Expanding positive scotoma, reproduced from Dahlem and Müller (2003).
Fully reversible visual symptoms presenting as a transient loss of vision may occur as typical aura with migraine headache, typical aura with non-migraine headache or typical aura without headache, depending on the presence and nature of associated headache.
One can distinguish various types of visual loss.
Blurred vision is characterized by minor visual loss with a difficulty of focussing objects.
"I've had daily migraines for about 2.5 years now. Lately, within the past 3-4 weeks, I've noticed that sometimes my right eye will not focus no matter what... Sometimes I've noticed that I can't focus at all, and it makes reading impossible. I've decided that these events are auras for me -- I've never had any aura before. A few times, the eye problems have occurred *during* the headache, not before it."
(Dennis T., Newsgroups: alt.support.headaches.migraine, Subject: headaches and blurred vision, August 19, 1998)
Austin Hall and Homer Eon Flint, The Blind Spot, 1921 (see here)
The term scotoma refers to some form of visual loss in an area of varying size and shape - a sort of "blind spot" - within the visual field.
"I started to get a blind spot on my left side. I thought it was a migraine blind spot..."
(Martha Walz, Newsgroups: rec.running, Subject: blind spot while running?, April 10, 2001)
Migraine Art: Negative scotoma with perceptual completion phenomenon. © 2007 Migraine Action Association and Boehringer Ingelheim Limited (see here)
Together with the disappearance of objects in the parts of the visual fields blanked out by a scotoma, the colour and texture of the background may be "visible" in the area of the scotoma, a phenomenon of "filling-in" or perceptual completion phenomenon which is illustrated in the following account from a software engineer's lifetime experience of visual migraine auras.
Perceptual completion phenomenon
"My auras were generally either scotomata or scintillating scotomata.
I don't know how to begin to convey the 'appearance' of a scotoma. The first time I experienced one, I was looking at the cover of a clothbound book, with a decorative border and the title in the center. When I looked at the title, it disappeared. There was no black spot, no hole, and, incidentally, no zigzag line or boundary. It looked like a bookcover with a decorative border and no title. The texture and appearance of the fabric extended across the blind spot. Only the title disappeared.
Many of my scotomata scintillated or flickered. I estimated once that they seemed to flicker at a rate of about 15 per second.
To me, the essential features of the experience were dynamic: the disappearance of objects as I looked at them, and patches of flickering vision.
Perhaps, in theory, someone could make computer animations of the appearance of these auras if I still had them... but it would be beyond my artistic skills.
I've only had about two dozen migraine headaches in my life -- that's about two dozen too many but I feel very thankful when I read about and talk to other migraineurs. I've had maybe two or three times as many occurrences of visual symptoms. They've become increasingly less frequent.
I'm nearsighted, am finicky about details -- in 'some' areas of my life, such as my work as a software engineer. I might match some descriptions of a 'typical migraine personality' (do people still believe there is such a thing?) My mother had migraine visual symptoms but never had headaches."
(Daniel P. B. Smith, Email to Klaus Podoll, July 2, 2005)
"In response to the request on the migraine-aura.org website, I am reporting the symptoms of my very first migraine aura (20 to 25 minutes from beginning to end) to you:
I am 47, male, and just had my first aura, without headache, yesterday. I had a breakfast of fresh pear and banana with yogurt at 9 a.m., then had a weight machine workout at 10 a.m. 15 minutes after the workout, I sat down at my computer and opened a document to read. I immediately noticed that I could not 'see' the word I was focusing on! The effect was similar to the local vision loss you get after having looked at a bright light. It’s not like the local area was 'black' – it was just 'missing'. After a couple of minutes, the small vision loss area began to drift to the left in my field of vision. I began experimenting with it by moving my finger horizontally and vertically through the vision loss area. I found that the blind spot remained when I covered either eye. At first, the blind spot moved left without getting any larger.
It was at this time that I witnessed the most bizarre phenomenon, which I have not read in the many personal accounts of aura on the Web. I opened a blank document on the computer and placed a letter on it. Then I adjusted my center of vision until the letter was in the blind spot. As soon as the letter was in the blind spot, the letter immediately began to reciprocate left and right in a very regular pattern both in time and space ('tick-tock-tick-tock-tick-tock') even though I was keeping my eyes and center of vision perfectly still. The letter moved a distance of about 1/2'' and back in about 1 second for each 'tick-tock'. It was as if my brain was trying to move the letter to a point where it could 'see' it, but couldn't decide on which way to move it!!
Yes, I was focusing on a point well to the right of the scotoma. The scotoma at that time was still very small, only about the size of the letter. The letter disappeared just momentarily, then it reappeared, alternating very regularly from left of the scotoma to right of the scotoma, never simultaneously on both left and right. But I was struck that this happened even when I very consciously kept my eyes, and center of vision perfectly still. It appeared to be a succession of two stationary images. It didn't 'slide' back and forth; it 'toggled' back and forth. I just saw the alternation of the two positions.
This phenomenon so interested me that I had not noticed something else going on further out in my field of vision. In the lower left quadrant, there was a vague sawtooth arc of scintillating images. I wouldn't say they were 'colorful', yet they had a quality that was almost colorful. At first, they were just sort of superimposed on the field of vision, without blinding me to what was behind them. But a minute or so after I noticed the sawtooth arc, it suddenly expanded into a large blind area consisting of a complete semicircle 'C' shape covering the entire left half of my field of view, as it also expanded all the way to the edge of my field of view. I think it may even have 'thickened', meaning the inner edge move closer to my center of vision. Before this, I had just been fascinated, but not at all worried. But when this major progression happened so quickly, it suddenly occurred to me that I may be having a stroke or brain aneurism, and I feared that I might be losing consciousness! Since no one else was at home, I grabbed the phone and dialed 911. I also became confused and had a little trouble actually dialing the phone and talking to the dispatcher. Later after reading other migraineur accounts, I believe my confusion was probably part of the aura.
When I hung up the phone, I stood up and began to walk around a little bit. It struck me that I was not the least bit dizzy or physically sick or anything. Then, the symptoms completely receded over a period of just a minute or so. By the time the ambulance arrived 15 minutes later, the symptoms were completely gone. I sheepishly walked out to greet the ambulance crew and reported my experience. They had no idea what had happened to me. They took my blood pressure, pulse and blood sugar, all of which were normal. After they left, I went back to my office and Googled 'temporary vision loss' and immediately got hundreds of hits on migraine aura. The many descriptions I have read on the Web left no doubt that this is what had happened to me.
I hope this account is helpful."
(TM, Email to Klaus Podoll, September 26, 2007)
Absolute and relative scotomas differ in their density, the former being characterized by a complete and the latter by an incomplete loss of vision in the region of the scotoma.
Delia Malchert, Scintillating scotoma, 2003. © 2003 Delia Malchert
Delia Malchert's illustration of her self-experienced visual migraine aura bears the typical features of a relative scotoma. "Shortly after a scintillating scotoma, which I experienced on New Year's eve 2003", she recalled, "I produced from very fresh memory a computer graphic representation. It shows the partial defect of the visual field [i.e. relative scotoma], which I didn't manage to represent satisfactorily in my previous pictures." [more]
Entry to art contest Migraine Images, 1992. © 2007 GlaxoSmithKline
Roger Heaton's entry to the 1992 Migraine Images art contest shows a C-shaped visual migraine aura completely obscuring the artist's view of a landscape, i.e., an absolute scotoma.
Migraine aura. © 2007 Richmond Eye Associates, P.C. (see here)
Another example for an absolute scotoma can be seen in the above migraine aura illustration reproduced by courtesy of Richmond Eye Associates, P.C.
Entry to art contest Migraine Images, 1992. © 2007 GlaxoSmithKline
The following is a report of a complete loss of the left half-fields of vision, i.e. absolute hemianopia: "During an ophthalmic migraine, my experience has usually been losing half the vertical vision. So if I were looking at a face I would see one side and not the other. (But I've had your pattern as well.) My first recognizable migraine began while driving with my children in the car on a curved parkway. I could not see any oncoming traffic, only the right side of the road."
(Judy, Newsgroups: alt.support.headaches.migraine, Subject: How about this Migraine site?, January 22, 1998)
The distinction between a negative and a positive scotoma, as first defined by the German ophthalmologist Richard Foerster in 1871, is frequently misunderstood. If the vision is absent in the area of the scotoma, often described as a blank, a void, an emptiness or nothingness, it is called a negative scotoma. If the vision is enhanced or enriched, so that the blind spot is experienced as an area of darkness, as a blackness, as a light or as an area comprising hallucinatory patterns, like a positive void, it is labelled a positive scotoma.
Negative scotoma: "You don't see blackness... you don't 'see' anything"
"Also, all my life I have suffered with what is called 'occular migraines'. They are a very strange kind of migraine for the most part. I usually don't get more than about three or four per year...so, no big deal. Unless, you are knee deep in a tennis match!!!
For those of you who don't know what an occular migraine is I will tell you. When they first come on or start they are actually pretty fantastic. You all of a sudden start seeing the most beautiful auras...colors of lights...flashing around in random patterns. These patterns zig-zag super fast with every color in the rainbow. It's almost like watching a July 4th fireworks display.
While the auras are subsiding you go basically blind. You lose your part or all of your vision. The blindness usually moves across your eyes until you see absolutely nothing. Now for those of you who think blindness is the same thing as seeing blackness when you close your eyes - you are completely wrong. Blindness is like trying to see and there is nothing registering with the brain. You don't see blackness... you don't 'see' anything. The sense to see is gone. This blindness or partial blindness can last from 15 minutes to up to two or three hours. Nothing you can do but wait it out. Once, your vision returns you have the most pounding headache you can imagine... nausea, etc."
, Newsgroups: rec.sport.tennis, Subject: Occular Migraine...talk about focusing on the ball, November 20, 2003)
A migraine artist's interpretation of negative scotoma
"A central irregular polygon of nothingness is the start of the first type of apparition. ... The size of the central nothingness might grow for some time, perhaps half and hour, and then disappear. It is an easy one to cheat, because the world can be seen around the edges of the central hole. The boundary of the central area is a polygon of straight but unpredictable sides. After some time the central nothingness fades away to reveal reality. It seems that the best way to represent this of visual migraine in a painting is to make a conventional oil painting, then superimpose a small irregular polygon in a cold dark colour in the centre. Depicting it the size that it finally grows to makes a less interesting picture. It is the deep thought image that is affected rather than a problem with retina or optic nerves because the effect is the same whether both eyes are used or whether one or other is covered." [more
, Visual Migraines, September 30, 2004)
A variety of positive scotoma: White blindness
"I had migraines for a little over two years (2 centuries on the migraine clock) while I was coming out of PTSD.
Sometimes mine became so intense I would lose my vision and suffer what the Docs called white blindness.
I was relating my migraine experiences at a party back in the late 70s. When I mentioned the 'white blindness', this dude leans over and whispered, 'I get the same reaction to peyote . . . but with euphoria rather than the pain. I think I also talked to the Great Spirit a coupla times, but I wouldn't swear to it.'
I cracked up and got the giggles. when I finally got my breath back, he was sittin' like a statue and staring at me.
He said, 'Hey, man I was being serious here.'"
, Omidyar Network, Groups - Religion - Discussion, Subject: Does God exist?, April 24, 2005)
Dianoux, Du scotome scintillant, 1875
The term scintillating scotoma refers to the pulsating movements of the hallucinatory patterns appearing on the border regions of a negative or positive scotoma. Thus, a scintillating scotoma either combines the features of a negative and a positive scotoma, qualifying as the latter because of the hallucinatory patterns at its margins, or it displays in its entirety the features of a positive scotoma.
"... surrounded with luminous angles, like those of a fortification" – 120 maps of fortifications from Hartwig Neumann, Festungsbau-Kunst und -Technik, 1988. © 2005 Bernard & Graefe Verlag, Bonn [more]
This scintillating scotoma or fortification spectrum is the best-known visual migraine aura symptom, a scintillating zigzag figure of bright luminous geometrical lines and shapes. The visual visual field defects of the fortification spectrum travel through the visual field. The scotoma gradually expands into a sickle- or C-shape in the homonymous visual fields. At the advancing (convex) edge of the scotoma may appear zig-zag patterns.
Fortification spectrum, reproduced from a computer model from Dahlem and Müller (2003) and Dahlem et al. (2000)
A vivid description of the pulsating movements of SS: "I had the strangest thing happen at work today and really need to touch base with anybody who has experienced something similar. The extent of my 'auras' are usually just a few little flashes. Today was very different and it lasted about ten minutes. Try to picture this, if you can: The lights above me seemed to be flickering and flashing in both eyes. While trying to see with my right eye, it was like I was under water, looking up with good vision through a small round hole, and yet all around it was all this activity, like waves, flashing, flickering, a little foggy. It was like part of my eye was under water and the rest looking right through the top."
(Sage, Newsgroups: alt.support.headaches.migraine, Subject: Alice in Wonderland syndrome, November 1, 2005)
An example of SS combining features of negative (white outs) and positive scotoma (jagged line): "I was finished with patients recently, and sat down at my desk and as I spoke with several staff members, I commented that it felt like I had just looked at the sun as I had several white outs in my visual field. I could not see the full face of the assistant in the room. I thought it would clear, but in about 5 to 7 minutes, it progressed to a multicolored jagged line primarily in the left lateral portion of my left eye and I could see a dimmer identical jagged line in the left portion of my right eye. As I was looking up the number for my opthomologist, the left portion of my left eye became a half moon fluttering wave-like image. My vision in the right eye was unaffected except for the small jagged line... My vision began to clear within 2 or 3 minutes and the physician called back and told me she 'knew exactly what it was' and this is my first exposure to ss."
(Samantha, Edith Frost's Homepage, June 20, 2004)
Conny K. Jonsson, Untitled, 1999. © 1999 Conny K. Jonsson
Another example of SS presenting with features of both positive and negative scotoma is provided by the image from Conny K. Jonsson: "A picture that I made some years ago", he wrote, "will show my visuals quite accurate, I think. It always starts as a small spot in the focus and 'grows' until it disappears in the periphery. The whiteness (to the right) is ... nothing ... just blindness." [more]
(Conny K. Jonsson, Email to Klaus Podoll, October 9, 2002)
An example of SS displaying exclusively features of a positive scotoma (grey hole + jagged edges): "Just had my 2nd SS after a break of several months.... My first experience was like watching an irregular shaped grey hole just off centre in my field of vision. The edges were jagged and 'shimmering' and over a 20 minute period the shape grew larger as though it were travelling towards me, and finally seemed to pass by me, almost as though I physically passed through its centre. Really spooky. There was no pain but I felt a little weird."
(Cheryl Fox, Edith Frost's Homepage, July 20, 2004)
A similar example can be seen in the following animated illustration reproduced by courtesy of David C. Haas, MD.
Visual migraine aura with herringbone pattern and [positive] scotoma. (David C. Haas, Headache Cybertext, Lost webpage, April 29, 1999)
Ocular migraine development narrative
"As I am writing, I am undergoing an episode of ocular migraine. I became aware of it earlier than usual.
I was reading and found that the reading portion of my bifocal was not working well and letters appeared blurry. At first I thought that my cataract was much worse, but it just happened too fast. Taking my glasses off helped somewhat.
After about five minutes, there were gaps in my field of vision. After ten minutes, I began to notice small areas with the typical zig-zag lines of ocular migraine but without the parallel striations I often see. At 15 minutes, the aura had greatly increased in size. At 20 minutes, it was of maximum size. At 25 minutes it was gone.
It is now about 30 minutes after I first noticed it. The aura appears to be completely gone. Nevertheless, I do not feel completely recovered yet."
, Newsgroups: sci.med.vision, Subject: Ocular migraine development narrative, June 29, 2001)
"I just saw your video about the aura on Youtube [see here
] ... Here is a little about myself and my experience with migraines. I've been receiving migraines, if my memory serves me correct, since the beginning of 2006, maybe even earlier. Nothing notable happened at that time as far as I know that may trigger my first migraine, except maybe an increase in hormonal growth or other pubertal effects. I am currently 19 years old. Migraines occurred regularly for me, varying to every couple of months to every week, and in some recent cases, every day. Just about every time I feel emotionally stressed (e.g., depressed), I am almost sure to have a migraine. I do not suffer from depression, just the usual short-term depression a teenager experiences. Because of this, I have to watch how I feel, trying to be optimistic as often as possible. Ever since my first year in college (I began in Fall 2009), I had migraines that happened 2 or 3 times in a row, one every day beginning around the same time as the first. Only a few have happened once at a time. Migraines became more often during my first year in college, probably because change in weather and atmosphere (moved to a new city for college), and getting less sleep due to homework (this is my fault, too much procrastination).
My migraines begin with an aura, which was closely described in your video... The central vision is ruined - letters vanish - this ALWAYS precedes the development of the arc. The arc is jagged and the zigzags appear to move up and down the arc. The arc is often very colorful - in fact it's quite a show with the eyes closed. The strange motion often leads to minor seasickness. The arc rapidly becomes very large as it drifts out to the periphery. Sometimes only a small gap is left from a complete loop. This accurately describes the auras I experience. Rarely, I get two auras, back to back. Generally, the loop forms to the right of the center of my vision, rarely to the left. Sometimes, I wake up with a migraine, so I don't get to experience the aura. Upon experiencing the aura, I get sickened. I don't think this is due to the migraine, the aura itself just sickens me. It is similar to the feeling of when you think of something that annoys you (e.g., nails scratching on a chalk board) or grosses you out. It sometimes gives me the 'shivers,' as some people call it. This sickening feeling also happens sometimes when I simply think of or envision an aura in my head. Also upon experiencing the aura, I get in either an angry, unhappy, or saddened mood. I don't think this is directly because of the migraine, but because of the inconvenience of the migraine, its horrible timing.
The aura is followed almost immediately by a small pain in my forehead, moderately growing in magnitude. The amplitude of my pain varies with my surroundings. I have found that when I'm surrounded in a busy, loud, bright location, such as an airport, the migraine usually doesn't hurt as much as usual, but the want to vomit stays the same, sometimes even worse than when I'm in a quiet surrounding. When I'm in a calm surrounding, such as laying in my room, with the lights turned off, the migraine's hurt more and tend to last longer. Once I went to class, qualifying it as a busy, loud, bright location, with a migraine. In this case, the migraine hurt as much as it would in a calm surrounding. The pain would last as short as 4 hours to as long as a day. During the migraine, it is very tough to sleep unless I sleep in between the aura and severe pain or before the aura (the aura also keeps me up, maybe because of the sickening feeling).
To provide some relief from the pain of these migraines, I put on patches... The patches always worked when I first started using them (a little more than a year ago), but recently, it has been a hit and miss on whether they work. This may be because the patches loose their healing ability if left exposed for too long (the patches come in a sealed package within the box; once opened, you can smell the aroma of the patch, which slowly loses strength over time, unless sealed). Pills have not provided any help from what I can tell. I've tried Ibuprofen (I believe the most I've tried is 600 or 800 mg).
As you can see, I've had a decently long history with migraines. I have yet to find a definite trigger of my migraines (with the exception of emotional stress). I'm still unsure if a change in weather conditions and such can trigger (I know they are popular triggers). I haven't found a food trigger or anything like that. If there is anything I can do to help, please ask...
(NN, E-Mail to Markus Dahlem, August 18, 2010; additions in square brackets by Markus Dahlem)
Migraine Art: Asthenopic scotoma. "A typical visual effect of migraine in typescript is to cause alternate letters or parts of them, all over the page, to vanish. As they reappear the same happens to those in between." © 2007 Migraine Action Association and Boehringer Ingelheim Limited
An asthenopic scotoma is a scotoma with an asthenopic mode of presentation, characterized by an abnormal fatiguability of visual function and manifesting itself as the disappearance of part or whole of a visual target after a latent time.
Cheshire Cat (see here)
Are you acquainted with similar phenomena associated with your migraine attacks? Please contact Dr Klaus Podoll if you wish to share and discuss your experiences.
Dahlem MA, Engelmann R, Löwel S, Müller SC. Does the migraine aura reflect cortical organization? Eur J Neurosci 2000; 12: 767-770.
Dahlem MA, Muller SC. Migraine aura dynamics after reverse retinotopic mapping of weak excitation waves in the primary visual cortex. Biol Cybern 2003; 88: 419-424. [PDF]
Foerster R. Lichtsinn bei Krankheiten der Chorioidea und Retina. Klin Mbl Augenheilk 1871; 9: 337-346.
Klee A, Willanger R. Disturbances of visual perception in migraine. Acta Neurol Scand 1966; 42: 400-414.
Podoll K, Robinson D. Migraine Art - The Migraine Experience from Within. North Atlantic Books, Berkeley, California 2009, p. 149-174.