Migraine is considered a multifactorial disease, the irritant of which is unknown. Hypothesis of the occurrence of migraine: in genetically predisposed individuals, long-term negative factors (chronic stress) cause - through cortico-nuclear pathways - excessive constriction of the pupils, which is manifested by significant activation of the parasympathetic nervous system. Constricted pupils (reduction in light flux) through the optic-vegetative system irritant pathological biochemical processes in the body, which leads to a deterioration in the physical and psychological conditions of patients with migraine.       

It is proposed to introduce medical pupil dilation into the treatment protocol for migraine (and all somatic and mental illnesses) in order to eliminate the negative impact on the body of an overly activated parasympathetic nervous system.

Keywords: migraine, pupil, optic-vegetative system, parasympathetic nervous system, mydriatics.

Migraine is a multifactorial disease with a hereditary predisposition, the irritant of which is unknown.^1,2 Symptoms: recurrent headaches, sensitivity to light, sound and smell, nausea, vomiting.^2,3 The prevalence of migraine is up to 15% in the population. Migraine develops more often in women of productive age who have a family history of this disease.             

Irritant for migraine attacks can be: stress, anxiety, depression; sudden changes in weather; lack of sleep or excessive sleep; hunger; hormonal changes; sensory stimuli: bright light, loud sounds, strong odors; physical overload; use of certain medications: sleeping pills, vasodilators, contraceptives.^4,5 The physiological processes that mediate the relationship between these factors and migraine are still unknown. The pathogenesis of migraine is not fully understood.¹         

The occurrence of migraine is associated with increased excitability of n.trigeminus cells. These cells have sensitive endings in the membranes of the brain and blood vessels, and during a migraine attack they release biologically active substances that lead to inflammation, dilation of cerebral arteries, irritation of pain receptors in the blood vessels.³ Scientists attribute a leading role to the neuropeptide CGRP; but blocking its action is ineffective, as are other existing methods of treating migraine (sedatives, analgesics; acupuncture, massage, reflexology; serotonin and norepinephrine reuptake inhibitors, tricyclic antidepressants, triptans; botulinum toxin; neuromodulation).⁵       

Let's look at the problem of migraine through the eyes of an ophthalmologist. Migraine attack irritants, in addition to the above negative factors, are: prolonged computer work (especially at night); prolonged reading.⁷ These conditions cause excessive pupil constriction. It is logical to assume that other negative factors - migraine attack irritants - cause similar changes in pupil width.             

It is known that “all diseases are from nerves.” Long-term negative factors cause chronic stress in genetically predisposed individuals, which causes - through cortico-nuclear pathways - excessive constriction of the pupils.            

Narrowed pupils (reduction in light flux) irritant pathological biochemical processes in the body through the optic-vegetative system, which leads to a deterioration in the physical and psychological condition of patients.            

Where there is a “weak link” in the body (which is genetically programmed) - there it “breaks” (i.e., a pathological process is implemented).             

Indeed, everything in the human body is interconnected. The eye is an important component of the optic-vegetative system: eye-hypothalamus-pituitary gland. Due to the stimulating effect of light in the body, hormones are produced by the endocrine glands: pituitary, adrenal, thyroid, sex and others. That is, the eyes provide not only vision, but also the harmonious development of all organs and systems of the body.         

If the organism - through the cerebral cortex, hypothalamus, reticular formation - affects the size of the pupil, then, according to the principle of "direct connection - feedback", the size of the pupil also affects the entire organism.

When the pupil is dilated, the mood is upbeat, the person is physically and intellectually active; when the pupil is constricted, the mood, physical and intellectual activity are reduced.^8–10         

So, during migraine, due to the action of negative factors, excessive constriction of the pupils occurs, while the parasympathetic nervous system is significantly activated, which is realized in the expansion of cerebral vessels; nausea, vomiting. There are also changes in the psyche of patients: anxiety, depression.               

Based on the above, we can say that excessively narrowed pupils irritant migraines.

The following facts support this hypothesis.

1. It has been found that pupil size is significantly reduced during a migraine attack compared to the inter-attack phase in migraine patients.¹¹
2. A shift in pupillary balance towards the parasympathetic nervous system has been established in patients with migraine.¹²
3. Dry eye syndrome has been found to be common in migraine.^3,13–15 We have hypothesized that the trigger for this syndrome is excessively constricted pupils.¹⁶
4. It has been established that migraine is often comorbid with hypertension, diabetes, and obesity.² We have substantiated that the irritant for these diseases is excessively constricted pupils.¹⁷
5. It has been established that patients with migraine often suffer from psychoemotional state (anxiety, depression, etc.). We have substantiated that the irritant for depression and other mental illnesses is excessively narrowed pupils.^8–10          

What do we offer?

Dilate the pupils of migraine sufferers.           

This can be done in the following ways:

1. Eye drops - mydriatics.
2. Activation of the sympathetic nervous system: physical exercise, limited use of gadgets, communication with family and friends, sufficient sleep, positive emotions, etc. The best prognosis is for those people who believe in God and do good deeds.
3. Wearing sunglasses (in case of excessive insolation) also dilates the pupils.            

I would like to share my practical experience.

In September 2025, patient P., 48 years old, contacted us regarding the selection of reading glasses.

Visual acuity of the right eye: 0.3 / 1.0 with sph-0.75D; left eye: 1.0. On examination of the eyes - the anterior segments and the fundus are normal. The pupils are round, photoreactive, 3 mm in diameter. The visual field and intraocular pressure of both eyes are normal.            

For a working distance of 40 cm, glasses are selected: right eye +0.5D; left eye +1.25D.

When collecting the history, it was found that the woman had been suffering from migraines (recurrent pain in the right side of the head) for 20 years. The irritants of the attack are: bright light, stuffiness, lack of sleep, intellectual or physical fatigue. The frequency of attacks is 3-5 per month. The attack is preceded by an olfactory aura - the smell of pepper is felt. The attack is accompanied by pronounced vegetative symptoms (excessive activation of the parasympathetic nervous system): rhinorrhea, nausea, vomiting, diarrhea. The duration of the attack, on average, is 12 hours. The symptoms are slightly relieved by taking a triptan drug (serotonin receptor agonist).            

We recommended that the patient use a mydriatic (cycloplegic) in the eye on the affected side of the head for subsequent migraine attacks. A week later, the patient called back and reported that she had used the mydriatic (along with her usual treatment) for a migraine attack. The duration of the attack was reduced to 3 hours.

It is important to note that the use of dilation drops (mydriatics or cycloplegics) may temporarily blur near vision due to the relaxation of the accommodative muscles. In some sensitive individuals, this blurred vision can itself lead to mild eye strain or even headaches. Therefore, it is essential to weigh the benefits of reduced migraine intensity against this potential temporary side effect. Proper patient guidance and dosage adjustment can help minimize discomfort while maintaining the therapeutic effect.           

It is necessary to pay attention to the following point: myopization of the eye in this patient on the affected half of the head. In our opinion, this can be explained as follows: during migraine attacks in the past, the pupil of the right eye was narrowed for a long time (more than in the left eye), this led to a pronounced weakness of accommodation and the eye, compensatory, myopized to reduce the load on accommodative apparatus.¹⁸ Kavuncu SK. et al. also noted a shift in refraction towards myopia in patients with migraine.¹²          

In addition, myopia is usually accompanied by moderate mydriasis - which, theoretically, can alleviate the course of a migraine attack. Due to the initial mydriasis (in the inter-attack period), myopic eyes form slightly less miosis (than in emmetropic and hyperopic eyes) during a migraine attack, which causes less activation of the parasympathetic nervous system, and, accordingly, alleviates the symptoms of the disease.            

That is, myopization of the eyes during migraine can be considered as a compensatory reaction of the body to this disease.          

The case described by us demonstrates the advantages of pathogenetic treatment of migraine - the effect on the irritant of the disease (an excessively narrowed pupil). The use of cycloplegics during a migraine attack not only alleviates headache and associated symptoms, but also prevents vision loss. It has been established that during a migraine attack, the vessels of the fundus narrow, which is often accompanied by deterioration or loss of vision.^1,19           

It is known that the cycloplegic atropine is used in retinal vascular occlusion. It dilates the pupil and dilates the vessels of the fundus, improving vision. Therefore, the use of cycloplegics during a migraine attack is justified from all points of view.              

Of course, randomized controlled trials are needed to thoroughly confirm the feasibility of the proposed method of migraine treatment - with the inclusion of mydriatics (cycloplegics) in the protocol.          

Summarizing the above, we believe that the irritant for migraines may be excessively constricted pupils and treatment should begin with their dilation with medication.          

By the way, the positive effect of triptan drugs on migraine attacks can be partially explained by their effect on pupil width (serotonin - the concentration of which in the body increases due to triptans - is the “happiness hormone”, and when the mood improves, the pupils dilate).

Migraine can be triggered by excessively constricted pupils (due to chronic stress), which is manifested by significant activation of the parasympathetic nervous system with worsening of the physical and psychological conditions of patients.         

It is proposed to introduce medical pupil dilation into the treatment protocol for migraine (and all somatic and mental illnesses) in order to eliminate the negative impact on the body of an overly activated parasympathetic nervous system.

None.

The authors declare that there are no conflicts of interest.

None.

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