Migraine prevalence in visual snow with prior illicit drug use (hallucinogen persisting perception disorder) versus without

Abstract

Background and purpose: This study was undertaken to investigate migraine prevalence in persons with hallucinogen persisting perception disorder (HPPD) presenting as visual snow syndrome (VSS).

Methods: Persons with visual snow as a persisting symptom after illicit drug use (HPPD) were recruited via a Dutch consulting clinic for recreational drug use. A structured interview on (visual) perceptual symptomatology, details of drugs use, and medical and headache history was taken. As a control group, persons with visual snow who had never used illicit drugs prior to onset were included. The primary outcome was lifetime prevalence of migraine. Symptom severity was evaluated by the Visual Snow Handicap Inventory (VHI), a 25-item questionnaire.

Results: None of the 24 HPPD participants had migraine, whereas 20 of 37 (54.1%) controls had migraine (p < 0.001). VHI scores did not differ significantly between the two groups; in both groups, the median score was 38 of 100. In most HPPD cases (17/24, 70.9%), visual snow had started after intake of ecstasy; other psychedelic drugs reported included cannabis, psilocybin mushrooms, amphetamine, 4-fluoroamphetamine, 3-methylmethcathinone, 4-Bromo-2,5-dimethoxypenethylamine, and nitrous oxide.

Conclusions: Whereas none of the HPPD participants had migraine, more than half of the visual snow controls without prior use of illicit drugs had migraine. This suggests that at least partly different pathophysiological factors play a role in these disorders. Users of ecstasy and other hallucinogens should be warned of the risk of visual snow. Further studies are needed to enhance understanding of the underlying neurobiology of HPPD and VSS to enable better management of these conditions.

Keywords: ecstasy; hallucinogen persisting perception disorder; illicit drugs; migraine; visual snow.

FIGURE 1

Flowchart of participant inclusion. HPPD, hallucinogen persisting perception disorder, VS(S), visual snow (syndrome). See Methods section for full study group definitions

FIGURE 2

Type of illicit drugs reported as trigger by HPPD patients. APB = 6‐(2‐aminopropyl)benzofuran; 4‐FMP = 4‐fluoramphetamine, ‘speed’ = amphetamine, 3‐MMC =3‐methylmethcathinone, 2C‐B = 4‐Bromo‐2,5‐dimethoxypenethylamine; XTC = ecstasy, cannabis = marihuana or weed, psilocybin = psilocybin mushrooms; nitrous oxide = ‘laughing gas’, unknown = one participant who used multiple illicit drugs at a party but not sure if it was XTC, ketamine, GHB (gamma‐hydroxybutyric acid) or ‘speed’. Eleven participants reported that they had used multiple drugs during the episode that was believed to have triggered the visual snow

FIGURE 3

Time between intake of illicit drugs and onset of visual snow in hallucinogen persisting perception disorder (HPPD) participants. Participants with HPPD were asked about the time between intake of illicit drugs and onset of their visual snow. Data are shown separately for ecstasy (XTC; black) and other drugs (gray). NA, not applicable (one patient reported that symptoms gradually developed during a period of extensive illicit drug use and that onset was not related to one specific episode of drug use)