Patient with ocular migraine that lasts for about an hour but this is the first

Management and Investigation of Ocular Migraine with New Visual Symptoms

For a patient experiencing an ocular migraine lasting about one hour with new visual symptoms such as seeing rectangular shapes instead of the typical blurring, the following approach is appropriate:

• Clinical Assessment: Conduct a thorough history and neurological examination to confirm the diagnosis of migraine with aura and to exclude other serious causes of headache or visual disturbance. Pay particular attention to the characteristics of the visual symptoms, their duration, and any associated neurological signs.
• Recognize Aura Features: Typical migraine aura symptoms are fully reversible, develop gradually over at least 5 minutes, and last between 5 to 60 minutes. Visual aura usually includes flickering lights, spots, or lines, but atypical visual symptoms such as rectangular shapes should be carefully evaluated to rule out other pathology.
• Consider Referral and Further Investigation: If the visual symptoms are atypical (e.g., unusual shapes like rectangles), new, or different from previous auras, or if there are any additional neurological symptoms such as motor weakness, double vision, or symptoms affecting only one eye, urgent referral to neurology or ophthalmology is recommended for further assessment and possible neuroimaging.
• Exclude Secondary Causes: Investigate for red flags such as sudden onset, neurological deficits, or changes in headache pattern. Blood pressure measurement and urinalysis should be performed to exclude secondary causes like pre-eclampsia or cerebral venous thrombosis.
• Patient Education and Self-Management: Explain the diagnosis and provide information about migraine and aura. Advise keeping a headache diary to monitor triggers and symptoms. Lifestyle modifications such as stress management, good sleep hygiene, hydration, and avoidance of known triggers are recommended.
• Medication Considerations: Acute treatment can be used as per migraine guidelines, but medication overuse should be avoided. If migraine with aura is confirmed, ensure that women are not using combined hormonal contraception due to increased stroke risk.

In summary, new or atypical visual aura symptoms warrant careful evaluation and possibly specialist referral to exclude other causes. If the presentation is consistent with typical migraine aura and no red flags are present, management includes reassurance, lifestyle advice, and appropriate migraine treatment.

References: ¹,²,³