Migraine art

Marcia Wilkinson, Derek Robinson

CEPHALALGIA Wilkinson M, Robinson D. Migraine art. Cephalalgia 1985;5:151-7. Oslo. ISSN0333-1024

An analysis is made of 207 drawings and paintings entered for a migraine art competition. Alltypes of visual disturbances were depicted. One hundred and fifty-four of the paintingsshowed spectral appearances with fortification or teichopsia in 99. Sixty-two showed either apartial or complete hemianopic loss. Metamorphopsia was seen in 32 and pain was depictedin some form or another in 80. Situational or trigger factors were shown in 23. • Hemianopia,migraine, teichopsia, visual disturbances

Marcia Wilkinson, The City of London Migraine Clinic, 22 Charterhouse Square, London, ECI;Derek Robinson, WB Pharmaceuticals Ltd., P.O. Box 23, Bracknell, Berks RG12 4YS;Accepted 1984 12 24

In 1973 one migraine sufferer noted "Like most other people suffering from migraine I get visualdisturbances. I've tried to depict these in my paintings, although it's a little difficult at times, as the patternschange in form . . . If the colours are strong, they're superimposed and tend to blot out my field of vision. Onthe other hand, the wavering grey patterns-they're like shimmers of light criss-crossing and swirling roundeach other-you can be right in the midst of these but still see through them. Then there are cellophanepatterns. It's like watching shallow waves rippling across the sand. The ripple is there yet you can see rightthrough and below it."

The visual impact created by the paintings of this migraine sufferer suggested an untapped source ofinformation about the visual disturbances in migraine, and inspired the first National Migraine Art Competitionwhich was jointly sponsored by the British Migraine Association and WB Pharmaceuticals. Competitors wereasked to draw or paint their own impressions of any of the forms of visual disturbance which heralded aclassical migraine attack or depicted the effect migraine has on their lives. The competition was open to allresidents of the British Isles who suffered from migraine. Entries from non-migrainous individuals were notaccepted.

A total of nearly 300 entries were received but many people put in more than one entry and somecompetitors wanted to have their pictures back. This left a group of just over 200 for analysis.

The standard of the entries was on the whole very high and included at least one artist and some otherprofessionals. The similarity of the visual disturbances shown in the entries was very striking but it is extremelyimprobable that there was any collusion. It is therefore reasonable to suppose that the pictures gave anaccurate representation of what the sufferer saw. There were many which were very similar to those of earlierdrawings of the visual aura and there was one in particular which was almost identical to one shown in apaper of Gowers (1) in 1904 (Figs. 1, 2). There was a similarity not only between the entries but over theyears.

From the earliest times mystics have seen visions, and in some cases it has been suggested that thesecould have been migrainous phenomena brought on by fasting and the other stressful circumstances of thevisionaries' lives. Descriptions of migraine go back to the time of Aretaeus but one of the first writers todescribe and draw pictures which were undoubtedly migrainous in nature was Hildegard of Bingen(1098-1180). She was a nun and a mystic who experienced many visions starting in her earliest childhoodand continuing through her life. Charles Singer (2) gives a good description of these in his book. "From myinfancy up to the present time I, being now more than seventy years of age, have always seen this light in myspirit

not with external eyes, nor with any thoughts of my heart nor with help from the senses. But my outward eyesremain open and the other corporal senses retain their activity. The light which I see is not located but yet ismore brilliant than the sun, nor can I examine its height, length or breadth and I name it the cloud of livinglight."

"These visions which I saw" she repeatedly assures us, "I beheld neither in sleep nor in dream nor inmadness, nor with my carnal eyes, nor with the ears of the flesh, nor in hidden pieces, but wakeful, alert, withthe eyes of the spirit and with the inward ear, I perceived them in open view according to the will of God."

In all her visions a prominent feature is a point or a group of points of light which shimmer and move,usually in a wave-like manner and are most often interpreted as stars or flaming eyes. In quite a number ofcases one light larger than the rest exhibits a series of concentric circular figures of wavering form and oftendefinite fortification figures are described radiating in some cases from a coloured area.

Other writers have given descriptions of their visual disturbances but it was not until the nineteenth centurythat a more careful evaluation of their medical significance was made.

One of the difficulties in studying migraine and the visual disturbances in particular, is that reliance has tobe put on the description given by the individual sufferer. Fortunately many physicians and other professionalssuffer from migraine themselves and they perhaps are our best observers.

Clinical material

Two hundred and seven pictures were included in this study. Of the 207 entrants, 148 (71%) were womenand 51 (25%) men. The remaining eight did not identify themselves.

The analysis of a group such as this is necessarily subjective and more than one label could be put onsome of the entries. Where there was such a doubt the picture was entered under each heading. Onehundred and fifty-four (70%) showed spectral appearances, 99 (48%) fortification spectra, 34 (16%) visualloss and 5 (2.5%) mosaic vision. Pain was represented in 80 (39%) and metamorphopsia in 32 (16%).Twenty-three (11%) entries showed either the condition which brought migraine on or the situation themigrainous patient found himself in.

The term spectral appearances or photopsia was used to include all who saw stars or who portrayedstars, flashes of light, etc. One hundred and fifty-four entrants showed such spectral appearances.Fortification spectra or teichopsia were represented in 99 contributions.

In the majority the primary colours, red, blue and yellow, predominated, but in some, green was added.The angulation of the fortification spectra varied, the more acute angles usually being in the middle and themore obtuse angles at either end. The angles varied in the different drawings.

Sixty-two (30%) entrants showed a hemianopic loss (Figs. 3, 4) either partial or complete in their drawings.In 37 (59%) the loss was right-sided and in 25 (41%) left-sided. Thirty-four patients had some visual loss. In29 it was central, in two peripheral and there was a lower half loss in two and an upper half loss of vision inone.

Metamorphopsia or alterations of shape or objects seen with distorted contours was shown in 32 entries.The face, head or eyes were distorted in 13 and in one, the head was that of a serpent. There were five inwhich the hand was abnormal; in one of which there was elongation of the fingers and nails and in anotherthe hand and foot were joined. Another drawing represented the sufferer as a pill bottle (Fig. 5). Mosaic vision(Fig. 6) was shown by five and micropsia by two. One patient showed distorted furniture in her room, anothera clock with the figures much larger on one side of the face and the numbers broken up, and two drewbuildings tilted away from the norm.

Pain

Pain was depicted in some form or another in 80 (39%) of the drawings. The most dramatic were those whichshowed the skull being gripped or squeezed by a variety of objects.

These included a spanner, a mole grip, a metal band, a steel cap with a vice (Fig. 7) and a strand of barbedwire being tightened round the head. Another five pictures showed the skull being fractured or broken or thehead being attacked with a tin-opener, hammer, hammer and nails, chopper, saw, drill, knives or a screw. Inone there was a coach bolt through the neck. In nine there was a heavy weight on top of the head-in someopening up the skull (Fig. 8). Tears were drawn in five and many represented pain as an enlarged eye withflashes of light round it. Thirteen depicted the sufferer holding his head or with hands over his eyes.

Situation or trigger factors

These were depicted in 23 drawings (11%). Three showed the effect on reading and two the effect on driving,and 14 showed some of the trigger factors which might precipitate an attack. Two depicted the anxiety of themigraineur and another two the need to go to bed and the vomiting.

Incidence of visual disturbances

Alvarez (3) studied 618 persons with migrainous scotomas and found that 12% of men and 0.7% of womenhad visual disturbances without ever having a headache. The migrainous men who usually only had a mildheadache or none at all were the ones most likely to have a brilliant and typical zigzag scotoma. In a group of44 migrainous physicians, 38 said that they had "solitary scotomas". Many of the descriptions in the earlierliterature are by professional men such as Hubert Airey (4) in 1868, and later Lashley (5) and Alvarez (3) in1960.

One of Sir William Gowers' patients was a distinguished water-colour artist and the winner of last year'scompetition was also an artist (Fig. 9).

Types of visual defect

In migraine the visual phenomena can be divided into two main types-those in whom there is partialobliteration or absence of vision in a limited portion of the visual field, Lashley's inhibitory process, and whathas been described as spectral appearances (Lieving (6), Gowers (7)) or an excitatory process. Either ofthese phenomena may occur separately but commonly an attack contains evidence of both. In addition tothese specific defects up to 90% of migraineurs suffer from photophobia (8).

Obliteration or partial loss of sight

There have been many descriptions of this over the years, but that of Lieving is as good if not better thanmost. "The obliteration or partial loss of sight is limited at the beginning to a small portion of the visual fieldwhich may be centric or eccentric. If it corresponds to the macula where the sense is most acute, it directlyinterferes with the vision and it is immediately apparent to the patient, especially if he is using his eyes on anynear object at the time." Gowers (7) says that the loss of sight is always imperfect. "There may be suddendimness of vision or there may be lateral limitation of the field extending from one side and not reaching thecentre, and that the resulting hemianopia may not be complete. In other cases a spot of dimness maygradually increase in size and spread towards the periphery. The degree of loss varies and it is oftendescribed as a 'cloud' but the darkness may be noticeable only when a bright light is looked at. As the darkspot increases in size, it often clears at the centre. When spectral appearances occur they may commenceas a bright spot gradually expanding or they may develop out of this area of dimness. The bright appearancemay be combined with an area in which vision is dimmed or lost. The area in which there is loss may presenta dim luminosity as if occupied by minute particles of luminous sand in constant mohicular movement. Thebright spectrum may surround the area of dimness."

A more recent classification is that of Klee (9) where he divides his patients into those who have total lossof vision, those with hemianopic loss and those with dimness of vision.

One of the best accounts of an hemianopic loss is that given by Alvarez of his own visual

disturbances: "Once when I had a scotoma as I was driving my car along a narrow country road, I must havehad a left hemianopia because suddenly I discovered a car a few yards away bearing down on me. I had notseen it as it approached. It is curious that just before this happened I was not conscious of this decided defectin the left half of my field of vision."

One of the entrants in the competition drew a picture depicting a similar situation (Fig. 10).

Spectral appearances

The visual disturbances of migraine present as their most frequent feature the zigzag or angled characterwhich is called the "fortification spectrum" (Figs. 11, 12). In this, the outer edge of the luminous spot assumesa zigzag shape with prominent and re-entrant angles like the ground plan of a fortification and hence called"fortification spectrum". Photopsia, according to Klee, are coloured geometrical figures in the visual fields.The most common types of photopsia are small spots, dots or stars (Fig. 13), or the zigzagged fortificationspectrum. The aura are usually confined to one half of the visual field and the classic description of these isthat of Dr Airey, and has been called the expanding angled spectrum (Fig. 14). "A bright stellate objectappears in one side of the combined fields. This rapidly enlarges, first as a circular zigzag but on the innerside, towards the medial line. The regular outline becomes faint and as the increase in size goes on theoutline here becomes broken, the gap becoming larger as the whole increases, and the original circularoutline becomes oval."

The spectral appearances may be of any colour and the lines which constitute the angled outline mayvary in length. The luminosity may be broken or continuous at their junction. Many of the angled lines presentconspicuous colours, bright red, dark blue and yellow.

The region of inhibition may also be one of subdued discharge. When seen in the dark, the region nearestthe limiting line presents a bright scintillation.

During an attack the angled spectrum may develop progressively. The loss of sight is always within theangled oval and outside the limiting line vision is preserved. Within it, vision may be totally lost. At first the lossis over the whole area, afterwards, when the sphere is broken and has become oval, the loss is most intenseclose to the limiting line and becomes less towards the middle.

Perceptual disturbances

There may be disturbance of visual perception as well as impairment of vision and spectral appearances in amigraine attack. These disturbances can be divided into those who see objects with distorted contours,changes in size, changes in position (Fig. 15), changes in colour, visual perseveration or disappearance ofobjects. In some cases there is re-duplication of an object or person or a positive after-image.

Alterations of shape are called metamorphopsia and Critchley (10) has described metamorphopsia ofcentral origin; in this, alterations in the appearance of objects may be either long continued or of a fleetingepisodic occurrence. He considers that this symptom occurs with lesions adjacent to the occipital lobe andthe geniculo-striate radiations. This and other phenomena are described in Alice in Wonderland as Todd (11)has pointed out. Alice, in the story, sometimes became remarkably tall (macropsia) or short (micropsia) andwas conscious of changes in herself and her environment (derealization). She sometimes addressed herselfas though she was two people (somatopsychic duality) and sometimes puzzled over her own identity(depersonalization). She also suffered from illusionary changes in size, feelings of levitation and hadalterations in the sense of passage of time. Todd suggests that in the Wonderland syndrome the site of thelesion is in the parietal lobe.

Critchley reports a patient with a temperoparietal glioblastoma in which objects for a short time seemedsmaller than usual.

Significance of disturbances

One question that is sometimes asked is "do

the visual disturbances indicate organic dysfunctions?" The answer to this is probably "yes", because over theyears the descriptions have remained constant. In the recent competition, sufferers were asked to draw orpaint what they thought of their migraine. These drawings could be divided into three main types-the actualvisual disturbances seen; the type of pain which the sufferer experienced and what could be described as"the migraine situation". Some were able to combine two or three of these aspects in one picture. The strikingthing about the pictures was that not only were they well executed, but that they were so similar and so likethe descriptions of the nineteenth century neurologists a hundred years earlier.

Lashley (5) showed that in his case the scotoma started as a disturbance of vision limited to theneighbourhood of the macular area and spread rapidly towards the temporal field, but noted that in others,spread from the temporal to the macular region might also occur. In an attack the area might be totally blind(negative scotoma), amblyopic or outlined by scintillations. As the scotomata are symmetric for the two eyesthey are almost certainly the result of a cortical disturbance. The scotoma usually occurred first as a smallblind spot subtending less than 1 degree in or immediately adjacent to the foveal field. The spot rapidlyincreased in size and drifted away from the fovea towards the temporal side of the field. He found that eachscotoma had a distinct shape and that when there were fortification figures, these also maintained theircharacteristic pattern. The rate of scintillation was 10 per second. A wave of intense excitation waspropagated at a rate of about 3 mm per min across the visual cortex and was followed by complete inhibitionof activity. The usual duration of the visual symptoms is 10-20 min, in Lashley's case 10-12 min, for spread ofthe outer margin from the region of the macula to the blindspot of the homolateral eye and the total timerequired to spread from the macular area to the temporal field about 20 min. In one patient in the series (Fig.16) the type of spread was slightly different but again the time of the attack was 20 min. Many patients reportthat for hours after a scotoma there may be increased sensitivity to light.

Lashley points out that a negative scotoma may completely escape observation even when it is just off themacula unless it obscures some object to which attention is directed. He quotes his own case when "talkingto a friend, I glanced just to the right of his face when his head disappeared. His shoulders and necktie werestill visible, but the vertical stripes in the wallpaper behind him seemed to extend right down to the necktie.Quick mapping revealed an area of total blindness covering about 30 degrees just off the macula. It wasquite impossible to see this as a blank area when projected on the striped wall or other uniformly patternedsurface although any intervening object failed to be seen."

Milner (12) was one of the first to recognize the significance between Lashley's inferences and theproperties of spreading depression.

Leão's (13) spreading depression can be set off by high potassium levels in the extracellular space andthere are many other effective triggering stimuli including trauma, anoxia, mechanical, and chemical stimuli.In a spreading depression there is a very profound, probably complete, depression of neuronal activity.

The phenomenon persists in any one region for a minute or two and is followed by complete recovery. Itprogresses through the tissue at about 3 mm/min and the affected tissue is typically only a few millimetreswide. After each wave there is a refractory period of about a minute. Gardner-Medwin (14) also considers thatit is probable that spreading depression does occur during attacks of classical migraine.

For many years it has been thought that the focal disturbances which occur in classical migraine were dueto vasoconstriction and subsequent headache to vasodilation. Studies on regional blood flow by Olesen (15,16, 17), and his colleagues suggest that the vasoconstriction may persist and that in classical migraine thereis no subsequent vasodilation. Their studies have shown a wave of reduced blood flow originating in theposterior part of the brain which progressed

anteriorly. The oligaemia advanced at a speed of 2 mm per min over the hemisphere, progressing anteriorly,but not crossing the Rolandic or Sylvian sulcus. The regional hypoperfusion appeared before and outlastedthe focal symptoms. The rate of progression within the individual lobes was about 2 mm per min, whichcorresponded fairly well with the known rate of Leão's spreading depression of 3 mm per min. As a result ofthese studies it was concluded that the focal symptoms were not secondary to the oligaemia but that thefocal symptoms and blood flow changes may be secondary to spreading depression of Leão.

In a classical migraine attack the ischaemic changes in the cerebrum are widespread, as has been shownby Olesen (15, 16, 17) and his colleagues and others. Sacks (18) points out that in a migraine attack themore complex disorders of function usually occur after the simple phenomena. That is to say the dots andstars may be succeeded by scintillating scotoma or the more bizarre alternatives of perception such as zoomvision, mosaic vision or the elaborate dream-like states that may occur. Like many other writers, Sacks doesnot think that local cortical ischaemia can explain all the aspects of a migraine attack.

Klee (19) on the other hand thinks that migraine might be primarily caused by a dysfunction of thevertebro-basilar system. The observations of Mullan and Penfield (20) in epileptics with a dominant lefthemisphere showed that visual illusions arise predominantly from the temporal cortex of the hemisphere thatis minor for handedness and that illusions of familiarity were associated with electrical stimulation of the samearea, while illusions of feat resulted from stimulation of the anterior part of either temporal lobe.

Other writers have thought that the scotoma might originate in the retina, the optic nerves, the chiasma,the optic tracts or the geniculate bodies, but the consensus is that the lesion is in the visual cortex.

Peatfield and Rose's (21) case would seem to confirm this as they report the case of a woman whoseeyes were enucleated in early childhood but who developed episodic sick headaches at the age of eight.When she was nine she started to have visual disturbances-bright flashes of light passing across the visualfield to the left.

Discussion

The Migraine Art competition produced many surprises, not the least of which was the standard of entriessubmitted.

Two letters which accompanied entries are worth noting: "Enclosed please find three paintings to beconsidered for the Art competition. One is mine, one from my 17-year-old son and one from my 27-year-olddaughter. We thought that you may like to see a family interpretation. Each painting was done without anyknowledge of what the other two members were doing, and we were surprised to find similarities when theywere compared." "I have suffered with migraine since my early teens and I am now 70. The only time that Ihave been free from them was during my 31/2 years as a prisoner of war with the Japanese. The stress therewas often at breaking point, so I cannot think that this was a contributory factor. I therefore reached theopinion that it must be richer foods that caused them, as my own diet was two small bowls of rice per dayplus water."

It has been suggested on many occasions that the migraine sufferer is more obsessional than thenon-migraineur. Without wishing to enter a debate, the following is submitted for consideration: Of 218 postalentries submitted for the competition, 156 indicated a postal code in their address (71.1%).

The Migraine Art competition gave the opportunity of seeing a great number of drawings and paintings ofpeople's ideas of what they saw and experienced during an attack. Prior to this most people interested inmigraine either drew their own visual disturbances or had a few patients who drew their's. Never before hasthere been an opportunity to compare and collate such a large series. The advantages of this are that onecan observe the recurring trends- hemianopia and fortification spectra appear in a large number. The sametypes of disturbance are found recurring and there was a marked similarity between drawings made

in the nineteenth century and those entered in the 1980 competition.

The visual sensations experienced by the migraine sufferer remain the most dramatic part of the wholesyndrome. At times their validity has been questioned as they can only be described by the sufferer, but the largenumber of similar representations probably confirms their organic nature.

Acknowledgements.-Our thanks are due to the British Migraine Association and WB Pharmaceuticals for theirkindness in giving us permission to reproduce the paintings, and to WB Pharmaceuticals for subsidizing the coloursupplement. We are also most grateful to Mrs. P. Kasserer for her help in preparing this paper.

References

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