Young Woman With Blurred Vision and Headaches

The case: A 28-year-old woman reports blurred vision and intermittent bouts of headache that last for at least a day, sometimes longer. These headaches started about 6 months earlier. They occur about once a month, often during the week before her period. Headache is frequently accompanied by nausea and preceded by visual changes that affect both eyes. These changes appear as bright geometrical shapes and zigzags. During her headaches, the blurred vision worsens. She often has blurred vision between bouts of headache and also describes a burning, gritty sensation in her eyes.

History: She works as a computer programmer and spends long hours in front of a screen. She denies fever, chills, rash, and history of recent trauma. The patient’s past medical history is unremarkable, except for myopia since age 10. She wears contact lenses. She is not currently taking any medications. Her mother suffers from migraine.

Physical examination: Temperature is 98.6°F (36.9°C); pulse, 86 beats/min; respirations, 20 breaths/min; blood pressure, 125/85 mm Hg. The patient is no acute distress. Results of abdominal, cardiac, and respiratory examinations are normal.

Neurological examination: Her speech pattern is normal. Her extraocular movements are full and symmetrical. Pupils are equal, round, and reactive to light, without papilledema. There is no visual field cut. Motor, sensory, and reflex exams are unremarkable. Coordination and gait are normal.

Further workup: The patient is sent for an ophthalmology consultation. Eye examination is notable for mild bilateral ocular hyperemia and increased blink rate at about 35 blinks per minute. She has decreased visual acuity on the Jaeger eye card. Slit lamp examination shows early tear film break-up time but is otherwise negative. Schirmer test and fluorescein staining suggest decreased tear formation, and Lissamine green reveals nasal and temporal interpalpebral staining. Exam is negative for signs of glaucoma, retinal detachment, or vascular abnormalities.

Laboratory and imaging studies: Complete metabolic panel and blood glucose level are within normal limits. Blood tests are negative for rheumatoid factor and antinuclear antibody. C-reactive protein level is not elevated. Thyroid-stimulating hormone level is within normal limits. Head CT scans with and without contrast are normal.

DIAGNOSIS: Migraine with aura/dry eye disease: The patient’s headaches appear consistent with a diagnosis of migraine with aura, given her symptoms of nausea, regular frequency of attacks, time of onset (typically the week before her period), family history of the condition, visual changes, and neurological examination within normal limits. The patient likely has comorbid dry eye disease. Women, contact lens wearers, and people who spend long hours at the computer are at increased risk for dry eye disease. Ophthalmological examination is notable for signs of dry eye disease: mild bilateral ocular hyperemia, increased blink rate, decreased near vision acuity, decreased tear formation, and early tear film breakup. Lissamine green staining confirms the presence of dry eye disease.

DIAGNOSIS: Migraine with aura/dry eye disease (cont'd): Except for migraine, the workup is negative for underlying causes of dry eye disease, such as rheumatoid arthritis, Sjogren syndrome, systemic lupus erythematosus, diabetes, and thyroid conditions. The patient has no history of eye surgery that could contribute to her condition. She is not taking any medications that could contribute to dry eye, such as tricyclic antidepressants, antihistamines, or diuretics.