Photophobia and sensations of dryness in patients with migraine occur independent of baseline tear volume and improve following botulinum toxin A injections

Abstract

Background: To evaluate the efficacy of botulinum toxin A (BoNT-A) in reducing photophobia and dry eye symptoms in individuals with chronic migraine. Additionally, we aimed to evaluate tear film volume as a potential contributor to symptoms in these patients. Methods: Retrospective review of seventy-six patients who received BoNT-A for chronic migraine (CM) between August 23, 2017 and December 13, 2017 at the Miami Veterans Affairs Medical Center Neurotoxin Clinic. Demographic data and all co-morbidities were queried via chart review. Standardized validated surveys were administered to assess symptoms prior to and after BoNT-A injection. Pre-injection tear volumes were obtained using the phenol red thread (PRT) test. Results: Pre-injection migraine, photophobia, and dry eye symptom scores were all significantly correlated, p<0.05; and none were associated with pre-injection PRT results. After BoNT-A, improvements in migraine, photophobia, and dry eye symptoms were also significantly correlated, p<0.05; and similarly did not associate with pre-injection PRT results. Photophobia scores significantly improved following BoNT-A, while dry eye symptoms significantly improved in those with severe symptoms at baseline (DEQ-5 score ≥12), p=0.027. In logistic regression analysis of all individuals with dry eye symptoms (DEQ-5≥6), individuals with more severe dry eye symptoms were more likely improve, OR 1.27, 95% confidence interval [1.06, 1.51], p<0.01. Conclusions: BoNT-A significantly improved photophobia in patients being treated for migraine and also improved dry eye symptoms in patients with severe symptoms at baseline, independent of baseline tear film volume. These improvements may be due to modulation of shared trigeminal neural pathways.

Exploring the Link Between Dry Eye and Migraine: From Eye to Brain

“… 41 In a retrospective cross-sectional study of 117 individuals with chronic migraine (≥15 headache days/month), 80% rated their photophobia (via 0–10 NRS) as severe (a score of ≥7/10; mean 7.91 ± 2.05). 42 Together, the data demonstrate that photophobia is a feature of both dry eye and migraine. The presence of photophobia in both diseases has implications for shared pathophysiology and treatments as discussed later in the review.…”

Periorbital botulinum toxin A improves photophobia and sensations of dryness in patients without migraine: Case series of four patients

“…One month was chosen as the follow-up timepoint as a previous study had detected significant reductions in photophobia and DE symptoms in individuals with chronic migraine about 1 month after injection with onabotulinumtoxinA. 16

Fig. 1 Injection Sites for Botulinum Toxin A Using a Modified Migraine Protocol.

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“…In the arena of neuropathic-like DE symptoms, prior studies have shown that BoNT-A injections improved photophobia and DE symptoms in individuals with underlying chronic migraine, independent of an improvement in tear film volume. 15 , 16 These improvements were thus hypothesized to be driven by modulation of vascular and neural pathways shared by migraine pain, photophobia, and DE symptoms.…”

“… 14 Similarly, individuals receiving BoNT-A injections for chronic migraine reported a significant improvement in photophobia and DE symptoms with BoNT-A treatment that was independent of improvements in tear volume. 15 , 16 …”

Ocular Surface Pain: A Narrative Review

“…In a study of 62 individuals with chronic migraine treated with BoNT-A (100–150 units every 3 months based on migraine protocol), BoNT-A not only decreased migraine pain 4–6 weeks post treatment compared to pretreatment but also interictal photophobia (3.4 ± 2.5 vs. 4.9 ± 3.0; p < 0.001) and overall light sensitivity (assessed using the Visual Light Symptom Questionnaire [VLSQ]-8 [ 110 ]: 27.7 ± 6.5 vs. 29.8 ± 5.1; p = 0.002). Responses to the questions in the VLSQ-8 questionnaire revealed improvements in frequency of glare (2.9 ± 1.3 vs. 3.4 ± 0.86; p = 0.001), light sensitivity from flickering lights or bright colors (3.1 ± 1.3 vs. 3.7 ± 1.0; p = 0.004), and severity of worst period of photophobia (3.7 ± 1.0 vs. 4.2 ± 0.88; p = 0.001) in the past month [ 111 ]. Interestingly, these findings were independent of tear volume, again suggesting that ocular surface findings do not drive ocular surface pain in many individuals.…”