Therapy of persistent aura

MH [subject #265], Diurnal visual snow, 2007. © 2007 MH [more]

MH [subject #265], Nocturnal visual snow, 2007. © 2007 MH [more]

Reliably effective treatment of persistent aura without infarction is not known (for a review see here). However, there are a number of medications that have been reported to be beneficial in some patients seeking help for this migraine complication. Unfortunately, the quality of evidence on which the recommendations below are based only represents type IV of evidence according to Clancy (1997), i.e. evidence obtained from opinions and/or clinical experiences of respected authors. Up to to now, there has been a sad lack of well-designed controlled therapy studies, not to speak of randomized controlled trials, both of which are a great desideratum of future research.

According to the available evidence from published case reports, a treatment with acetazolamide (Haan et al., 2000) should be attempted in cases presenting with the rare repetitive variety of persistent aura without infarction. For the more frequent persistent variety, the two drugs reported to have helped some patients are valprocic acid (Rothrock, 1997; Celiker et al., 2007) and lamotrigine (Chen et al., 2001). When these oral drugs are ineffective, an intravenous injection or injections of furosemide (Rozen, 2000) should be tried (these are official drug names, not trade names).

Blythe et al. (1986) reported the case of a 24-year-old woman suffering from a relapsing and remitting neurological disorder for 3 years, her neurological symptoms including a variety of persisting visual disturbances with visual hallucinations of random form dimension ("white spots 'like fireflies'"), increased visual discomfort, increased afterimages and trails ("a streak along the path described by the moving object"). Whereas a definitive clinical diagnosis was not reached by the authors, it can be noted that her history fulfills the diagnostic criteria of possible persistent aura without infarction (MAS score = 2). After 6 weeks of treatment with carbamazepine, the duration of the increased afterimages fell by about 30%, but no further reduction occurred over the following 3 months.

Patient 7 from Liu et al. (1995) had 2 episodes of possible persistent aura without infarction (MAS score = 3), manifesting with "constant white and black dots, 'snow', and 'TV static' over her entire visual field" and "persistence of visual images (palinopsia)", respectively. According to the authors, "Nortriptyline and carmabazepine resolved only the palinopsia, and the other visual phenomena have persisted over 2 years" (Liu et al., 1995, p. 666).

According to Walsh and Hoyt's Clinical Neuro-ophthalmology (Miller et al., 2005), "Treatment of persistent migraine aura is notoriously unsatisfactory, but medications that have been used include amitriptyline and gabapentin" (p. 1290).

According to David Haas, topiramate may be effective in the treatment of the persistent variety of persistent aura without infarction, too (anecdotal observations). Unfortunately, topiramate use may also cause palinopsia as rare side-effect (see here).

According to Weinberger (2006), patients "with migraine with aura with persistent focal neurologic deficits can be treated pharmacologically with intravenous Verapamil or magnesium sulfate to relieve the symptoms in familial hemiplegic migraine and sporadic hemiplegic migraine". Anecdotal evidence suggests that verapamil may also be effective in the treatment of persistent aura without infarction. After three months' standing of the visual disturbances of Sheri's (subject's #86) 1st episode of persistent aura, a treatment with verapamil "reduced the visuals" within a week "and almost eliminated the headaches".

(Sheri [subject #86], Ezboard Forum Visual snow or static - Discussion - Persistent migraine aura, February 18, 2006)

In a study of 16 patients with chronic (> 6 months) migrainous vertigo, Waterston (2004) recorded a good or very good response of the vestibular symptoms (and headaches) to anti-migraine treatment with Dosulepin (formerly the BAN Dothiepin) (25 mg daily), Pizotifen (0,5-2,0 mg daily), Propanolol (80 mg daily) or Verapamil (80-180 mg daily), the outcome ranging from marked improvement to complete resolution. It has yet to be established whether this marked success of migraine prophylaxis treatment (Fontebasso, 2005) with the aforementioned drugs can also be seen in sufferers of persistent aura without infarction presenting with symptoms other than vertigo or dizziness.

In patient 8 from Liu et al. (1995), sertraline, an antidepressant of the selective serotonin reuptake inhibitor (SSRI) class, reduced the visual phenomena ("snow" and "flickering") brought on by possible persistent aura (MAS score = 2) by 50%.

If you had experiences with any of the aforementioned drugs for the treatment of persistent aura without infarction, please contact Dr Klaus Podoll to share your experience and to contribute to a databasis collecting the therapeutic outcomes of various treatments.

Beyond pharmacological approaches, prolonged visual rest, stress recuction, relaxation techniques, distraction techniques, appropriate counselling and cognitive behavioral interventions that focus on coping with the condition (Sharoff, 2004a,b) may be of huge importance; representing a field of "neuropsychological" psychotherapy that is virtually unexplored.

There is anecdotal evidence that long periods of visual rest may be helpful to some migraineurs suffering from persistent aura without infarction.

For computer users at work or at home, a recommendable eye exercise providing visual rest is described on a webpage of the Department of Education and Training of the Government of Western Australia: "Look up and away from the screen and focus on a distant object (more than 3 metres from you) such as a picture or out the window."

Stress reduction (e.g. mindfulness-based stress reduction), relaxation techniques (e.g. Jacobson's Progressive Muscle Relaxation) and sleep hygiene are basic behavioural and cognitive-behavioural interventions from which most persistent aura sufferers will benefit. To cope with acute high levels of stress, occasional use of diazepam as anxiolytic (beware: addictive potential of benzodiazepines even with low doses) and of antihistamines as hypnotic drugs to facilitate falling asleep have been reported as helpful.

Distraction techniques can be a useful way to help coping with the visual snow (as well as with other symptoms of persistent aura).

Persistent aura sufferers with chronic tinnitus can benefit from a masking approach, the technique of producing external "white noise" sounds that will mask the tinnitus and make it less distracting (Schechter and Henry, 2002).

George Frederick Watts, Hope, 1885.

Francisco de Goya, The sleep of reason produces monsters (El Sueño de la Razon Produce Monstruos), Plate 43 of Los Caprichos, second edition, etching and aquatint (18.1 cm x 12.2 cm), circa 1803.

With an established diagnosis of persistent aura without infarction, to the best of our knowledge, the many additional therapies advocated by some sufferers from "visual snow" (often based on concepts from alternative medicine that are not shared by evidence-based medicine) will in most cases not add anything of benefit to promote the sufferer's psychological welfare, or to lessen or "heal" his persisting visual problems (it's a fair guess that if such proposed therapies could fulfil the great promises they tend to make to attract sufferers' interest and money, it would not take long for such success stories to find their way into the public domain and especially into peer-reviewed medical journals, which is, tellingly, not the case). So many people are turning to alternative therapies, and, although there is nothing wrong with that, these therapies should be used in a complementary sense, not as treatment in themselves because no medical diagnosis/treatment is offered.

References

Blythe IM, Bromley JM, Ruddock KH, Kennard C, Traub M. A study of systematic visual perseveration involving central mechanisms. Brain 1986; 109: 661-675.
Celiker A, Bir LS, Ardiç N. Effects of valproate on vestibular symptoms and electronystagmographic findings in migraine patients. Clin Neuropharmacol 2007; 30: 213-217.
Chen WT, Fuh JL, Lu SR, Wang SJ. Persistent migrainous visual phenomena might be responsive to lamotrigine. Headache 2001; 41: 823-825.
Clancy CM. Ensuring health care quality: an AHCPR perspective. Agency for health care policy and research. Clin Ther 1997; 19: 1564-1571.
Evans RW. Reversible palinopsia and the Alice in Wonderland syndrome associated with topiramate use in migraineurs. Headache 2006; 46: 815-818.
Fontebasso M. Migraine management: current preventive and treatment options. Prescriber 2005; 16: 43-53 (October 5). [PDF]
Grossman P, Niemann L, Schmidt S, Walach H. Mindfulness-based stress reduction and health benefits. A meta-analysis. J Psychosom Res 2004; 57: 35-43. [PDF]
Haan J, Sluis P, Sluis LH, Ferrari MD. Acetazolamide treatment for migraine aura status. Neurology 2000; 55: 1588-1589.
Miller NR, Walsh FB, Hoyt WF, Newman NJ. Walsh and Hoyt's Clinical Neuro-ophthalmology. Lippincott Williams & Wilkins, New York 2005.
Rothrock JF. Successful treatment of persistent migraine aura with divalproex sodium. Neurology 1997; 48: 261-262.
Rozen TD. Treatment of a prolonged migrainous aura with intravenous furosemide. Neurology 2000; 55: 732-733.
Schechter MA, Henry JA. Assessment and treatment of tinnitus patients using a "masking approach". J Am Acad Audiol 2002; 13: 545-558.
Sharoff K. Coping Skills Manual for Treating Chronic and Terminal Illness. Springer Publishing Company, New York 2004b.
Sharoff K. Coping Skills Therapy for Managing Chronic and Terminal Illness. Springer Publishing Company, New York 2004b.
Waterston J. Chronic migrainous vertigo. J Clin Neurosci 2004; 11: 384-388. [PDF]
Weinberger J. Interactions between migraine and stroke. Curr Treat Options Neurol 2006; 8: 513-517.

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