1. Mid Sussex/Brighton VTS
Migraine prevention
using colour filters
Dr Yolande Knight
GP ST2
Mid Sussex/Brighton VTS

2. Basic migraine pathophysiology Cortical hyperexcitability
Introduction
Introduction
Concepts
Basic migraine pathophysiology
Cortical hyperexcitability
Visual stress
Precision spectral filters and ophthalmic tints
Evidence
'Seeing the light'
Clinical application

3. Migraine pathophysiology- cortical excitability
Visual aura, photophobia
Visual triggers
(Merck)

4. Migraine pathophysiology- cortical hyperexcitability
(Merck)

5. Migraine art- the perceptual experience of migraine

6. Visual stress- aversive art
Bridget Riley exhibition. Daily Telegraph (1971): guards complained of headaches and requested dark glasses

7. Visual stress- uncomfortable art
Most uncomfortable images
Least uncomfortable images
AJ Wilkins, 2006

8. Visual stress- aversive imagery from a migraineur's view

9. Visual stress- aversive imagery from a migraineur's view

10. Visual stress- visual environments
Pretty J, Peacock J, Sellens M and Griffin M Int'l Journal of Environmental Health Research 15(5),

11. Text as a visual stressor
Pages of print can resemble visually stressful patterns

12. Visual stress- spatial frequency and threshold of discomfort
Some people find striped patterns uncomfortable to look at
The discomfort depends on the spatial frequency of the stripes
(AJ Wilkins, 2006)
Spatial frequency: 3 cycles per degree
Degree of discomfort depends on individual susceptibility
Migraineurs experience discomfort from patterns causing only mild aversion in non-migraineurs, typically 3 cycles/degree

13. Visual stress- symptoms and signs
Also known as Irlens syndrome
Co-morbid with migraine? Or a sub-symptom of migraine?
Associated with dyslexia
Visual distortions
Illusions of motion, shape, colour
Reading difficulties
Physiological symptoms
Eye strain
Nausea
Headache
Seizures
Signs
Using finger as a marker for reading
Skipping words
Excessive blinking

14. Visual stress- mechanism and manipulation
Hyperexcitability in the visual cortex
Hypothetical manipulation
Pattern of excitation in ophthalmic cortex neurons changes in response to colour stimulus, either by direct stimulus of that colour or absorption of opposing colour
Which colour reduces hyperexcitability is 'specific to the individual'

15. Assessing visual stress- colorimetry
Intuitive Colorimeter projects coloured light onto a page of text found to be stressful or aversive to the migraineur
Manipulate hue and saturation to identify the most comfortable colour (of 100,000 possible colours)
Replace text with a stressful stripe pattern of 3cpd to test the effectiveness of this particular colour in reducing visual stress

16. Coloured plastic sheet to overlay on text
POTs in practice
Cerium manufactures Precision Tinted Lenses (PTL)
Spectacles
Contact Lenses
Coloured Overlays
Coloured plastic sheet to overlay on text

17. The effect of POTs on reading

18. Evidence - Precision Ophthalmic Tints (POT) in migraine
Wilkins et al. Cephalalgia 2011.
N=11 migraineurs
9/11 h/o visual triggers for migraine
7/11 MwA
11/11 experienced illusions/distortions during study
fMRI
Reduced cortical activation in V2 in migraineurs wearing POT under visual stress
visual discomfort score (/10)
8.0±2.1 without lens
2.4±1.7 with POT lens

19. Evidence - Coloured lenses in migraine
Huang et al. Cephalalgia 2002.
N=17 migraineurs
12/17 MwA
In 45% of MwA patients, headache frequency reduced by 50% or more on days when POTs were worn versus days wearing control colour lens
Afra et al. Headache 2000.
Visual evoked potentials
N=12 MwA vs controls
Glasses in red, green, yellow, blue, grey
No effect in MwA

20. Evidence - rose tinted spectacles...
Good et al. Headache 1991.
20 children with clinically diagnosed migraine
Rose vs blue tint for 4 months
After 4 months, those with rose tint had mean h/a frequency improve from 6.2 episodes to 1.6 per month
Mechanism of light-sensitivity in migraine?
Noseda R et al. Nat Neurosci. 2010
Posterior thalamo-cortical neurons that are both dura- and light-sensitive apposing photo-regulatory retinal ganglion axons

21. Seeing the wood for the trees
Pros
Cons
Some supportive studies in migraineurs, albeit with small numbers
Field is dominated by 1 lead researcher (Wilkins) who also worked with Cerium and MRC to develop the Intuitive Colorimeter and lens specs.
No significant reported side effects of wearing colour lenses
RCTs are lacking
Does not require GP referral. Direct attendance at Optometrist
Within the Ophthalm field there is some scepticism about Irlen and her theories of visual stress
Low cost to the NHS: private payment
American Academy of Paediatrics does not believe there is any scientific basis for the use of coloured lenses in children to treat 'visual stress' because “the method used to select the lens or filter colour has been highly variable,the colour selection has also shown considerable variability,and the test-retest consistency has been poor”
American Assoc of Optometrists and of Ophthalmologists believes there is no evidence for use of coloured lenses nor of a distinct Irlen syndrome entity

22. Information for patients
Wear the tinted glasses for all daily activities
Cost
£55 each colorimetry test, performed twice before precision lenses made
£90 to make coloured lenses
Total £200
Local variance in DLA/subsidized costs
Optometrists
Check on the Cerium website for nearest specialist Optometrist with an appropriate Intuitive Colorimeter
Irlen support