Cotton Wool Spots May Be Associated With Visual Disturbances in Migraines

Branch Retinal Vein Occlusion (BRVO)
A case series details the link between cotton wool spots and migraines both with and without scotoma.

The following article is a part of conference coverage from the 2021 meeting of the North American Neuro-Ophthalmology Society, being held virtually from February 20 to 23, 2021. The team at Ophthalmology Advisor will be reporting on the latest news and research conducted by these leading experts in neuro-ophthalmology. Check back for more from the NANOS 2021 Meeting.


Researchers presenting a case series at the North American Neuro-Ophthalmology Society Annual Meeting reviewed the cases of 4 patients with migraines who also displayed areas of retinal whitening, known as cotton wool spots. The researchers state that their series suggests an association between the finding and migraines, but that the diagnosis should only be made after extensive workup and exclusion of other known causes of cotton wool spots.

In this case series, 4 patients (a 27-year-old woman, a 30-year-old woman, a 38-year-old man, and a 40-year-old man) all presented with cotton wool spots to the neuro-ophthalmology clinic, each with a past medical history of migraine. All except the 38-year-old also presented with a new scotoma in a single affected eye described as a “smudge,” “grain of rice,” or “sausage.” In the 1 patient whose migraines were previously undiagnosed, the cotton wool spots were an incidental finding. However, a month after its discovery, he experienced a new typical migraine with visual aura and without headache.

All patients were evaluated using coagulopathy, vasculitis, and infectious workups as well as typical measurements of vital signs. All testing was negative. They were also given a complete ophthalmic evaluation and were found to have normal intraocular pressures, best corrected visual acuities, and visual fields. 

Their research is not the first to explore the link between migraines and cotton wool spots. A 2018 investigation also pointed to the stronger likelihood for patients who experience migraines to present with cotton wool spots as well as vasospastic symptoms, poor temperature control, blood pressure regulation, and even permanent vision loss as a result of retinal artery occlusion, the poster shows.

However, cotton wool spots can also be associated with a number of additional systemic issues, such as hypertension, diabetes, infectious diseases, inflammation, or as the result of trauma. 

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Yuan P, Micieli J. Cotton wool spots in patients with migraine. Presented at: North American Neuro-Ophthalmology Society Annual Meeting; February 20-23, 2021; Poster 176.