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Year : 2021  |  Volume : 1  |  Issue : 4  |  Page : 774-775

Case report on migraine with photophobia – Is the pupil at fault?

Department of Ophthalmology, Apex Eye Care, Cuttack, Odisha, India

Date of Submission16-Jan-2021
Date of Acceptance31-Mar-2021
Date of Web Publication09-Oct-2021

Correspondence Address:
Dr. Ruby Moharana
Department of Ophthalmology, Apex Eye Care, Kathagola Road, Mangalabag, Cuttack, Odisha
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijo.IJO_131_21

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Pupillary abnormalities can be a potential cause of migraine with photophobia. A 32-year-old female developed Adie's pupil following concussion injury which triggered severe episodes of migraine with extreme photophobia. We used diluted Pilocarpine drops (0.125%) for treatment and the patient had significant improvement in MIDAS (Migraine Disability Assessment) score after treatment. This case highlights the importance of pupillary examination in cases of migraine.

Keywords: Adie's pupil, MIDAS (Migraine Disability Assessment), migraine, photophobia

How to cite this article:
Moharana R, Bhandari KB. Case report on migraine with photophobia – Is the pupil at fault?. Indian J Ophthalmol Case Rep 2021;1:774-5

How to cite this URL:
Moharana R, Bhandari KB. Case report on migraine with photophobia – Is the pupil at fault?. Indian J Ophthalmol Case Rep [serial online] 2021 [cited 2021 Oct 26];1:774-5. Available from: https://www.ijoreports.in/text.asp?2021/1/4/774/327624

Migraine is the third most common disease in the world with an estimated global prevalence of 14.7% (1 in 7 people affected).[1] Migraine attacks have a core component of photophobia (light sensitivity) in 80% of cases.[2] In 1/3rd of the migraine patients, bright light is the triggering factor for the migraine attack.[2] Pupillary size and function as triggers for migraine attacks have not been studied extensively. Chance association of Adie's pupil with migraine is reported and Adie's pupil developing during migraine attack has also been reported.[3],[4],[5] However Adie's pupil as a cause of migraine and reduction of migraine attacks by treatment with 0.125% topical Pilocarpine drops has not been reported.

  Case Report Top

A 32-year-old female presented with a chief complaint of severe episodes of headache since the last 4 years. The headaches were always on the right side of the head and throbbing in nature lasting for 48-72 hours at a time. These headaches were always triggered by bright lights and subsided after vomiting. Her headache episodes started after a concussion injury suffered by the patient 4 years ago due to an accident where she fell down while cycling. The patient had no history of headaches prior to the accident. Her discharge records mentioned normal CNS examination and normal ophthalmological examination except for pupillary asymmetry with a mention of the right pupil being larger than the left but no treatment had been prescribed for the same. She had been extensively evaluated by a few neurologists and had been diagnosed to have migraine with photophobia and was prescribed medications, however the headaches continued despite the medications. Her records mentioned normal MRI, MRV and MRA of the brain.

The patient reported to us with complaints of a severe discomfort due to her headaches for which she had to leave her job. Her MIDAS score at this point was 23 (severe disability). She had no complaints of diplopia or asthenopia and she specifically mentioned bright lights to be the triggering factor for her migraine attacks.

On ocular examination her VA was 6/6 for distance in both eyes unaided. Near vision was N8 in right eye and N6 in the left eye. Fundus evaluation was normal. Anterior segment evaluation was normal except for the pupils. The pupillary evaluation showed anisocoria with the right pupil being larger than the left which did not constrict to light and constricted very slowly to near [Figure 1]. On slit lamp evaluation, segmental vermiform movements in the right pupil were noticed. 0.125% Pilocarpine drops caused prompt constriction of the right pupil confirming Adie's pupil [Figure 2]. The patient was started on 0.125% Pilocarpine drops 2 times a day and she reported 1 month later with significant reduction in photophobia and migraine attacks. Patient continued the drops and at 6 months' follow up, her MIDAS score had significantly improved to 6 (mild disability). Patient reported a significant improvement in her daily outdoor activities and was able to resume her job.
Figure 1: Right Pupil is Larger Than the Left (Anisocoria)

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Figure 2: 0.125% Pilocarpine Caused Prompt Constriction of Right Pupil Confirming Adie's Pupil

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  Discussion Top

Pupillary abnormalities as a cause of migraine with photophobia has not been studied extensively. The use of tinted glasses and blue light filters have been suggested as a treatment modality in patients with migraine, as certain wavelengths of light have been seen to trigger migraine attacks more frequently.[6]

The association of Adie's pupil with migraine has been previously reported in a few case reports, but this condition being a trigger factor for migraine is not known.[4] Most of these studies suggest Adie's pupil to be secondary to the migraine attack due to prolonged vasospasm causing damage in parasympathetic pathway.[3],[5] However in our case, the patient did not have any light sensitivity or migraine attacks prior to development of post traumatic Adie's pupil. Whether Adie's pupil and migraine are a chance association or a causative association needs further research and treatment options should be made available to such patients to assess the response.

More studies in a larger number of subjects needs to be carried out to assess pupillary responses in migraine patients where bright light is the trigger factor. Treatment options in the form of protective or tinted glasses or treatment of the pupillary abnormalities, if any, should be done first prior to prescribing migraine medications as treatment of the root cause can help in alleviating the migraine attacks.

  Conclusion Top

This case highlights the importance of pupillary examination in cases of migraine. This case also illustrates Adie's pupil as a cause of migraine with photophobia and significant reduction of migraine related disability with use of 0.125% Pilocarpine drops as a topical therapy in this condition.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Steiner TJ, Stovner LJ, Birbeck GL. Migraine: The seventh disabler. J Headache Pain 2013;14:1.  Back to cited text no. 1
Drummond PD, Woodhouse A. Painful stimulation of the forehead increases photophobia in migraine sufferers. Cephalalgia 1993;13:321-4.  Back to cited text no. 2
Tafakhori A, Aghamollaii V, Modabbernia A, Pourmahmoodian H. Adie's pupil during migraine attack: Case report and review of literature. Acta Neurol Belg 2011;111:66-8.  Back to cited text no. 3
Drouet A, De Carvalho A, Mage F, Guilloton L, Felten D. [Adie's tonic pupil and migraine: A chance association?] J Fr Ophtalmol 2008;31:e5.  Back to cited text no. 4
Massey EW. Pupillary dysautonomia and migraine: Is Adie's pupil caused by migraine? Headache 1981;21:143-6.  Back to cited text no. 5
Afra J, Ambrosini A, Genicot R, Albert A, Schoenen J. Influence of colors on habituation of visual evoked potentials in patients with migraine with aura and in healthy volunteers. Headache 2000;40:36-40.  Back to cited text no. 6


  [Figure 1], [Figure 2]


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