibitors are oral nerve modulators that have been shown to be useful in the treatment of chronic migraine, whereas triptans have been shown to be beneficial in the treatment of acute migraine episodes.14,20
Given the comparable pathophysiology to migraine, patients with dry eyes may benefit from oral nerve modulators as well. Gabapentin, pregabalin, and alpha 2 delta ligands are particular oral nerve modulators that have been studied in dry eye and are hypothesized to work by decreasing excitatory neurotransmission along the trigeminovascular pathways.21 Supportive therapy may be used in people who do not respond to oral nerve modulator medications for dry eye and migraine.
Though these specific treatments are more typically utilized in migraine therapy, they may also help with dry eye care:21,22,23
  • Botulinum toxin (BT): Inhibits pain responses by reducing facial muscle contraction and, as a result, trigeminal signaling.22
  • Transcutaneous electrical nerve stimulation (TENS): Is thought to alleviate discomfort in dry eyes and migraines by sending pulsed electrical currents over the skin's surface to activate deep sensory afferents, which then suppress nociceptive input in the trigeminovascular system.23
  • Blocking occipital nerve afferents: This triggers the trigeminovascular pathway with a local anesthetic, resulting in a considerable reduction in the number and intensity of headaches.
    • When administered to trigeminal nerve afferents, this method has the potential to treat individuals suffering from dry eye discomfort.21

In conclusion

Dry eyes and migraines are both prevalent conditions. Clinicians can ask dry eye patients about headaches or vice versa during the case history to better assess both conditions. The occurrence of photophobia in both conditions, as well as the co-morbidity of dry eye and migraine, suggests a pattern of similar etiology and possible therapies.
More studies, along with current data, may be utilized to not only better understand the physiological causes of both disorders, but also to aid in the development of tailored therapeutics for lessening the severe symptoms of migraine and dry eye.
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  2. Headache Classification Committee of the International Headache Society (IHS). The international classification of headache disorders, 3rd edition. Cephalalgia. 2018;38(1):1–211.
  3. McDonald M, Patel DA, Keith MS, Snedecor SJ. Economic and humanistic burden of dry eye disease in Europe, North America, and Asia: a systematic literature review. Ocul Surf. 2016;14(2):144–167.
  4. Younger DS. Epidemiology of migraine. Neurol Clin. 2016;34 (4):849–861.
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  13. Patel S, Hwang J, Mehra D, Galor A. Corneal nerve abnormalities in ocular and systemic diseases. Exp Eye Res. 2020;202:108284.
  14. Burch RC, Buse DC, Lipton RB. Migraine: epidemiology, Burden, and Comorbidity. Neurol Clin. 2019;37(4):631–649.
  15. Yang S, Kim W, Kim HS, Na KS. Association between migraine and dry eye disease: a nationwide population-based study. Curr Eye Res. 2017;42(6):837–841.
  16. Ismail OM, Poole ZB, Bierly SL, et al. Association between dry eye disease and migraine headaches in a large population-based study. JAMA Ophthalmol. 2019;137(5):532–536.
  17. Wang TJ, Wang IJ, Hu CC, Lin HC. Comorbidities of dry eye disease: a nationwide population-based study. Acta Ophthalmol. 2012;90(7):663–668.
  18. Silbert JA, Bitton E, Bhagat K. Advances in diagnosis and management of dry eye disease. Adv Ophthalmol Optom. 2019;4:13–38.
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  20. Konstantinos S, Vikelis M, Rapoport A. Acute care and treatment of migraine. J Neuro Ophthalmol. 2020;40(4):472–484.
  21. Small LR, Galor A, Felix ER, Horn DB, Levitt RC, Sarantopoulos CD. Oral gabapentinoids and nerve blocks for the treatment of chronic ocular pain. Eye Contact Lens. 2020;46 (3):174–181.
  22. Herd CP, Tomlinson CL, Rick C, et al. Cochrane systematic review and meta-analysis of botulinum toxin for the prevention of migraine. BMJ Open. 2019;9(7):e027953.
  23. Tao H, Wang T, Dong X, et al. Effectiveness of transcutaneous electrical nerve stimulation for the treatment of migraine: a meta-analysis of randomized controlled trials. J Headache Pain. 2018;19(1):42.
Deepon Kar, OD
About Deepon Kar, OD

Dr. Kar is from Calgary, Alberta. She started her healthcare career in academic research by successfully completing a Master’s degree in Neuroscience at the Cumming School of Medicine in Calgary in 2012. She then graduated from the Illinois College of Optometry in 2019 with a special interest in dry eye disease management and specialty contact lenses.

Dr. Kar moved to Lethbridge, Alberta to provide optometric care to the rural community. When she’s not looking after her patient’s eye care needs or joining her co-hosts on the Four Eyes Podcast, you can find her exploring the local trails and eateries in Lethbridge, and searching for a rescue dog to add to her family!

Deepon Kar, OD
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