Alison V. Crum

Chronic migraine is associated with reduced corneal nerve fiber density and symptoms of dry eye

We used in vivo corneal confocal microscopy to investigate structural differences in the sub‐basal corneal nerve plexus in chronic migraine patients and a normal population. We used a validated questionnaire and tests of lacrimal function to determine the prevalence of dry eye in the same group of chronic migraine patients. Activation of the trigeminal system is involved in migraine. Corneal nociceptive sensation is mediated by trigeminal axons that synapse in the gasserian ganglion and the brainstem, and serve nociceptive, protective, and trophic functions. Noninvasive imaging of the corneal sub‐basal nerve plexus is possible with in vivo corneal confocal microscopy.

Increased prevalence of depression and anxiety in patients with migraine and interictal photophobia

BackgroundMost patients with migraine report photophobia associated with headache; a subset report interictal photophobia. These patients are light sensitive even during headache-free periods. The objective of this case–control study was to assess the prevalence of symptoms of anxiety and depression in migraine patients with and without interictal photophobia.MethodsWe recruited 16 subjects with migraine and interictal photophobia, 16 age- and gender-matched migraine subjects without interictal photophobia, and 16 age- and gender- matched controls. Migraine subjects met International Headache Society classification criteria. Participants completed a photophobia questionnaire, Beck Depression Inventory (BDI-II), and Beck Anxiety Inventory (BAI). Chi-square analyses and two-tailed Wilcoxon rank sum tests were used for the analyses.ResultsSubjects with interictal photophobia had significantly higher scores on the photophobia questionnaire compared to subjects without interictal photophobia. Subjects with interictal photophobia had significantly higher scores on the BDI-II and BAI compared to subjects without interictal photophobia.ConclusionsMigraine patients with interictal photophobia are more likely to manifest symptoms of depression and anxiety compared to migraine patients without interictal photophobia. Care providers should be aware of increased prevalence of these symptoms in this population and consider appropriate referrals. Future research could assess whether treatment of photophobia leads to improvements in symptoms of depression and anxiety in migraine patients.

Thin-film optical notch filter spectacle coatings for the treatment of migraine and photophobia

Previous evidence suggests optical treatments hold promise for treating migraine and photophobia. We designed an optical notch filter, centered at 480nm to reduce direct stimulation of intrinsically photosensitive retinal ganglion cells. We used thin-film technology to integrate the filter into spectacle lenses. Our objective was to determine if an optical notch filter, designed to attenuate activity of intrinsically photosensitive retinal ganglion cells, could reduce headache impact in chronic migraine subjects. For this randomized, double-masked study, our primary endpoint was the Headache Impact Test (HIT-6; GlaxoSmithKline, Brentford, Middlesex, UK). We developed two filters: the therapeutic filter blocked visible light at 480nm; a 620nm filter was designed as a sham. Participants were asked to wear lenses with one of the filters for 2weeks; after 2weeks when no lenses were worn, they wore lenses with the other filter for 2weeks. Of 48 subjects, 37 completed the study. Wearing either the 480 or 620nm lenses resulted in clinically and statistically significant HIT-6 reductions. However, there was no significant difference when comparing overall effect of the 480 and 620nm lenses. Although the 620nm filter was designed as a sham intervention, research published following the trial indicated that melanopsin, the photopigment in intrinsically photosensitive retinal ganglion cells, is bi-stable. This molecular property may explain the unexpected efficacy of the 620nm filter. These preliminary findings indicate that lenses outfitted with a thin-film optical notch filter may be useful in treating chronic migraine.

An Estimation of the Risk of Pseudotumor Cerebri among Users of the Levonorgestrel Intrauterine Device

ABSTRACT Because of a previous association of pseudotumor cerebri (PTC) with levonorgestrel, we wished to evaluate the use of levonorgestrel-eluting intrauterine devices (“levonorgestrel intrauterine systems”, LNG-IUS) in our University of Utah and Rigshospitalet PTC patients. In our retrospective series, PTC prevalence was approximately 0.18% and 0.15% in the LNG-IUS population versus 0.02% and 0.04% in the non-LNG-IUS population (Utah and Rigshospitalet, respectively), with no significant differences in PTC signs and symptoms among the two groups. Our investigation suggests that women with an LNG-IUS may have increased risk of developing PTC but does not suggest an LNG-IUS can cause PTC.

Optic disc edema and optic nerve head drusen

pletely. Several follow-up MRIs were performed. The most recent MRI, 1.5 years after the onset of symptoms, revealed an increase in number and extent of the white matter hyperintensities (Fig. 2). Glatiramer acetate therapy was initiated. On occasion, a one-and-a-half syndrome can be accompanied by a facial paresis if the fascicle or nucleus of the seventh cranial nerve in the lower part of the dorsal pontine tegmentum is also affected. Eggenberger (2) designated this as eight-and-a-half (1.5 1 7) syndrome. As mentioned by Connors et al (1), variations of this syndrome caused by pathology of the dorsal pontine tegmentum have since been described including a combination of a one-and-a-half syndrome and a bilateral peripheral facial paresis which Bae and Song (3) designated fifteen-and-a-half (1.5 1 7 1 7) syndrome. Only 3 cases of isolated eight-and-a-half syndrome caused by MS have been described in the literature (4,5). In one of these cases (4), the eight-and-a-half syndrome was, as in our patient, the initial symptom of MS. A 16 syndrome caused by MS has not been reported previously. Hennie Lee, MD Paul L.M. de Kort, MD, PhD Department of Neurology, St. Elisabeth Ziekenhuis, Tilburg, the Netherlands, h.lee@elisabeth.nl

Patients With Migraine Have Substantial Reductions in Measures of Visual Quality of Life

Migraine is associated with several important visual symptoms, during both acute attacks and headache‐free intervals. The purpose of this investigation was to use validated vision‐related quality of life instruments to assess the effect of migraine on visual quality of life.

Shingles as the underlying cause of orbital myositis in an adolescent: A case report

Purpose Orbital myositis is characterized by pain with eye movements, gaze restriction, diplopia, and enlargement of extraocular muscles on imaging. Varicella zoster virus (VZV) is an extremely rare cause of the disease in the elderly and has never been reported in a patient younger than forty-five years old such as the adolescent described herein. We present this case to raise awareness of an entity that will likely become more prevalent due to current vaccine strategies. Observation We present the case of a 13-year-old girl with VZV-associated orbital myositis and meningitis that had a quick and complete recovery following IV acyclovir and oral steroids. Conclusions and importance In conclusion, orbital myositis is an extremely rare complication of facial VZV infections. Our case highlights the importance of prompt detection and treatment in the pediatric population.

Ataxia at the Masquerade Ball.

F ive years previously, a 52-year-old man developed diplopia requiring prism glasses. This was followed by imbalance resulting in frequent backward falls as well as oscillopsia and episodic vertigo. Subsequently, he developed fatigue, dysarthria, weight loss, numbness of his right foot, and easy bruising. He had complaints of cognitive decline but formal neuropsychological testing was normal. He had had 1 previous neurology consult and brain magnetic resonance imaging (MRI) without an explanation for his symptoms. His medical history consisted of hypertension, viral pericarditis, mononucleosis, hepatitis, and treated prostate and squamous cell skin cancers. His only medications were over-the-counter supplements. His father had undiagnosed balance problems. At the time of initial evaluation, he reported progressive worsening of his balance. Visual acuity was normal as was examination of the anterior and posterior segment of each eye. His fixation was interrupted by intermittent squarewave jerks, and his eye movements were abnormal, with saccadic pursuit, slowed adducting saccades, gaze-evoked torsional-downbeat nystagmus, and minor bilateral abduction deficits with an esodeviation in both right and left gazes. He was unable to suppress his vestibular-ocular reflex. His neurologic examination showed normal cranial nerves and normal strength, but he had mild dysarthria, a widebased ataxic gait, unsteady tandem walk, appendicular dysmetria, absent ankle reflexes, and decreased peripheral sensation in his feet. His workup revealed normal nerve conduction studies, but brainstem auditory evoked responses showed delays in waves 3 and 5. Evaluation of his swallowing showed mild dysphagia with intermittent delay of pharyngeal response. MRI demonstrated only white matter disease consistent with microvascular ischemia, which was unchanged from previous studies. The following laboratory studies were normal or negative: complete blood count with differential, erythrocyte sedimentation rate, comprehensive metabolic panel, thyroid stimulating hormone, thyroxine, vitamins B1, B12, D, and E, serum protein electrophoresis/immunoelectrophoresis, mercury, arsenic, and cadmium levels, urine protein electrophoresis, antinuclear antibody (ANA) assay, Bartonella henselae, Bartonella quintana, Lyme disease, rapid plasma reagin, fluorescent treponemal antibody absorption, Mycoplasma pneumoniae, antineutrophil cytoplasmic antibodies (ANCA) titers, Toxoplasma, Anti-Ro(SSA) and Anti-La(SSB), Coxiella burnetii, acid-fast bacilli, Mycobacterium tuberculosis antibody, quantiferon gold, Tropheryma whipplei, hepatitis C virus (HCV), herpes simplex virus (HSV), anti-JC virus (JCV) antibodies, Rocky Mountain spotted fever, varicella-zoster virus (VZV), HIV-1, HIV-2, and Epstein– Barr virus. He had a low absolute CD4 count with a low CD4:CD8 ratio, normal anticardiolipin IgG but high anticardiolipin IgM, high parvovirus B19 IgG but normal IgM, and normal cerebrospinal fluid (CSF) studies except for high HSV IgG. CSF cytology revealed no malignant cells. He had an unremarkable whole-body bone scan as well as negative findings on computed tomography of chest, abdomen, and pelvis. A subsequent sleep study confirmed sleep apnea for which he was placed on continuous positive airway pressure treatment. He was also evaluated at the cerebellar ataxia clinic and diagnosed with familial spinocerebellar ataxia as the most likely etiology of his symptoms. He was offered genetic testing but declined due to cost. He was placed on acetazolamide and then memantine without improvement. Over the next 6 years, his symptoms worsened despite physical and occupational therapy. He became disabled and wheelchair bound. Due to progressive decline, he had repeat MRI of the brain.