Headache

Ocular Symptoms and Conditions: Headache

Headaches often appear centered around the eyes or behind the eyes. There are many ocular disorders which can cause headache from eyestrain focusing problems to glaucoma and inflammatory conditions of the eye. There are other problems which cause headache where findings of that problem can be seen with a complete eye examination. Finally, there are many conditions where the eyes are not involved with the cause of the headache, but the area around the eyes seem to ache because of "referred pain" to that area.

Patients will often be referred to an ophthalmologist in order to determine if an ocular condition could be causing headache. Unfortunately, most of the time, the eyes are not the cause. However, many conditions of the eyes which cause headache are easily treatable, making the eye evaluation worthwhile.

This page is divided into a group of disorders causing headache which also can affect the eyes. The next section discusses "other causes" of headache which cause pain around the eyes, but there is no ocular abnormality. The last section contains links to ocular problems known to cause headache.

Conditions Discussed on this Page:

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Eyestrain (focusing spasm)

"Eyestrain" refers to overworking of the focusing muscle within the eye. To read at a close distance (within arm's length), the lens within the eye must change shape in order to bring images into focus. The closer an object is held, the more focusing that has to be done. Furthermore, the focusing ability of the eye diminishes with age, and noticeable problems with focusing can appear usually between age 38 and 48. If the eye is forced to focus more intensely and for a longer duration than it is comfortable with, eyestrain symptoms can result. These symptoms include:

  • Headache, usually a brow ache or an ache behind the eyes.
  • Fluctuating vision, with trouble in changing focusing between near and distance.
  • Inability to focus at close range, or blurred distance vision occurring after a period of close work.
  • A burning, uncomfortable eye sensation.

Eyestrain symptoms can be relieved by taking a few steps:

  • Limit the amount of time spent focusing at one fixed distance, and take periodic breaks for a few minutes every 15 to 20 minutes. During this break time, focus at a distant object, not at a near one.
  • Vary the distance that you hold reading material, and avoid getting closer and closer to what you are reading.
  • Consider using reading glasses, after an eye examination has been performed to determine the proper power of the glasses.

For more information on eyestrain, and for information on computer related eyestrain, go to Eyestrain.

Migraine Headache

Migraine is a vascular type of headache, and is caused by a change in vascular tone in the brain. It is a common cause of headache surrounding one or both eyes. Migraine headache may be difficult to localize in some cases. It is often preceded by a visual "aura", which typically is a jagged zigzag pattern of shimmering lights in the side vision lasting up to 30 minutes. Some people experience this aura and then have no headache. This is commonly referred to as Ophthalmic Migraine. Some people experience neurological changes during this period, such as tingling or numbness on one side. After the aura, the headache begins, and may be associated with nausea, vomiting, and sensitivity to light and sounds.

There are many medications that can be used to treat migraine. There are also numerous factors which may set off a migraine. Some of these can be identified as a factor in some people:

  • Foods containing tyramine (cheese, bananas, yogurt), phenylethylamine (chocolate, wine, cheese), nitrates (food coloring, preservatives, processed meats), MSG, alcohol, caffeine, and artificial sweeteners.
  • Medications such as estrogen and oral contraceptives. Some women may be sensitive to hormonal changes.
  • Factors such as fatigue, stress, depression, and exertion can play a role in some people.
  • Bright lights, glare, loud noises, and flickering lights may trigger some migraines.

Cluster Headache

Cluster headache is a severe one-sided headache especially involving the area around the eye. It lasts for up to 2 hours at a time, several times a day, for up to 6 to 8 weeks (thus, a cluster of headaches). Associated symptoms include tearing and nasal drainage (on the affected side), eye redness, and a temporary smaller pupil on the affected side.

Treatment is similar to the treatment of migraine headache, and steroids and other medications may be needed as well.

Giant Cell Arteritis (Temporal arteritis)

Giant Cell Arteritis, or "Temporal Arteritis", is a serious condition usually affecting the elderly. This is an immune disorder where medium sized arteries becomes tender and inflamed. The condition is named after the "temporal artery", which runs from in front of the ear and up the scalp along the hairline. This artery is commonly involved, and the headache associated with this is a constant, throbbing pain in the temples. Associated symptoms are weight loss, fatigue, arthritis (especially of the shoulders), fever, and pain or fatigue with chewing. Visual symptoms occur due to a loss of blood supply to the optic nerve, or due to a loss of retinal blood supply. Both of these conditions can cause either a temporary (Amaurosis fugax) or permanent loss of vision, usually in one eye first (see Optic nerve stroke or Retinal artery occlusion.)

Most people with this condition have an elevated lab tests, including an elevated "sed rate" and C Reactive Protein (CRP). Diagnosis, however, is made by taking a biopsy of the temporal artery. Steroids can treat the condition, and the vision is the unaffected eye can often be saved. Untreated, temporal arteritis can often cause visual loss in both eyes.

Idiopathic Intracranial Hypertension

Idiopathic intracranial hypertension (IIH), also known as Benign Intracranial Hypertension or Pseudotumor cerebri, is a neurological disorder where there is increased intracranial pressure without a known cause such as a tumor. Symptoms include headache, nausea, and vomiting, pulsatile tinnitus (a whooshing sensation in one or both ears which is synchronous with the pulse). The headaches are usually worse in the mornings and with any activity that further raises intracranial pressure, such as coughing or sneezing.  Visual symptoms include double vision and visual obscurations.  These are a transient or momentary fading out of the vision in one or both eyes, often associated with a change in posture (such from going from sitting to standing). Some notice visual obscurations with head or eye movement. Papilledema is present in nearly all cases of IIH, which is swelling of the optic nerves where they enter the eyes. However, except in chronic long standing cases, there is usually no visual loss noticed with papilledema except for an enlarged blind spot.

In chronic cases of papilledema from IIH, optic atrophy may result, which represents damage to the optic nerves. In these cases there may be peripheral or even central vision loss. Double vision comes from compression or traction on cranial nerves that supply eye movement, with the 6th cranial nerve being most commonly involved.  Other cranial nerves can be affected as well, which can lead to a decreased sense of smell and weakness of facial muscles.

IIH is most common in young women, especially those with obesity. Any age group can be affected, however. Diagnosis is by performing MRI to rule out a structural cause for the increased pressure followed by lumbar puncture (spinal tap). Treatment can be achieved sometimes through performing the lumbar puncture, but other cases might require medication (acetazolamide) or surgery (optic nerve fenestration surgery or spinal shunt surgery).

"Idiopathic" means "of unknown etiology". Therefore, IIH can only be diagnosed if there is no alternative explanation for the symptoms. Intracranial pressure may be increased due to medications such as high-dose vitamin A derivatives (e.g. isotretinoin), long-term tetracycline antibiotics (for a variety of skin conditions) and hormonal contraceptives. There are numerous other diseases, mostly rare conditions, that may lead to intracranial hypertension. In these cases, the increased intracranial pressure would be considered "secondary" to that cause, rather than idiopathic. Common causes of secondary intracranial hypertension include obstructive sleep apnea, systemic lupus erythematosus, chronic kidney disease, and Behçet's disease.

Sinus Disease

The eye socket, or orbit, is surrounded by sinuses, except on the outside wall. Infection of the sinuses can lead to pain over the affected area, often radiating to the eye and face. The headache is usually dull, aching, and throbbing. Bending or stooping may worsen the headache. Fluid retention within the sinuses around the eyes can cause similar symptoms, but less severe.

Sometimes sinus congestion or infection can be associated with obstruction of the tear drainage system. This leads to frequent tearing of the affected side, and possible infection of the tear duct.

It is possible for sinus infection to spread into the skin around the eyes (Eyelid Cellulitis), or even spread into the orbit behind the eyes (Orbital Cellulitis), especially in children. These conditions require aggressive antibiotic therapy, often given IV.

Shingles (herpes zoster)

Shingles refers to a reactivation of the chicken pox virus along the distribution of a nerve. Once a person has had chicken pox, the virus lies dormant in nerve cells. Sometimes the virus becomes reactivated (often during a period of stress of illness), and a rash of blisters will appear on the skin along the distribution of that nerve. The nerve that supplies sensation to the scalp, upper eyelid, eye, and nose is commonly involved, and the rash may appear in this area. Note that the rash never crosses the midline of the forehead, and this gives a very obvious appearance. The area involved is usually painful, with a burning aching. This pain may precede the rash. Antiviral medications given promptly by mouth may shorten the duration and intensity of the flare up.

The eye can be involved with shingles if this particular nerve is involved. Almost any part of the eye can be affected, and consultation with an ophthalmologist is important to prevent problems. The most common ocular complications include acute and chronic inflammation within the eye, corneal problems, and eyelid scarring.

Other Causes for Headache near the eyes

There are many other conditions which can cause headache around the eyes that do not directly involve the eyes themselves. The eye and orbits are frequent areas of "referred pain", that is, pain coming from another source. Some of these conditions include:

  • Ear and tooth pain can radiate to the eyes and orbits.
  • TMJ disease (temporomandibular joint) can cause eye, tooth, ear, neck, or sinus pain.
  • Degeneration of the cervical (neck) spine can cause pain which can radiate to the eye and orbits.
  • Trigeminal neuralgia (tic douloureux) is a brief attack of severe pain affecting one side of the face, often near the eye. The pain is can be very severe, sharp, and cutting. It is a wincing type of pain, sometimes referred to as a "lightning pain".  There are different treatment options available for this problem.

Other Conditions causing headache found on other pages:

A link to each condition is listed along with other hallmark features of the condition.

  • Contact lens related problems - headache may come from a poorly fitting, tight lens, corneal infection or swelling, or from a lack of oxygen in the cornea.
  • Corneal abrasion - pain, tearing, redness, and a sensation that something is in eye.
  • Corneal ulcer - an infected cornea can cause pain, headache, blurred vision, and redness.
  • Conjunctivitis - swelling of the conjunctiva and eyelids can cause headache, along with the itching, redness, and discharge.
  • Dacryocystitis - an infected tear drainage sac (inside corner of the eye) can lead to pain and headache, as well as tearing.
  • Dry eye - irritation, scratchy sensation, sometimes tearing and blurred vision.
  • Glaucoma (acute) - pain, blurred vision, rainbows around lights, and headache.
  • Iritis - pain, sensitivity to light, blurred vision.
  • Paralysis of the eye muscles - when caused by a nerve paralysis, there may be significant headache as well.
  • Optic neuritis - inflammation of the optic nerve can cause headache and pain on eye movement along with blurred vision.
  • Orbital cellulitis (infection) - infection of the orbit behind the eye can lead to blurred or double vision, pain, and eye protrusion.
  • Scleritis - pain, blurred vision, redness.
  • Thyroid related eye disease - scratchy sensation, double or blurred vision, protruding eyes.

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