Childhood steroid-responsive painful ophthalmoplegia: Clues to ophthalmoplegic migraine

Abstract

We read with great interest the report by Zafeiriou and Vargiami, in which they presented a case of ophthalmoplegic migraine with corticosteroid responsiveness.1Zafeiriou D.I. Vargiami E. Childhood steroid-responsive painful ophthalmoplegia: clues to ophthalmoplegic migraine.J Pediatr. 2006; 149: 881Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar We also experienced a case of ophthalmoplegic migraine, which fulfilled the ICHD criteria for ophthalmoplegic migraine.2Classification Committee of the International Headache SocietyInternational Classification of Headache Disorders.Cephalalgia. 2004; 24: 1-160Google Scholar Contrast-enhanced MRI of the brain showed nodular enhancement of the exit zone of the right oculomotor nerve in our case, too. In contrast to their case, corticosteroids were not so effective in our case.3Ogose T, Manabe T, Abe T, Nakaya K. A case of ophthalmoplegic migraine with a rise in cytomegalovirus-specific IgG antibody. (in contributing).Google Scholar In another previous report, corticosteroids have been used with mixed results.4Levin M. Ward T.N. Ophthalmoplegic Migraine.Curr Pain Headache Rep. 2004; 8: 306-309Crossref PubMed Scopus (55) Google Scholar Furthermore, the value of steroid treatment in ophthalmoplegic migraine remains questionable because symptoms tend to resolve spontaneously.5Dussen D.H. Bloem B.R. Liauw L. Ferrari M.D. Ophthalmoplegic migraine: migrainous or inflammatory?.Cephalalgia. 2004; 24: 312-315Crossref PubMed Scopus (41) Google Scholar For these reasons, we do not consider the responsiveness of corticosteroid as a diagnostic criterion for ophthalmoplegic migraine. The cause of ophthalmoplegic migraine is still unclear. Recently, ophthalmoplegic migraine is more likely to represent an inflammatory cranial neuropathy with recurrence,5Dussen D.H. Bloem B.R. Liauw L. Ferrari M.D. Ophthalmoplegic migraine: migrainous or inflammatory?.Cephalalgia. 2004; 24: 312-315Crossref PubMed Scopus (41) Google Scholar so we guess that clinical reactivation of some virus, in the family Herpesviridae, causes this illness, like herpes zoster and Ramsay Hunt syndrome. In our case, serum cytomegalovirus (CMV)-specific IgG titer, measured by the fluorescent antibody method, was elevated from ×20 to ×160 during the acute phase of the disease.3Ogose T, Manabe T, Abe T, Nakaya K. A case of ophthalmoplegic migraine with a rise in cytomegalovirus-specific IgG antibody. (in contributing).Google Scholar Although CMV-related ophthalmoplegia has not been reported, the data do allow us to frame a hypothesis that ophthalmoplegic migraine may be a clinical reactivation of CMV and antiviral agents may be effective in treating some cases of ophthalmoplegic migraine. We should be most grateful if Zafeiriou and Vargiami would examine CMV-specific IgG titer in their case. ReplyThe Journal of PediatricsVol. 151Issue 2PreviewOgose et al1 raise a number of questions regarding a case of ophthalmoplegic migraine reported by us. We agree with Ogose et al that the etiological differential diagnosis of painful ophthalmoplegia is extensive and consists of numerous etiologies including vascular (eg, aneurysm, carotid dissection, carotid-cavernous fistula), neoplasms (eg, primary intracranial tumors or metastatic disease), inflammatory conditions (eg, orbital pseudotumor, sarcoidosis, Tolosa-Hunt syndrome), infectious etiologies (eg, viral, fungal, mycobacterial), and other conditions (eg, microvascular infarcts secondary to diabetes, ophthalmoplegic migraine, giant cell arteritis), most of which can be promptly recognized by a systematic clinical and laboratory approach. Full-Text PDF