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persistent visual aura

  • 1.  persistent visual aura

    Posted 12-11-2025 09:46
    Hi all,

    I have an 18 yo pt who for the last 1-2 yrs has been experiencing visual disturbances almost like things are "moving in slow motion, or fish-eye like in a concave/convex mirror, sometimes in association with light sensitivity". 

    I have characterized it generally as possible persistent visual aura related to alice-in-wonderland syndrome. She did not respond to any CGRP or typical migrainous therapies such as topamax/propranolol, but then had a marked response to lamictal w/near complete resolution for the last several months, but has been having significant tolerance issues w/the med and wants to try something different. She does appear to have dose-responsiveness to the lamictal. 

    Does anyone have any suggestions for another similar med that might treat 'persistent visual aura' in this way similar to lamictal? I'm wondering about possible oxcarbazepine or vimpat?

    thanks,
    Nathan


  • 2.  RE: persistent visual aura

    Posted 12-11-2025 13:06
    I have had good success with such symptoms using nortriptyline. 

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    Obada Subei, M.D. 
    Chief Executive Officer
    www.brainandeye.org
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  • 3.  RE: persistent visual aura

    Posted 12-19-2025 19:05
    You might try the cocktail of riboflavin, Co-Q 10 and mag citrate. 





  • 4.  RE: persistent visual aura

    Posted 12-19-2025 20:47
    Great cocktail except for mag citrate, which does not cross the bbb. Only Mg threonate does and that's why this is the only Mg form that helps migraine. 
    +=+=+=+=+=+=+=+=+=+=+=+=+=+=+=+=+=+=+=+=
    Scott Forman, MD
    Senior Fellow North American Neuro-ophthalmology Society

    Adult and Pediatric Neuro-ophthalmology
    Comprehensive Ophthalmology
    Functional Medicine












    Original Message


  • 5.  RE: persistent visual aura

    Posted 12-21-2025 18:43

    The form that was studied in a clinical trial and shown to be beneficial was mag oxide. A lot of medications for migraine work peripherally (such as triptans); crossing the BBB is not necessary.

    Deb




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  • 6.  RE: persistent visual aura

    Posted 12-22-2025 08:19
    Mg Oxide, deb does not cross the blood brain barrier in sufficient quantities hence too high doses are needed. Mg Threonate is the only one that does.
    +=+=+=+=+=+=+=+=+=+=+=+=+=+=+=+=+=+=+=+=
    Scott Forman, MD
    Senior Fellow North American Neuro-ophthalmology Society

    Adult and Pediatric Neuro-ophthalmology
    Comprehensive Ophthalmology
    Functional Medicine












    Original Message


  • 7.  RE: persistent visual aura

    Posted 12-22-2025 08:40
    Dr. Friedman is saying that magnesium only needs to have peripheral action in order to have an effect for migraine, and this is presumably through a vascular effect. For migraine management typically magnesium sulfate IV or or magnesium oxide or magnesium citrate are given.  

    I am not sure of what the role magnesium has for prolonged visual aura. The original question is what anti-epileptics might work similarly to lamotrigine. Lacosamide as another sodium channel blocker seems reasonable though I would be cautious about going after persistent visual phenomena with anti-epileptics.  There is some limited evidence lacosamide might help with migraine through reduction of CGRP levels.

    Robert

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  • 8.  RE: persistent visual aura

    Posted 12-22-2025 09:32
    I am getting patients headaches reduced and even acephalgic migraines reduced in severity and frequency with Threonate form of magnesium.  So I will use this instead of other forms, since it also helps them sleep better and there is less likelihood of diarrhea. 
    +=+=+=+=+=+=+=+=+=+=+=+=+=+=+=+=+=+=+=+=
    Scott Forman, MD
    Senior Fellow North American Neuro-ophthalmology Society

    Adult and Pediatric Neuro-ophthalmology
    Comprehensive Ophthalmology
    Functional Medicine












    Original Message


  • 9.  RE: persistent visual aura

    Posted 12-22-2025 13:30
    Hi all,

    Thanks so much for the ideas and discussion. I'll have her try some different forms of magnesium and follow-up. 

    She tried to dc the lamictal and things got worse than expected so it does still to be helping, she will just see if side effects continue/to improve.

    Best,
    Nathan



    Original Message


  • 10.  RE: persistent visual aura

    Posted 12-22-2025 16:14
    I also use verapamil sometimes with success for persistent aura.
    Bart

    Bart K. Chwalisz, M.D.

    Neuro-ophthalmology, Headache Unit, and Skull Base Neurology Clinic. Division of Neuroimmunology, Massachusetts General Hospital

    Skull Base Clinic: https://www.massgeneral.org/neurology/services/treatmentprograms.aspx?id=2070

    Neuro-ophthalmology, Massachusetts Eye & Ear Infirmary




    Original Message


  • 11.  RE: persistent visual aura

    Posted 12-19-2025 20:54
    Couldn't these be a form of occipital lobe seizures? Not most typical but nevertheless. Especially that she responded so well to Lamictal?





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