Retinal Migraine (unilateral visual symptoms)

[LogicRising]

It was always a dream to fly, but never thought it would be an option financially. Recently, I came to the realization that I could comfortably afford private pilot lessons. So I built the home simulator, became a student of youtube, reread my FAA glider flying handbook from the last bout of flying I did 7 years ago, and started to plan out the whens and wheres of my training.

Then, out of nowhere in May, I started experiencing a vision problem. I'll suddenly see a gray or black spot at a random location within a few degrees of center of vision in one eye. These have the same characteristic as if I had just been looking at the bright reflection of the sun off a shiny surface, where the presence of an afterimage becomes evident when blinking. The spot is always about the size of an aspirin tablet held at arms length or smaller, never in both eyes, persisting for an average of 15 minutes, then gradually disappears. This is the only symptom. It does not cause any difficulty reading or driving, but tends to occur about 10-15 times per month.

My first visit was to an ophthalmologist, who did a complete exam and found no abnormality in either eye. He said at the time that I was probably experiencing something called "retinal migraine" which is a monocular form of migraine which occurs in and around the retina. He said that not all people with migraines experience the headache pain. He referred me to a neurologist to rule out other etiologies.

I've since had a negative brain MRI, negative carotid ultrasound, and a slew of blood tests showing normal results. I've had a couple of visits with the neurologist who has not given me an official diagnosis (or really even an opinion). I see a neuro-ophthalmologist in September, and given the history and literature I think there is a fair chance she will diagnose retinal migraine.

Assuming this course, what is the likelihood that this will dash my dreams of getting a 3rd class medical? How do you guys think I should approach this?

Thanks for reading!

 

[flyingron]

Migraines with aura (the visual disturbance) isn't issuable while you are still having periodic episodes. However, the spot in your vision doesn't sound like a typical migraine aura (I do agree that the auras may precede the actual head pain which may be very slight). Usually, the aura is descrbed as waving, flashing, or scintillating. Hopefully, the neuro-optho will have a better idea of what is going on.

 

[Lindberg]

Migraines with aura (the visual disturbance) isn't issuable while you are still having periodic episodes. However, the spot in your vision doesn't sound like a typical migraine aura (I do agree that the auras may precede the actual head pain which may be very slight). Usually, the aura is descrbed as waving, flashing, or scintillating. Hopefully, the neuro-optho will have a better idea of what is going on.

That's incorrect, as long as the frequency is low. Classic Migraine (migrane with aura) is issuance by the AME. Ocular migraines are not. OP is not describing migraine with aura. Since this started out if the blue, the OP needs to figure out what the trigger is and avoid it. But if diagnosed with ocular migrane, he may need to take prophylaxic meds to make FAA happy.

OP: here's the guide for AMEs on headaches: https://www.faa.gov/about/office_or...me/guide/app_process/exam_tech/item46/amd/ha/

Read that and the CACI chart. Tread carefully. Consider whether Sport Pilot or finishing your glider rating might be a better choice than a rating that would require an FAA medical.

 

[Lindberg]

There's also the possibility your not experiencing migraines at all. You say a single small spot that looks like a bright flash. A few years ago, I had annoying spots in my peripheral vision. Went to the eye doctor, no loss of acuity and no loss of peripheral vision. Opthomologist and retinal specialist found nothing over several visits. Eventually, he came to the conclusion that I was experiencing normal floaters, seeing them more that usual due to new work environment, and was just fixating on it. When I stopped looking for them, they went away. We all have normal spots in our vision. Even blind spots that the brain hides from us. Just something to think about. If none of the doctors can find anything, it might just be something you're noticing more now that you're paying attention to it.

 

[LogicRising]

That is a good point about the possibility of it not being caused by migraine. Given all of the negative tests there might also be a fair chance that this remains a mystery without diagnosis, but I am certain this is not a floater.

I've read all of the FAA literature I could find, including the AME guides you mention. It just seems incomprehensible to me that a transient spot appearing in one eye that doesn't affect reading or driving might preclude a 3rd class medical, while issuance can be granted for those who only have vision in one eye at all to begin with. It also seems strange that the FAA has decided to be more restrictive for migraine visual symptoms if they only occur in one eye as opposed to both simultaneously.

My plan is to wait on contacting an AME or pursuing anything else aviation until I can get some kind of diagnosis or closure from these specialists, even if it's an "I don't know, and there is nothing else I can do". Given the FAA's stance on "migraine", that might even make it easier.

Thanks for the responses. I'll keep you guys updated.

 

[murphey]

Another possiblity - allergies.

 

[bbchien]

Visual migraine is EXCLUDED from CACI. The spot cannot be central, frequency has to be less than once per month.....

....need Neurologist description, to include frequency, treatment...onetime MFI, Oohthalmology evaluation, and humphrey 24-2 visual fields, each eye separately.....

 

[LogicRising]

If it is as black and white as you describe (although I'm not sure what 'central' means when the visual disturbance is so small) then there is a fair chance I'll end up having to find a school that will do a sport certificate unless this stops happening (with treatment or otherwise). That's unfortunate and frustrating, but doable since there is no actual safety concern in my case.

To be continued!

 

[bflynn]

A couple of points about the FAA medical system.

1) the FAA will approach problems based on the diagnosis, even of that diagnosis is wrong. So, you’ve had a diagnosis of reticular migraine and that is what you will have to prove it isn’t now. Dr. Chien has laid out the testing needed.

2) if you have any conditions for your medical, never just get get a FAA medical exam to “find out”. Failing a medical exam disqualifies you from being a pilot of any kind. If there is anything out there, contact the AME and ask for a consult. If there is testing to be done, make sure you understand exactly what the testing is, what level of testing needs to be done, what the pass criteria are and what the time frames are. Then go get the tests before your medical and have everything ready. It is much faster and surer if you have all the testing nderstood, already done, and submitted with your medical than to have to get a deferral and then go back and forth with the FAA under time frames which sometimes they cannot even meet. You should never go into your medical with any open questions.

3) there is a flying option called Sport Pilot which only requires a drivers license (And a pilots license) but no medical exam. The airplanes are limited to 1320 gross weight, 120 knots, daytime VFR, and two seats - you +1. No medical exam is needed....but if you fail the above medical exam, you are also disqualified from sport. So again, never go into an FAA medical with any question that you don’t understand. I’m not familiar with gliders, but I believe they are a similar situation.

 

[LogicRising]

Yes I certainly don't want to just waltz into the AME's office unprepared and botch it forever.

Just to pass along my update - I just had my second (and likely final) follow-up with the neurologist. He doesn't know what the cause is. We discussed the possibility of it being retinal vasospasm (a.k.a "retinal migraine") and he was reluctant to issue that diagnosis because the visual phenomenon I describe is so small and I don't have any other symptoms. Apparently retinal migraine is normally associated with much more dramatic visual deficits (e.g. complete blindness in one eye or blindness over half the visual field, flashes and scintillations) and produces other symptoms like headache. He deferred making any diagnosis to the neuro-ophthalmologist.

I like to stay as proactive as I can, so I started researching where I would be able get training for sport pilot. So far, the options look quite limited / far away, but I am reading that the FAA is slated to lift some of the LSA restrictions (e.g. 1320lb MGTOW) by 2023 so I acknowledge that may further enrich the sport pilot privilege in the not too distant future.

Meanwhile I still hold hopes for an eventual 3rd class medical, and intend to do a consult (either with a local AME and/or perhaps Bruce Chien) depending on what happens with this long-term.

Thanks for the responses!

 

[Eldorado]

I would get a definitive diagnosis with a neurophthalmologist as sugggested by the neurologist. A definitive diagnosis involving a sudden neurological symptom needs to be evaluated. The ophthalmologist and neurologist are both uncomfortable giving you a diagnosis. A retinal migraine is a possibility, but so are focal seizures and restricted blood flow from other causes.

 

[LogicRising]

It seems to have abruptly stopped occurring late last month after happening 13 times in August (knock on wood).

Discussed the symptoms with the neuro ophthalmologist who did a slit lamp exam and told me everything looks healthy. He says he does not think it's "retinal migraine" (vasospasm). In fact, he seemed to think it's floaters. I told him I disagreed. He said even if it isn't floaters, there isn't any pathology in the literature which causes what I describe, and since it never caused a visual deficit I should just forget about it and call him back if it ever returns and gets worse.

He took detailed notes on audio recorder which sounded quite favorable and I asked him to send me a copy once it is transcribed. Perhaps this won't be an issue after all?

 

[Lindberg]

It seems to have abruptly stopped occurring late last month after happening 13 times in August (knock on wood).

Discussed the symptoms with the neuro ophthalmologist who did a slit lamp exam and told me everything looks healthy. He says he does not think it's "retinal migraine" (vasospasm). In fact, he seemed to think it's floaters. I told him I disagreed. He said even if it isn't floaters, there isn't any pathology in the literature which causes what I describe, and since it never caused a visual deficit I should just forget about it and call him back if it ever returns and gets worse.

He took detailed notes on audio recorder which sounded quite favorable and I asked him to send me a copy once it is transcribed. Perhaps this won't be an issue after all?

You seem disappointed to learn that there's no pathology. Our bodies are not perfect. Stuff happens. Especially as we age, it might just take getting used to the fact that things don't work exactly the way they used to or we wish they did. Make sure you get the complete report from the neuro ophthalmologist for your AME and you'll likely have no issues.

There's also the possibility you're not experiencing migraines at all. You say a single small spot that looks like a bright flash. A few years ago, I had annoying spots in my peripheral vision. Went to the eye doctor, no loss of acuity and no loss of peripheral vision. Opthomologist and retinal specialist found nothing over several visits. Eventually, he came to the conclusion that I was experiencing normal floaters, seeing them more that usual due to new work environment, and was just fixating on it. When I stopped looking for them, they went away. We all have normal spots in our vision. Even blind spots that the brain hides from us. Just something to think about. If none of the doctors can find anything, it might just be something you're noticing more now that you're paying attention to it.

 

[Eldorado]

Congratulations, you got an expert opinion and he found no pathology and followup only if it gets worse or new symptoms. I’d continue to monitor it, but forget about it unless it becomes worse. I’d put down “floaters” as the diagnosis whether I agreed or not.

 

[bbchien]

Congratulations, you got an expert opinion and he found no pathology and followup only if it gets worse or new symptoms. I’d continue to monitor it, but forget about it unless it becomes worse. I’d put down “floaters” as the diagnosis whether I agreed or not.

Terrible idea. The agnecy can get the diagnosis codes if it desires.

Falsification of the record is not a sweet deal. Last I looked it's a class 4 felony.

 

[Eldorado]

Falsification of the record? The neurophthalmologist said he did not have a retinal migraine, but had “floaters”. What diagnosis did the neurologist give? Nothing. The ophthalmologist could not make a definitive diagnosis. All his lab tests were negative. What is false about vitreous floaters? Do you think he needs more tests till something comes up abnormal?

 

[bbchien]

He’s going to have to disclose the entire evaluation and not simply report “floaters”. The problem is that retinal Vasospasm is a sibling to epilepsy. I would disclose EVERYTHING unless the diagnosis of “floaters” in in the diagnoses.

 

[Eldorado]

My point is the ‘retinal migraine’ has been explored by an ophthalmologist, neurologist, and a neurophthalmologist, none of which could confirm this diagnosis, and the latter(a sub specialist) stated it wasn’t a retinal migraine. I did not suggest he not report his visits I merely suggested he follow the neurophthalmologist recommendation. I doubt if the FAA is going to go against the neurophthalmologist unless new symptoms occur.
.

 

[LogicRising]

I do not expect "retinal migraine" or "vasospasm" would appear anywhere in the written medical record, especially not as a diagnosis, but I will obtain records from each of these doctors to be sure.
I get the feeling that waiting a bit would be wise, especially since this is no longer occurring.

I truly appreciate all of your input.

 

[Lindberg]

I do not expect "retinal migraine" or "vasospasm" would appear anywhere in the written medical record, especially not as a diagnosis, but I will obtain records from each of these doctors to be sure.
I get the feeling that waiting a bit would be wise, especially since this is no longer occurring.

I truly appreciate all of your input.

Get your records and hang on to them. You may also want to have the neuro-opthomologist complete a form 8500-7. That's all my AME really cared about. He didn't need to see all the records or what-might-have-beens. He cared about what was. YMMV.

https://www.faa.gov/forms/index.cfm/go/document.information/documentID/185784