People who have experienced “visual snow” know what it means. Their vision tends to be distorted by white spots that resemble what you see on the television when there is no signal.

At the latest meeting of the International Headache Society, the topic of visual snow was addressed in four presentations. The first presentation by British and Swiss researchers attempted to give a definition, so that this phenomenon can be studied scientifically. They collected data on 636 subjects by using an online survey of patients. 636 is a surprisingly high number because this is thought to be a relatively uncommon symptom. I certainly do not see more than a handful of patients each year. They found this phenomenon to be present with equal frequency in men and women and 39% reported to have it all their lives. The majority (56%) saw black and white static, 44% saw colored spots, while 45% experienced flashing, and 52% described it as transparent. The most common non-visual symptom was tinnitus, or ringing in the ears, which was present in 74%. Only 226 patients gave information on headaches and 83% of them suffered at least one attack of migraine. They concluded that visual snow is an unrecognized symptom, which can be very disabling and which deserves further research.

The second presentation reported on 90 patients of the original 636 who agreed to keep a diary of their symptoms for 30 days. The results showed that the visual snow was least noticeable outdoors, in bright sun. It was most pronounced at night. The amount of distraction that was caused by visual snow was correlated to the size and density of the static.

The third study by German and Swiss doctors showed that visual snow is a phenomenon that is common in migraine sufferers, but it is distinct in its character. They came to this conclusion by testing the excitability of the visual cortex of the brain.

The fourth paper described the effectiveness of various treatments. The data was collected by reviewing questionnaires that were returned by 204 patients. The effect of 112 drugs was reported. Unfortunately, less than half (92) of the responders had any relief from medications. Antidepressants and anti-epilepsy drugs were most commonly used. Only 29% improved from benzodiazepine drugs (Valium or diazepam, Klonopin or clonazepam, and other). Recreational drug use was reported 117 times and in 32% produced worsening and in 61% there was no change.

We clearly do not know how to treat this condition, but if you have it, have your doctor check your RBC magnesium level since magnesium deficiency increases the excitability of the nervous system. I would also check vitamin B12, D, and CoQ10 levels, thyroid function, and routine blood tests, looking for an underlying medical condition (for example, anemia) which can worsen many symptoms. Regular and sufficient amounts of sleep, exercise and meditation can also reduce the excitability of nervous system.

It is an established fact that migraine, and especially migraine with aura increases the risk of strokes. The increase in the risk is small, but according to a new study published in the British Medical Journal, it is higher during and after surgery.

The researchers examined records of 124,558 surgical patients at the Massachusetts General and two other hospitals. Among these, 8.2% or 10,179 patients had a history of migraines with 1,278 or 12.6% having migraine with aura. The risk of stroke during or within 30 days after surgery was 1-2 in 1,000 among patients without migraine history, 4 in 1,000 in those who had migraines and 6 in 1,000 in patients who had migraine with aura. So, the absolute risk of a stroke is still very small, but the relative risk is statistically much higher. They also discovered that strokes were more common in patients who during surgery needed medications to increase their blood pressure. Most of the strokes occurred within the first two days after surgery.

We do not know why migraine carries an increased risk for strokes, so the only recommendation the authors offer is for migraine diagnosis to be included in the preoperative risk assessment of patients. I would add that according to another study, taking high doses of magnesium and potassium supplements could possibly reduce this risk. Magnesium alone was shown to reduce the risk of strokes in another review of studies involving 6,477 patients. Our own research and that of others have shown the beneficial effect of magnesium on the prevention of migraines as well. Here is one of a dozen posts on magnesium on this blog that provides dosing recommendations.

Stroke is slightly more common in migraine sufferers. There are two main types of stroke: hemorrhagic, which results from a burst blood vessel in the brain and ischemic, which is due to a blood clot closing off blood supply to a part of the brain. Closure of a blood vessel by a clot can be due to a blood clotting disorder, cholesterol plaque, or dissection of a blood vessel. Dissection is a lengthwise tear in the blood vessel wall.

A study just published by Italian researchers in JAMA Neurology included 2,485 patients aged 18 to 45 years with first-ever acute ischemic stroke. Of these patients 334 or 13% had a dissection and 2151 or 87% had a stroke not caused by dissection. Migraine was more common in the dissection group 31% vs 24% in non-dissection group. These differences are relatively small, but the importance of the study is that it should make doctors consider the possibility of a dissection when a patient with migraines develops a different type of headache or has a new onset of neck pain. If a dissection is suspected, a CT angiogram or an MRA should be done. Luckily, many dissections do not cause strokes and heal on their own. However, we do recommend blood-thinning medications (anticoagulants) for several months after the dissection even in the absence of a stroke.

My previous post described a scientific review on this topic, that showed a two-fold increase in the risk of dissection in migraine sufferers. Another practical aspect of these studies, which is mentioned in that previous post, is that if you suffer from migraines, avoid neck manipulation by chiropractors. If you do see a chiropractor, ask them not to do high velocity manipulations (sudden jerky movements), as I did when I visited a chiropractor.

Restless leg syndrome (RLS) has been reported to be more common in patients with migraines. I wrote about this association in a previous post about 4 years ago. Another study, just published in The Journal of Headache and Pain confirms this association.

RLS is a common condition that often goes undiagnosed. This is in part due to the fact that RLS begins in childhood and it often runs in the family, so it is not perceived as an illness.

The new study involved 505 participants receiving outpatient headache treatment. The researchers collected information on experiences of migraine, RLS, sleep quality, anxiety, depression, and demographics. Participants were divided into low-frequency (1–8/month), high-frequency (9–14/month), and chronic (>15/month) headache groups.

Analysis revealed that with an increase in migraine frequency the occurrence of RLS also increased, particularly in those who had migraines with auras. Anxiety and sleep disturbance was also associated with RLS.

Sometimes the diagnosis of RLS is very easy to make – a person who constantly shakes his or her foot, usually has it. However, in some people the excessive leg or body movements occur only in sleep, so the diagnosis is less obvious to the doctor, but not to the bed partner who is constantly kicked and woken up by these movements. One of my patients could not sleep in the same bed with his wife, because he would move and kick her all night long. After he started taking ropinirole, one of the medications for RLS, he reported that he was able to sleep in the same bed with his wife for the first time in 20 years. If the diagnosis is in doubt, an overnight sleep study can confirm the diagnosis.

Unfortunately the person with RLS suffers much more than the bed partner. Moving all night means not getting good quality sleep and being tired all day. Treating RLS leads not only to improved sleep, but also to an overall improvement in the quality of life.

Tremor of the hands is usually a benign condition. It is even called, benign essential tremor or, if it runs in the family, benign familial tremor. Patients with tremor are twice as likely to have migraines, so this is why I am writing about it. Tremor is also a symptom of Parkinson’s disease, but these two types of tremor can be easily differentiated. Parkinsonian tremor is a resting tremor, which means that hands shake at rest, while essential tremor occurs in action, like when trying to drink from a cup.

Even though it is benign, essential tremor can be incapacitating and socially embarrassing. Fortunately, in most people it responds to treatment. We usually start with propranolol (Inderal), a drug that belongs to the beta-blocker family, which is used for the treatment of high blood pressure and migraines. If propranolol or another beta-blocker is ineffective or causes side effects (due to low blood pressure or slow pulse), tremor can be treated with epilepsy drugs such as primidone (Mysoline), gabapentin (Neurontin), zonisamide (Zonegran), or an alpha-2 agonist such as clonidine (Catapres), which is a different type of blood pressure medicine.

In rare cases, tremor affects not hands but the voice. I recently treated such a patient. He tried some medications, but when they did not help, he was given Botox injections into the vocal cords. This reduced the tremulousness of his voice, but only partially. Botox can also help with hand tremor, but because there are so many small muscles involved, the results are not very good. Taking careful history revealed that this patient tried only 10 mg of propranolol and when it did not help, he stopped it. I decided to give it another try and built up the dose to 30 mg, which provided complete relief without any side effects. For migraines, we usually go up to 60 to 120 mg of propranolol, but some patients need and tolerate even higher doses.