SUBACUTE ANGLE CLOSURE MISDIAGNOSED AS MIGRAINE CHRONIC HEADACHE

SUBACUTE ANGLE CLOSURE MISDIAGNOSED AS MIGRAINE / CHRONIC HEADACHE IN MIDDLE AGED SOUTH INDIAN POPULATION Poornima Kandasamy 1, Ajita Sasidharan 1 1 Glaucoma, Sankara eye hospital, Coimbatore, India.

INTRODUCTION: Headache is one of the most common symptoms of subacute angle closure attack. Recurrent headaches has become more common in people who does concentrated near work for long time. Unilateral headache is often misdiagnosed as migraine and treated. Simple Gonioscopy and a laser Iridotomy may alleviate recurrent headaches due to occludable angles.

AIM / PURPOSE: To determine the percentage of middle age patients with subacute angle closure misdiagnosed as migraine / chronic headache.

STUDY METHOD: Descriptive study All the middle aged patients with history of chronic headache including those diagnosed as migraine attacks attending the ophthalmology out patient department at a tertiary eye care hospital were included in the study. An elaborate history was taken. Examination including visual acuity, retinoscopy, intraocular pressure by applanation tonometry, Gonioscopy, Slitlamp bio microscopy to assess optic disc cupping were done. All the patients with occludable angles on Gonioscopy were noted and underwent laser peripheral Iridotomy. All the patients were followed up to note the recurrence of headache.

STUDY METHOD: 136 patients aged between 39 to 51 years (average 44. 5 years) were evaluated in the study. 40 -45 patients were treated as migraine in the past after neuro evaluation. There were 132 female and 4 male patients in the study. 108 out of 136 (79. 4%) in the study group had occludable angles on Gonioscopy. None of the patients received Topiramate in the past. 95 out of these 108 patients (88%) were involved in occupations requiring concentrated near work. Among 108 patients with occludable angles who underwent laser Iridotomy. 97 patients (89. 4%) had no recurrence of headache in the 6 month follow up period.

FREQUENCY 160 140 136 108 120 100 80 FREQUENCY 60 40 20 0 Total patient occludable angels

PATIENTS 108 95 OCCLUDABLE ANGELS OCCUPATION REQUIRING NEAR VISION

PATIENTS 108 97 IRIDOTOMY DONE NO RECCURANCE OF HEADACHE

CONCLUSION: There is a high incidence of subacute angle closure in middle aged patients with chronic headache on our population. Subacute angle closure attacks are often misdiagnosed as migraine attacks. It is more common in middle aged female patients doing concentrated near work. All middle aged patients with chronic headache need to be evaluated by glaucoma specialist/ophthalmologist.

Discussion: Headache may be unilateral / bilateral Pain around the eye radiating to the forehead / occipital region has been the usual description of headache in most of our patients. Occupation seems to be most important in all these patients , people who does concentrated near work for long time / dim light (teachers, tailors, weavers, beautician, painters). Stress is an aggravating factors. Middle aged people who accommodate for long time can go for intermittent pupillary block (due to increase in lens volume and decrease in anterior chamber depth due to aging) resulting in subacute angle closure attacks. Asian females are affected when compared to males due to shorter axial length and anterior chamber depth Any type of chronic headache must be screened for occludable angels

Reference: 1. Schindler KS, Sankar PS, Volpe NJ, Pilts Seymour JR. Intermittent attacks of headaches as the presenting sign of subacute angle-closure glaucoma. Neurology 2005 Sep 13; 65(5)757 -8. 2. Nesher R, Hering-Hanit R, Nesher G. Subacute glaucoma masquerading as migraine. How to avoid the pitfall and make the diagnosis. Postgrad Med 2006 Sep -oct; 119(3): 70 -3