Visual Snow in Migraine With Aura: Further Characterization by Brain Imaging, Electrophysiology, and Treatment--Case Report

Abstract

Objective: This study aims to investigate characteristics of visual snow accompanied by migraine and special interest on occipital bending, electrophysiological properties, and response to treatment.

Background: Visual snow is characterized by continuous dynamically flickering dots in the visual field. Most patients also have comorbid migraine. Cortical hyperexcitability is a feature of migraine. Recent studies indicate an association between occipital bending with psychiatric disorders such as depression. Here, we demonstrate a patient with visual snow, migraine with aura, left occipital bending, and cortical hyperexcitability. Treatment response to lamotrigine was objectively assessed by repetitive pattern reversal visual evoked potentials (rVEP).

Methods: A 25-year-old woman with a 10-year history of migraine with aura (2-3 attacks/week) admitted for 1-year history of visual snow. She reported continuous bright and colorful lights, palinopsia, floaters, nyctalopsia, and photopsia. Brain magnetic resonance imaging (MRI) was performed. Visual habituation response was assessed before and after lamotrigine treatment by rVEP.

Results: Brain MRI revealed left occipital bending. On rVEP study, there was potentiation response. After lamotrigine treatment, the patient had no more complaints of visual snow, was able to sleep, and the frequency of migraine decreased to 2 attacks/month. Electrophysiologically, the cortical hyperexcitability was improved.

Conclusions: The visual snow and loss of habituation ability in migraine associated with occipital bending can be improved with lamotrigine treatment. This report may provide new insights on "visual snow" pathophysiology in migraine.

Keywords: anticonvulsant; cortical excitability; headache; magnetic resonance imaging; occipital bending; repetitive pattern-reversal visual evoked potential.