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OPTHALMOPLEGIC MIGRAINE
Dr
...
Darshan
...
Chudgar
Dr
...
Goudinho
MIGRAINE
Migraine is a periodic and paroxysmal protean
disorder that affects nearly 10 % of the population
...
The term migraine
stems from Galen’s usage of hemicrania to describe a periodic disorder comprising of paroxysmal
blinding hemicranial pain, vomiting, photophobia,
recurrence at regular intervals and relief by dark
surroundings and sleep
...

This oculomotor nerve paresis persisted beyond
the headache phase of the attack
...


CLINICAL DEFINITON OF MIGRAINE
To make a diagnosis of Classic or Common
migraine; the patient must have recurrent headaches accompanied with at least three of the
following six criteria:
• Recurrent abdominal pain (with or without
headache), nausea and vomiting (with headache)
...

• Complete or substantial relief after a brief
period of rest
...

• A history of migraine headaches in one or
more members of the immediate family
...

Headache usually is unilateral, but occasionally
bilateral or alternating
...

Ophthalmoplegia – including one or more nerves
and may alternate sides with attacks
...

Exclusion of the other causes; by arteriography,
surgical exploration or autopsy
...
There is a hereditary predisposition towards attacks and the cranial circulatory phenomena that attend the attacks appear to be secondary to a primary C
...
S disorder
...
The
symptom complexes or syndromes of migraine
include Common migraine, Classic migraine,
Complicated migraine, Cluster headaches and
migraine equivalents
...

Migraine in which the symptoms outlast the
headache by more than 24 hours
...


AGE OF ONSET
The majority of the patients experience their
initial attack in the first decade of life, usually
before five years of age
...

Rarely patients experience their first attack in
adulthood, but such patients almost always have a
history of typical migraine headaches with and
without aura since childhood, a family history of
migraine or both
...

The patient has a history of other types of migraine in the past
...

SEX
Ophthalmoplegic migraine does not occur more
often in women then in men, unlike most other
forms of migraine
...

FAMILY HISTORY
Rare; though not unknown , for ophthalmoplegic
migraine to have occurred in other family members; but for other varieties of migraine like “
Common “ or “Classic”; a family history is invariably found
...
If the pattern is not followed then there is
probably some cause other than migraine for the
clinical symptomatology
...
The
older children
describe pain in,
around and above
one eye, purely
unilateral at first ,
but at the height
of severity pain
becomes less
localizable
...

Ptosis begins at the time of severe pain and then
followed by diplopia , which ceases when the
ptosis becomes complete
...
Nevertheless some patients with
ophthalmolegic migraine have a complete oculomotor nerve paresis except for total sparing of
pupil
...
Recovery is seen as improvement of ptosis and improved
ocular moility or pupilllary constriction to light or
near stimulation
...
Here
however may come the most important diagnostic

Vol
...
3

feature, the symptoms and signs, still unilateral ,
affect solely the side opposite from the first
occasion
...

Gradually as the child gets older these attacks
die out, often replaced by the more familiar varieties of migraine
...
More than
one ocularmotor nerves maybe affected during an
attack of ophthmoplegic migraine
...


been suggested :

PATHOGENESIS
The pathogenesis is
unclear
...

Two theories have
Compression theory
Ischemic theory
Some have ascribed ophthalmoplegic migraine to
compression of one or more of the ocularmotor
nerves by a dilated or oedematous intracavernous
portion of the Internal Cavotid Artery
...
C
...

A more plausible explanation for ophthalmolegic
migraine is that during an attack, a reduction in
the blood flow through the I
...
A and perhaps
through the posterior cerebral artery or Basilar
artery, reduces flow to one or more of the
ocularmotor nerves, producing an ischemic
ocularmotor paresis
...

Other theories of the pathogenesis of
ophthalmolegic migraine are :
• Swelling of the posterior cerebral artery
• Pitutary
swelling
• Unilateral
brain
swelling
SEQUELAE
As a rule
oculomotor
paresis recovers
completely
...
However diplopia is rare
because of visual suppression
...

DIFFERENTIAL DIAGNOSIS AND INVESTIGATIONS
Features favouring the diagnosis of ophthalmoplegic migraine include concomitant or subsequent headaches that fulfil the criteria for the
diagnosis of migraine and a family history of
migraine, along with elimination of other possible
causes, which invariably requires a CT scan
...
The most common site of
such an aneurysm is at the junction of the internal
Carotid and the posterior communicating arteries
or at the junction of the Basilar and the superior
cerebellar arteries, at the tip of the basilar artery,
within the cavernous sinus
...

Myasthenia can be ruled out if the pupil is

97
involved and also to response to edrophonium
(tensilon)
...

Diabetic
ophthalmoparesis
– rarely occurs in
children, beside
the
ophthalmoparesis
that occurs in
patients with
diabetes
melliteus, hypertension, giant cell
arteritis , other
systemic
vasculopathies
persist longer than the ophthalmoplegia associated
with migraine
...

In a few cases of ophthamoplegic migraine the
MRI showed enhancement and enlargement of the
cisternal portion of the oculomotor nerve which
spontaneously resolved after two and four years
...

TREATMENT
Very little evidence is available that there is any
effective treatment for a particular attack, which in
any case is self limiting
...
Attempts to treat with steroids to
reduce the endomural oedema have raised equivocal results, but if one started treatment at the very
onset of an attack, this might constitute a measure
for ending the attack swiftly
...
The most likely possibility appears to be an orbital or retro- orbital
inflammatory reaction – The Tolosa – Hunt Syndrome, which consists of recurrent attacks of
orbital and periorbital pain and ophthalmoplegia
...

REFERENCES
1
...
J
...
Blau
2
...
Walsh and Hoyts – clinical neuro ophhalmology
volume II Section 4
4
...
Ophthalmoplogy
...

5
...
Neurologia
...
Diagnostic problems in painful ophthalmoplegia
...
1999 Apr ;20(2) 838-41
A case of ophthalmoplegic migraine
...
1999 Jan – 31(1) : 54 – 8
...
Oculomotor nerve schwannoma associated with
ophthalmolegic migraine
...
1999 Nov; 128(5) : 658 – 60
...
Resolution of MRI abnormalities in third nerve in

Vol
...
3

ophthamoplegic migraine
...
1999 Sept;
19(7) : 655 – 9
...
Enhancement of oculomotor nerve
...
Pediatr –
neurol
...

10
...
Cephalalgia
...

11
...

Headache
...

12
...
Headache
...

13
...

Headache 1993 May; 33 (5): 234 – 7
...
Ophthalmoplegic migraine
...
1990 Jan ; 81 (1) : 54 – 60
...
Internal ophthalmoplegia and migraine
...
1988 June 28(5) : 372 – 3
...
Internal ophthalmoplegia in complicated
migraine
...
1987 Oct; 27(9): 489 – 90
...
A case simulating ophthalmoplegia migraine
...
1985 Nov 25 (8): 426 – 8
...
A case of ophthalmoplegia migraine
...
1985 Oct; 25(7) : 372 – 5
...
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