Neuro-ophthalmologists outline how eye clinicians can recognize and manage headache | AAO 2026

Migraine and other primary headache disorders frequently show up first in eye clinics, and ophthalmologists can diagnose and begin treating many of them with a few targeted questions and a stepwise plan, according to a session at the annual meeting of the American Academy of Ophthalmology (AAO), held October 9 through October 12, 2026, in New Orleans.

Recognizing migraine and aura

During ‘What You Need to Know About Headache: A Pain for the Patient and a Pain for the Doctor,’ Sam Spiegel, M.D., a neuro-ophthalmologist at UCI Health in Orange County, CA, told attendees that a patient seeking care for a headache at an academic medical center has about a 75% likelihood of having a migraine. Diagnostic criteria call for at least five migraines a month lasting four to 72 hours, with two of four pain features (unilateral, pulsating, moderate to severe intensity or worsened by activity) plus nausea or both light and sound sensitivity. Because those criteria are so detailed, he said, three questions (whether headaches limit the ability to work, whether nausea occurs and whether the patient wants to shade the eyes during an attack) yield a positive predictive value of 93% when all three answers are yes.

Spiegel was joined on stage by Vivek Patel, M.D., chief of neuro-ophthalmology services at UCI Health, who said a visual aura typically builds gradually over at least five minutes, resolves within 60 minutes and comes before or during the headache. An aura that follows the headache is a red flag. Aura reflects cortical spreading depression, a wave of depolarization that moves across the visual cortex, and some patients experience it without any headache. Patel added that migraine is the most common neurologic cause of photophobia and recommended FL-41 tinted lenses, which can be worn indoors.

A stepwise treatment ladder

Every patient starts with lifestyle management, Spiegel said. "Our brains like consistency," he said, explaining that regular sleep and wake times matter more than total hours of sleep. He advises protein at every meal, hydration and 15 minutes a day of exercise that raises the heart rate. Over-the-counter supplements such as magnesium have some evidence for reducing headache frequency and can be offered to nearly everyone.

For acute treatment, nonsteroidal anti-inflammatory drugs remain first line, followed by triptans, whose main contraindication is cardiovascular disease, and gepants. Treating at the first sign of aura or pain improves the odds of stopping an attack, and patients should limit headache abortive medication, such as Advil, to fewer than 10 days per month to avoid medication overuse headache. Daily preventives such as anti-seizure medications, beta blockers or nortriptyline are appropriate when attacks are frequent or debilitating or acute therapy fails.

CGRP-targeted preventives and onabotulinumtoxinA (Botox) for chronic migraine sit at the top of the ladder, Spiegel said. Because those therapies require prior authorization and support staff that ophthalmology practices often lack, and headache clinic waits can reach nine to 12 months, he recommended referring early and starting the lower steps in the meantime.

Headaches that mimic migraine

Several less common disorders are often misdiagnosed as migraine, the presenters said. Trochleitis causes pain near the inner upper eye socket that worsens with eye movement and touch, without vision loss. Patel said it responds well to an in-office steroid and anesthetic injection near the trochlea, with oral indomethacin or prednisone as alternatives.

Red flags such as a new headache after age 50, a change in headache pattern, papilledema or cranial nerve palsy warrant imaging. Otherwise, Spiegel said, eye care clinicians should not hesitate to refer. "It's your job to make sure that they have the tools they need that can improve their life along the way," he said.