As the exam concludes, you pause to inquire if your patient has any remaining questions. Suddenly, they recall their history of migraine with visual aura. Your patient shares that although they have been prescribed medication, they are highly sensitive to light, which triggers their migraine episodes. They wonder if there might be additional help for their light sensitivity. You confidently inform them about a clinically-proven treatment for photophobia linked to migraine called Avulux.
A Brief Overview of Migraine
A migraine is “an episodic headache associated with certain features, such as sensitivity to light, sound, or movement” or “a recurring syndrome of headache associated with other symptoms of neurologic dysfunction in varying mixtures.”1
The most important thing we must do is distinguish between a headache and migraine. A primary headache has no underlying cause, with migraine and tension-type headaches being two of the most common primary headache disorders. Other types of migraine also exist, including hemiplegic migraine.2
Migraine triggers include:
- Precipitating: weather changes, smells, smoke, light
- Aggravating: physical activity, noise, and motion that involves straining and bending over
- Other triggers: stress, fatigue, lack of sleep, irregular eating habits, menstruation, and consumption of dairy products and alcohol.2
The pathophysiology and etiology of migraine are complicated.2,3 Migraine is a complex disorder with a synergistic relationship between the peripheral nervous system and the central nervous system. There are two schools of thought3:
- External triggers generate migraine or
- Migraine is largely generated from changes within the brain itself.
There are three types of migraine that we will focus on in this overview: acute migraine, migraine with aura, and chronic migraine.4
Acute Migraine
An acute migraine typically occurs unilaterally, accompanied by a pulsating sensation.2 It typically involves 1 to 2 migraine or headaches per month and is characterized by a reduced frequency of headaches or migraine compared to chronic migraine.3 A migraine can last between 4 and 72 hours and is typically associated with nausea, photophobia (sensitivity to light), and phonophobia (sensitivity to sound). It is classified as moderate to severe intensity and may be exacerbated by physical activity. Patients may describe feeling pressure, stabbing, or aching.2
Several risk factors increase the likelihood of migraine, including biological and psychological factors.1 Biological factors include being born female, advanced age, hormonal imbalances, sleep disorders, metabolic, and genetic disorders.1 Psychological factors include anxiety, depression, obsessive-compulsive disorder (OCD), and attention-deficit/hyperactivity disorder (ADHD).1
Chronic Migraine
A chronic migraine patient is defined as someone who experiences headaches, which may not always be migraine, on 15 or more days each month for over three months. Additionally, they must have features of migraine headaches on at least eight of those days.2 Chronic migraine often develops from episodic migraine due to an increase in the frequency of attacks and/or various risk factors.3
These risk factors include a high frequency of baseline episodic migraine attacks, overuse of acute medication, obesity, experiencing stressful life events, being female, and having a lower socioeconomic status.2 Other contributing factors may include ineffective treatment of acute migraine and medication overuse.1
Migraine with Aura
Migraine can occur with or without aura. Aura are reversible neurological symptoms that have a short duration and may manifest before a migraine headache or occur concurrently with the headache.2 The pathophysiological mechanism of aura is not fully elucidated.5
One theory posits that cortical spreading depression (CSD) primarily causes aura. CSD is an abnormal occurrence characterized by a gradually spreading wave of depolarization that affects cortical neuronal and glial cells, resulting in reduced electrical activity. This event involves a notable influx of sodium, calcium, and water, coupled with the outflow of potassium, protons, glutamate, ATP, and several neurotransmitters. These alterations may link aura to headache by activating perivascular trigeminal nerve endings.5
Aura may manifest as different symptoms2:
- Visual: a complete or partial blind spot at a fixed point with a zigzag pattern, characterized by a distorted and bright convex edge;
- Sensory disturbances: numbness and a migratory pins-and-needles sensation on the body, face, and/or tongue;
- Speech disturbance: aphasia, which is characterized by difficulty in expressing oneself;
- Motor weakness;
- Brainstem symptoms: tinnitus, vertigo, diplopia, dysarthria or difficulty speaking, and decreased consciousness.
Prevalence
Migraine is estimated to affect 14.7% of the world's population, making it the third most prevalent and sixth most debilitating medical disorder globally.6 Women are more likely to experience migraine than men, with rates of 17,902.5 cases per 100,000 women compared to 10,337.6 cases per 100,000 men.1
Migraine prevalence in children and adolescents mirrors that of adults.7 In a recent meta-analysis, the overall prevalence of primary headaches was 11% for migraine, 8% for migraine without aura, and 3% for migraine with aura globally.8 Among individuals under the age of 50, migraine is the leading cause of years lived with disability.6
Impact on Quality of Life
Individuals who suffer from migraine often face significant impairment in their quality of life and experience related disabilities.1 Globally, the age-standardized prevalence of migraine increased by 1.7% from 1990 to 2019.1 In 2019, there were 1.1 billion prevalent cases of migraine, resulting in 525.5 years lived with disability (YLDs) per 100,000 population.1
This impact is most pronounced among those aged 30 to 39 years.9 Factors, such as the intensity and duration of pain, as well as the frequency of migraine, have a negative impact on health-related quality of life.9 Furthermore, migraine can lead to emotional and mental distress, which may include coexisting anxiety and depression.9
Migraine in children and adolescents are linked to significant disability, including mental health issues, impaired learning, poor academic performance, and disrupted sleep patterns.10-12 It can also lead to children withdrawing from social activities and missing school.13
Migraine significantly affect migraineurs’ family relationships, work, and financial stability.1 A survey found that about half of the respondents believe they would be better parents and partners without migraine.14
On average, individuals lose 1.8 hours per week due to headaches, with 76.5% of this time attributed to reduced performance.15 Nearly 29% of those experiencing more than 11 headaches monthly account for 49% of lost productive time, and one-third believe migraine harm their careers and financial security.14
In the U.S., the economic burden on migraine sufferers averages $11,010, compared to $4,436 for those without migraine.1
Clinical Signs and Symptoms
A migraine is a cyclical disorder characterized by several distinct phases: the premonitory phase, transient neurological symptoms (referred to as migraine aura), an intense headache attack, and the postdrome phase (Figure 1).1,16
Figure 1. Migraine Phases16
The prodromal phase, also referred to as the premonitory phase, may commence hours or even days prior to a migraine attack.2 This phase typically presents symptoms such as fatigue, photophobia, phonophobia, and nausea. Additionally, it may include yawning, which differs from an aura as it does not involve neurological symptoms.2 Mood changes, neck stiffness, and discomfort in the neck may also occur.3 Approximately one-third of migraineurs experience aura, which can happen during this phase or the headache phase.2
Following the prodromal phase are the aura and the headache phases. After the headache resolves, individuals enter the postdromal phase, which can last anywhere from 48 hours to 72 hours.2,3 Symptoms during this phase may include fatigue, difficulty concentrating, and neck stiffness.2
There is also an additional phase called the interictal phase16, which refers to the period when migraine attacks are usually pain- and symptom-free.2 Some patients may still experience migraine symptoms even when they are headache-free during this period.16 The duration and frequency of this phase can vary widely.2
Diagnosis
Migraine diagnosis encompasses several key components, including a thorough medical and family history, diagnostic aids such as a headache diary and calendar, and screening tools like the ID-Migraine questionnaire and the Migraine Screen Questionnaire (MS-Q), which aid in diagnosis.4
Differential diagnosis for migraine includes other primary and secondary headaches4:
- Primary: tension vs. migraine vs. cluster
- Secondary headache consideration: medication overuse headache.
The diagnosing doctor must be able to distinguish between headaches for proper management, as some secondary headaches, like subarachnoid hemorrhage, are life-threatening.4 Neuroimaging should only be ordered if a secondary headache is suspected and an MRI is preferred over CT because it provides higher resolution images and does not expose patients to ionizing radiation.4 However, an MRI can sometimes result in unnecessary follow-up tests by identifying clinically insignificant abnormalities, such as white matter lesions, arachnoid cysts, and meningiomas, which may cause unnecessary concern for the patient.4
Treatment & Management
Patient education is essential, and it is important to explain information clearly and reassure the patient.4 Modifying risk factors through proper evaluation is crucial for effective headache management.3 It is important to discuss potential triggers, but these can only be managed if they are correctly identified.4
Pharmaceutical Treatment
The treatment algorithm encompasses both acute and preventive management of migraine as illustrated in Figure 2.16
Figure 2. Treatment Algorithm16
Abortive therapy stops acute migraine.2 These include ergotamine, triptan medications (serotonin agonist), ditans, gepants, and over-the-counter medications like acetaminophen and NSAIDs.2 Triptans can cause medication overuse headaches and have a discontinuation rate of between 50-82%.2
Preventive therapy is taken daily to reduce the occurrence of migraine which include antihypertensives like propranolol, antidepressants like amitriptyline, topiramate, and CGRP human monoclonal antibodies.2 Additionally, Onabotulinum toxin A can be used to manage migraine.2
Opioid and barbiturate-containing medications are not recommended because of their strong association with the development of medication overuse headaches and medication dependency.3
Non-Pharmaceutical Treatment
There are several non-pharmacological options for treating headaches, including behavioral therapy, acupuncture, and non-invasive neuromodulation.17-19
An emerging treatment option for managing migraine is behavioral therapy, which includes techniques such as cognitive behavioral therapy (CBT), relaxation techniques, and biofeedback.17 Research has shown that these therapies can reduce the frequency of migraine attacks and related disorders.17 CBT helps patients develop strategies for both preventive care and acute management of migraine.17 This involves identifying triggers, modifying negative thoughts and behaviors associated with headaches, and employing techniques for physiological self-regulation.17
Acupuncture can also help reduce migraine frequency, and it is recommended to limit acupuncture treatment to 16 sessions over 2 months, at three sessions per week.18 The duration between courses of sessions remains unknown; however, it has been shown that the number of migraine attacks improves for at least 3 months.18
Peripheral neurostimulation with non-invasive neuromodulatory devices effectively and safely modulates the central nervous system for headache treatment.19 This approach can be particularly beneficial when patients do not respond to pharmacological therapies, experience intolerances, or have contraindications due to medical comorbidities, polypharmacy, pregnancy, or the peripartum period.19 These devices can generate external trigeminal nerve stimulation, transcutaneous electrical nerve stimulation, single-pulse transcranial magnetic stimulation, and noninvasive vagus nerve stimulation.19
Response to treatment should be evaluated within 2–3 months after initiation or a change in treatment, and regularly thereafter. If there is no improvement, the patient should be referred to a specialist for further evaluation and treatment.4
Avulux
As we have discussed, migraine is associated with light sensitivity. 30–60% of migraine attacks are triggered by light or glare, sunlight, flickering from motion pictures, television, and fluorescent lights, and up to 80% of migraineurs experience photophobia during an attack.20
In a 2018 Migraine in America Symptoms and Treatment Study (MAST), which surveyed over 6,000 migraine patients, more than 49% identified light sensitivity as their most bothersome symptom.21 Photophobia can occur continuously, even between migraine attacks, and this interictal photophobia is experienced by up to 30-60% migraineurs.22 Nausea was the next most bothersome symptom, affecting 29% of individuals.21
Exacerbation of migraine-related headaches by light is likely to involve both extrinsic photoactivation of photosensitive retinal ganglion cells (ipRGCs) by rods and cones, as well as intrinsic photoactivation of melanopsin when ipRGCs are activated by wavelengths between 400-500 nm.23 This is observed even in blind patients who had retinal function, who experience photophobia, supporting Noseda’s research.20
Photophobia can be treated in a few ways, including using tints and filters. Red-tinted contact lenses have been used, but they exacerbate migraine-associated photophobia. In contrast, the FL-41 tint (a rose-colored tint) decreased photophobia in children by half.20
However, darkly tinted glasses are not recommended to be worn at all times, as they increase dark adaptation. This chronic darkness exacerbates the perception and pain associated with light sensitivity.20
In one study, fewer participants reported light sensitivity and a reduction in pain scores after wearing IPRGC lenses for two and four hours.24 These lenses blocked over 80% of certain wavelengths while transmitting more than 50% of the green spectrum (500 nm to 570 nm).24
The study compared the Avulux lens with a clear sham lens that did not block migraine-triggering wavelengths.24 Seventy-nine subjects completed the three-week study, which measured migraine pain using an 11-point scale.24 A drop of about 1.8 points was considered clinically significant.24 Results showed that when the Avulux lens was applied within the first hour of a migraine attack, it was both statistically and clinically superior to the sham lens, provided no abortive medications were taken.24
38% of Avulux wearers have migraine that last 12-24 hours, and 27% experience severe, debilitating headaches. Avulux filters up to 97% of harmful blue, amber, and red light while allowing 70% of green light (Figure 3).25
Figure 3. Comparison of Avulux with other filters
According to a survey of Avulux wearers25:
- 96% of Avulux wearers experience decreased sensitivity to light during and between migraine attacks.
- 94% of Avulux wearers say that Avulux brings a soothing sensation to their eyes during a migraine attack.
- 93% of Avulux wearers could engage more fully in daily activities, such as work, hobbies, and time with family and friends.
- 96% of Avulux wearers would recommend Avulux lenses to a friend or colleague
For Dr. Baron, the ideal candidates for Avulux possess the following characteristics:
- Photophobia as a prominent symptom: Patients experiencing light sensitivity during or between migraine attacks (up to 80% of migraine sufferers) are key candidates, including those who find bright lights, screens, or fluorescent lighting intolerable.
- Frequent or severe migraine triggered by light: Individuals who experience migraine that are triggered or worsened by light exposure benefit the most. A migraine diary that confirms light as a trigger supports candidacy.
- Prodromal light sensitivity: Patients experiencing light sensitivity during the prodromal phase (e.g., before headache onset) may use Avulux to prevent escalation.
- Inadequate response to standard glasses: Those who have tried FL-41 lenses or other migraine-type glasses without sufficient relief may benefit from Avulux’s advanced filtering technology.
- Chronic or episodic migraine: Patients with frequent or chronic migraine may wear Avulux continuously, while those with episodic migraine can use it as needed during attacks or prodromal phases.
- Anyone with migraine: Photophobia and light sensitivity are common symptoms for most patients with migraine. Thus, this essentially makes anyone with migraine a candidate for Avulux migraine and light sensitivity lenses.
Implementing Treatment In Optometry Clinical Practice
Many individuals do not receive a comprehensive approach to migraine therapy. To effectively manage migraine, it’s essential to identify and diagnose them confidently, which begins with proper screening. Staff should be trained to assist in this screening process during case history discussions.
Dr. Helmus notes that most optometrists routinely ask patients about their history of migraine. While many optometrists feel confident in identifying patients who may experience migraine, they often do not use a validated screening tool. Instead, their approach typically centers on discussing the patients' symptoms.
Patients may downplay symptoms as there is stigma associated with migraine as a “woman’s disease”. However, using a screening tool like the Patient Impact Assessment, which can be completed in a few minutes, reduces the risk of misdiagnosis, as the doctor gains a better understanding of the symptoms.
Engaging in a discussion about migraine takes time, but it demonstrates that you are thorough, caring, and committed to improving your patients' lives. This approach fosters greater loyalty, ultimately enhancing your practice's bottom line. When a patient is in your chair, you are their headache advocate. Encourage patients to continue consulting their primary care physician for long-term migraine management and to request a referral to a neurologist or headache specialist as needed.
Patient education about Avulux is essential. When discussing treatment with Avulux, it is important to emphasize that prevention plays a key role in managing migraine. Patients should put on the glasses as soon as they notice any warning signs of an impending migraine attack. It is especially important to wear the glasses during activities that may cause light sensitivity and are known to trigger migraine. For example, these situations include extended screen time or working under bright, fluorescent lighting.
Having brochures available to patients and allowing patients to try the lenses in the clinic may convince them that it is a worthwhile investment.
Finances can often pose a barrier to purchasing these lenses, but offering payment plan options can help alleviate that burden. It's important to highlight that managed vision care plans can be utilized to cover the cost of frames and clear lenses. The only out-of-pocket expense for the patient will be the Avulux clip-on. Additionally, Dr. Helmus has provided promotions where patients receive a free frame with the purchase of Avulux lenses.
Staff involvement is essential. An Avulux representative can assist in training all staff members and offer retraining when needed. Sharing patient success stories during staff meetings is important, as these stories can be both inspiring and rewarding for the team. Dr. Helmus also prescribes Avulux to staff members who experience migraine disorders, allowing them to witness the benefits firsthand.
Case 1
Case 2
Conclusion
Migraine is a complex disorder that necessitates accurate diagnosis and management, affecting both children and adults. Treatment options include preventive and abortive measures, which may consist of medication, acupuncture, and behavioral modifications. Additionally, light sensitivity associated with migraines can be alleviated by using Avulux lenses.
