Photosensitivity and the Headache and Migraine Patient

Photosensitivity and the Headache and Migraine Patient

Photosensitivity is a term used to describe an abnormal sensitivity to light. For practitioners, photosensitivity is a vexing symptom since the pathophysiology of its cause is not well understood and little is known about appropriate treatment. For the patient who has the symptom, disability may ensue and frustration from lack of understanding of the medical community can be prevalent.

Terminology

The term “photophobia” is somewhat of a misnomer since phobia refers to a fear of light. We use the word to denote patients who have an abnormal sensitivity to light. While all of us have experienced an uncomfortable sensation when we have gone from a darkly lit room or theatre to the bright outdoors, we soon adapt to the sensation and the light is comfortable again. However, in some patients, bright lights—even normal lights—are always experienced as uncomfortable. “Photo-oculodynia” refers to a non-painful light source producing pain in the eye. “Dazzling” is a term used when things appear too bright, but, while everything is bright overall, the light is not bothersome or painful.

Etiology of Photophobia

Many conditions cause photophobia, and the most common condition is migraine. Indeed, photophobia is one of the cardinal features and appears prominently in the International Headache Society’s classification of migraine. Photophobia has been shown to be present during and in between migraine attacks. Furthermore, just having the symptom of photophobia predicts that the individual has underlying migraine (Muelleners et al).

Other causes of photophobia include:

  • Blepharospasm: an abnormal, involuntary blinking or spasm of the eyelids. Light sensitivity associated with blepharospasm occurs as frequently as it does in migraine (Adams et al). It can be present during attacks and in-between attacks and is disabling (Judd et al).
  • Ocular causes of photophobia: a search for an ocular cause is very important. Dry eyes and ocular irritation can stimulate photophobia. Sometimes, even after the dry eyes or a corneal problem has resolved, a corneal neuropathy may persist. Inflammatory conditions of the eye such as iritis (inflammation of the iris of the eye) are associated with photophobia. Photophobia is a cardinal feature of retinitis pigmentosa (an eye disease that damages the retina) and cone dystrophies, inherited degenerative conditions of the retina, and congenital glaucoma.
  • Central nervous system disorders: photophobia may be a presenting symptom of meningitis, subarachnoid hemorrhage and pituitary tumor. Other accompanying findings such as reduced visual acuity, stiff neck, and fever will alert the observant clinician of these conditions. (Amini et al)
  • Functional disorders: while photophobia is often thought to be associated with individuals who have an underlying psychiatric disorder, a careful search into the underlying cause can be rewarding. Migraine and depression are treatable conditions.

For a complete list of causes of photophobia see Digre, Brennan.

Pathophysiology

The cause of photophobia is not known. However, there are several clues about its cause. The trigeminal system has multiple connections throughout the brainstem and thalamus. The trigeminal system is of course intimately involved in the pathophysiology of migraine. In addition, projections to and around the thalamus and midbrain have been proposed anatomical sites. (Amini) Noseda et al also found that melanopsin (non-vision but light sensing) cells in the retina project to areas where light and pain meet—giving an explanation for why some individuals who are blind to formed vision still have severe light sensitivity. These connections in the brainstem, thalamus project to higher centers in the brain.

Treatment

In order to treat photosensitivity, the correct diagnosis must be made since there are many causes of photophobia. The treatment of photophobia with or without a headache is difficult, as nothing magically cures the disorder. If the photosensitivity occurs only with migraine, prompt treatment of the migraine usually aborts the symptom. The more difficult issue is when patients are chronically photosensitive. Patients frequently wear multiple pairs of dark glasses in hopes of dimming the light enough so that it is not uncomfortable. However, this is actually makes photophobia worse since chronic dark adaptation occurs and then any light is perceived to be brighter.

The use of tinted lenses has been shown to reduce light sensitivity. In particular blocking blue light seems to be the most soothing to those with light sensitivity. One tint, FL-41 (a rose color) has been studied and was shown to reduce headaches and migraines in children (Good et al). More information about the tint can be found: http://uuhsc.utah.edu/MoranEyeCenter/patientcare/FL-41_faq.html. Light yellow tint may also be helpful. Other treatments are geared to reducing the underlying condition, such as treating the depression, migraine prevention, dry-eye therapy, and botulinum toxin injections for blepharospasm.

References

Adams WH, Digre KB, Patel BC, Anderson RL, Warner JE, Katz BJ. “The evaluation of light sensitivity in benign essential blepharospasm.” Am J Ophthalmol. 2006 Jul;142(1):82-87.

Amini A, Digre K, Couldwell WT. “Photophobia in a blind patient: An alternate visual pathway.” Case report. J Neurosurg. 2006 Nov;105(5):765-8

Digre KB, Brennan KC. “Shedding light on photophobia.” Journal Neuro-ophthalmology 2012; 32:68-81.

Good PA, Taylor RH, Mortimer MJ. “The use of tinted glasses in childhood migraine.” Headache. 1991 Sep;31(8):533-6.

Judd RA, Digre KB, Warner JEA, Schulman SF, Katz BJ “Blepharospasm: Light Sensitivity and Effects on Activities of Daily Living.” Neuro-Ophthalmology 2007 31(3):49-54.

Mulleners WM, Aurora SK, Chronicle EP, Stewart R, Gopal S, Koehler PJ. “Self-reported photophobic symptoms in migraineurs and controls are reliable and predict diagnostic category accurately.” Headache. 2001 Jan;41(1):31-9.

Noseda R, Kainz V, Jakubowski M, Gooley JJ, Saper CB Digre KB, Burstein R. A neural mechanism for exacerbation of headache by light. Nature Neuroscience 2010 Feb;13(2):239-45

© Kathleen Digre, MD, 2015. All rights reserved.
Professor Neurology, Ophthalmology, University of Utah
July 26, 2015