Ophthalmoplegic Migraine Research Articles

Ophthalmoplegic Migraine: Two Patients, one at Middle Age with Abducens Palsy

Ophthalmoplegic Migraine: Two Patients, one at Middle Age with Abducens Palsy

Ophthalmoplegic migraine.

Ophthalmoplegic migraine is a rare condition, previously thought to represent a variant of migraine. Recent observations regarding its usual clinical presentation and common magnetic resonance imaging findings have given rise to speculation that this illness is more likely to represent an inflammatory cranial neuropathy. The recent revision of the International Headache Classification has reclassified ophthalmoplegic migraine from a subtype of migraine to the category of neuralgia. In this article, potential pathophysiological mechanisms are discussed. The typical clinical presentation of ophthalmoplegic migraine generally involves transient migraine-like headache accompanied by often long-lasting oculomotor, abducens or, rarely, trochlear neuropathy with diplopia and (if oculomotor nerve is involved) pupillary abnormalities and ptosis. Ophthalmoplegic migraine generally occurs in children, but a number of adult cases have been reported. Prognosis is good because symptoms almost always resolve, but, after several episodes, some deficits may persist. Differential diagnosis is rather large, although most other possible causes of ophthalmoplegia and headache have distinctive presentations or can be excluded with fairly straightforward diagnostic testing. Optimal prophylactic and acute treatment is still unclear, but migraine prophylactic medications such as b blockers and calcium channel blockers have been proposed. Steroids have been used with mixed results.

Ophthalmoplegic migraine

Ophthalmoplegic migraine is a rare presentation of migraine complicated by an isolated oculomotor paresis. Vasodilation of extracranial vessels is believed to underlie the headache, and vasoconstriction to account for the ophthalmoplegia. Whether the vascular insult involves the central or peripheral portions of the oculomotor nerve is still uncertain. We describe a child who presented with ophthalmoplegic migraine and was demonstrated to have a deficiency of the near triad documented by eye movement and pupillary recordings. Voluntary conjugate eye movements—saccades, smooth pursuit, and optokinetic nystagmus—were normal. Vergence amplitudes appropriate to fixation distance were elicited for Snellen optotypes but not to a point source of light. Concurrent measures of pupillary diameter failed to reveal significant modulation to either stimulus. Brain magnetic resonance imaging scan was normal, and there was no contrast enhancement of the oculomotor nerve at its exit from the midbrain. Both the oculomotor paresis and concurrent presence of a deficiency of the near triad localized the vascular insult to the oculomotor nerve complex in the brainstem.

MRI Findings and Effectiveness of Cyproheptadine in Two Patients with Ophthalmoplegic Migraine

MRI Findings and Effectiveness of Cyproheptadine in Two Patients with Ophthalmoplegic Migraine

Magnetic resonance imaging in ophthalmoplegic migraine of children

Purpose: To present 2 children with ophthalmoplegic migraine and characteristic magnetic resonance imaging (MRI) findings post enhancement with gadopentetate dimeglumine diethylenetriamine pentaacetic acid (Gd-DTPA). Methods: Two patients, ages 3 years and 7 years, underwent MRI during the acute phases of a recurring oculomotor palsy. MRI was repeated several weeks later as symptoms resolved. Results: In both cases, enhancement and thickening of the cisternal segment of the oculomotor nerve were present at initial presentation. Ophthalmoplegia resolved spontaneously in 1 child and after steroid treatment in the other. Both postresolution MRIs demonstrated decrease in enhancement and thickening of the third nerve. Conclusions: The enhancing, thickened lesion identified on MRI in our patients may represent an inflammatory process similar to Tolosa-Hunt syndrome occurring in the interpeduncular segment of the oculomotor nerve. Patients with ophthalmoplegic migraine may, therefore, benefit from the use of steroids. MRI of the brain post enhancement is a useful adjunct in the diagnosis and treatment of ophthalmoplegic migraine and should be considered as part of a workup of ophthalmoplegic migraine in children. (J AAPOS 2001;5:307-10)

Migraine variants.

The term "migrant variant" is not used in the headache classification of the International Headache Society (IHS), but it includes those forms of migraine that are not typical of migraine with or without aura. Headaches that do not quite fulfill all of the IHS criteria are termed "migrainous disorder." Migraine associated with auras arising from unusual sites includes basilar migraine, retinal migraine, and ophthalmoplegic migraine. Two of the chromosomal sites for hemiplegic migraine have been identified. Migraine aura may occur without headache and an aura may be prolonged. Migrainous infarct has occurred when the aura lasts more than 1 week or imaging studies are positive and other etiologies have been ruled out. If the migraine attack is prolonged beyond 3 days the term "status migrainousus" is applied.

Painful ophthalmoplegia with reversible carotid stenosis in a child

Painful ophthalmoplegia in childhood has different causes. One is Tolosa-Hunt syndrome, in which a first episode may be difficult to diagnose because of its clinical similarity to ophthalmoplegic migraine. A 10-year-old male with painful ophthalmoplegia and a cavernous sinus inflammation associated with an intracavernous carotid stenosis demonstrated by magnetic resonance imaging and angiography is reported. These findings resolved in follow-up imaging. This report suggests that in the presence of painful ophthalmoplegia, magnetic resonance imaging detection of cavernous sinus inflammation can facilitate the diagnosis of Tolosa-Hunt syndrome when other causes are excluded.

A Pediatric Case of Ophthalmoplegic Migraine with Recurrent Oculomotor Nerve Palsy

Purpose: A young patient of ophthalmoplegic migraine with recurrent oculomotor nerve palsy is reported. Case: A 4-year-old girl came to our hospital complaining of recurrent left ptosis and double vision which completely resolved within a few days. She had a history of drowsiness after vomiting every two months. Left oculomotor nerve palsy with internal ophthalmoplegia was observed. Electroencephalography revealed mild changes, but computed tomography, single photon emission computed tomography, and cerebrovascular Doppler-ultrasound examination demonstrated no abnormalities. This oculomotor nerve palsy completely improved on the next day. Results: Thereafter, left episodic mydriasis and oculomotor nerve palsy occurred twice each. However, the frequency and symptoms of migraine were remarkably reduced by topical administration of 0.25% timolol maleate twice daily to both eyes. Conclusion: In isolated oculomotor nerve palsy in childhood, ophthalmoplegic migraine should be also considered. We emphasize that a detailed case history is very important to its diagnosis.

Recurrent isolated ptosis in presumed ophthalmoplegic migraine of childhood

Purpose To report a rare case of isolated, recurrent unilateral eyelid ptosis as the sole manifestation of ophthalmoplegic migraine in a healthy young girl. Design Single observational case report with review of the literature. Testing Serologic evaluation, electromyographic, nerve conduction and Tensilon testing, magnetic resonance and computerized tomographic imaging, and magnetic resonance angiography were performed. Main outcome measures Four-year descriptive history of recurrent eyelid ptosis. Results Between 1994 and 1998, seven discrete episodes of right upper eyelid ptosis without ophthalmoplegia or pupil abnormality occurred. On each occasion, spontaneous resolution occurred over a period of 6 to 10 weeks. Extensive clinical and laboratory evaluation, including testing for myasthenia gravis and magnetic resonance cerebral angiography, was unremarkable. Conclusions Recurrent isolated ptosis is a rare manifestation of presumed ophthalmoplegic migraine in childhood. As far as we are aware, this has not been previously reported.

Random comments: neurologists and neuro-ophthalmology; the "ocular motor" system; and update on ophthalmoplegic migraine.

In this brief commentary, I recount the entry of neurologists into the field of neuro-ophthalmology, which was previously regarded as exclusively within the purview of ophthalmology. I then quickly describe the difference between "oculomotor" and "ocular motor," before summarizing "ophthalmoplegic migraine," a rare condition with a rich history that engendered a heated debate among legendary neurological luminaries in 1946.

Midriasis unilateral benigna episódica. Caso clínico en un niño

Pupil asymmetry is an alarm signal which should lead to investigation to rule out severe underlying neurological disorders. Among its causes are tumors, aneurysms and hernia of the uncus. The differential diagnosis should also include other conditions such as Adie's tonic pupil, the Pourfour de Petit syndrome and local disorders such as closed angle glaucoma or segmental spasm of the iris dilator muscle. In practice however, exposure to mydriatic substance is one of the commonest causes. Another cause of this sign is benign episodic unilateral mydriasis. This uncommon condition has been defined as an isolated benign cause of pupil asymmetry. The underlying physiopathology is not always clear and may involve either parasympathetic deficiency or sympathetic hyperactivity affecting the iris. Usually related to migraine, some authors classify it as a limited form of ophthalmoplegic migraine, although some cases have been described with no accompanying headache. We describe a case of benign episodic unilateral mydriasis in a six-year-old girl who presented with intermittent episodes of pupil asymmetry with no other neurological symptoms. We underline the rarity of this condition in children with no simultaneous headache.

Oculomotor nerve schwannoma associated with ophthalmoplegic migraine

PURPOSE: To describe a patient with an oculomotor nerve schwannoma who had symptoms of ophthalmoplegic migraine. METHODS: Case report. RESULTS: A 23-year-old woman had a history of recurrent headache accompanied by transient right oculomotor palsy since age 7 years. Ophthalmoplegic migraine was diagnosed. She was subsequently found to have a structural lesion of her right oculomotor nerve on magnetic resonance imaging. The magnetic resonance image characteristics were consistent with schwannoma originating from the oculomotor nerve. CONCLUSIONS: This case illustrates that an intrinsic lesion of the oculomotor nerve (schwannoma) may be associated with a painful relapsing-remitting oculomotor palsy mimicking the clinical syndrome of ophthalmoplegic migraine.

Neuroophthalmologic manifestations of systemic disease

Significant contributions on the neuroophthalmologic manifestations of systemic disease have been published in the past year. The first part of this paper is devoted to practical guidelines that may help in the diagnosis and the management of oculomotor disorders, especially in connection with systemic diseases; the second part is focused on specific entities. Including idiopathic intracranial hypertension and ophthalmoplegic migraine in this review might be debatable; however, although the cause of these conditions is still unclear, relevant findings suggest that they may be the consequence of other adjacent processes rather than the cause itself. We believe that the diagnosis of idiopathic intracranial hypertension as well as that of ophthalmoplegic migraine remains a challenging issue for the ophthalmologist and may easily be overlooked.

A Case of Ophthalmoplegic Migraine: Swelling and Gd-DTPA Enhancement of the Oculomotor Nerve on MRI

A Case of Ophthalmoplegic Migraine: Swelling and Gd-DTPA Enhancement of the Oculomotor Nerve on MRI

117 Transient oculomotor paresis due to a swelling of the third nerve: a possible cause of ophthalmoplegic migraine

117 Transient oculomotor paresis due to a swelling of the third nerve: a possible cause of ophthalmoplegic migraine

Enhancement of oculomotor nerve: A diagnostic criterion for ophthalmoplegic migraine?

The oculomotor nerve of a 6-year-old boy with recurrent headache and recurrent ophthalmoplegia was contrast-enhanced on a magnetic resonance imaging (MRI) scan during an episode. The boy exhibited dramatic response to steroid treatment. The clinical features of ophthalmoplegic migraine and Tolosa-Hunt syndrome overlapped in this patient. We suggest that a positive MRI finding can be included as one of the diagnostic criteria in the classification of ophthalmoplegic migraine and that a trial of steroid is worthwhile in the presence of enhancement of the oculomotor nerve since ophthalmoplegic migraine may be noninfectious but inflammatory in etiology.

Diagnosis of migraine.

Migraine headache is a common and increasing problem in the United States; it is under-recognized and under-reported. The clarification of headaches by the International Headache Society (IHS) has become the standard for the diagnosis of migraine and other headache disorders. It categorizes most migraine headaches under the following diagnosis: migraine without aura, migraine with aura, ophthalmoplegic migraine, and retinal migraine. Diagnostic criteria used to make the diagnosis of migraine include such factors as the location and character of headache pain; the extent to which pain inhibits function; the effect of physical activity on the pain; and the presence of nausea, vomiting, photophobia, or phonophobia. Proper use of the IHS classification and diagnostic criteria is important for accurate diagnosis and treatment of migraine, as well as for standardization of patients for research protocols.

Ocular palsy and CIPD

To the Editor: The interpretation of an observation with the potential to evolve into an unprecedented causal association [1] must be guarded. In the absence of tissue/definitive diagnosis or assistance from MR studies, meticulous attention to differential diagnosis is essential. Besides intracranial aneurysm, [1] ophthalmoplegic migraine (OM) as well as Tolosa-Hunt syndrome are both rare but important diagnoses that must be …

Ophthalmoplegic migraine

Ophthalmoplegic migraine is a rare condition usually beginning in infancy or childhood and characterized by paralysis of ocular cranial nerves in association with vascular headache. The diagnosis is one of exclusion. Most patients should have high resolution magnetic resonance imaging (MRI) or magnetic resonance angiography (MRA) to eliminate the possibility of aneurysm, tumor, or granulomatous inflammation.

A Contrast Enhanced Lesion of the III Nerve on MR of a Patient With Ophthalmoplegic Migraine as Evidence for a Tolosa‐Hunt Syndrome

A 23-year-old female with a six year history of migraine without aura twice developed a nearly complete internal and external III nerve paresis ipsilateral to her headache, two days after the onset of migraineous headache. An MR scan performed one week after the second episode showed a contrast enhanced lesion of the prepontine III nerve, where it enters the cavernous sinus on the left side. The headache, as well as the paresis ameliorated spontaneously. We suggest this is a further well documented case of "ophthalmoplegic migraine" which might reflect Tolosa-Hunt syndrome.