From ophthalmoplegic migraine to cranial neuropathy

Tolosa-Hunt syndrome and recurrent painful ophthalmoplegic neuropathy, case reports: what to do and when?

BACKGROUND

Tolosa-Hunt syndrome (THS) and recurrent painful ophthalmoplegic neuropathy (RPON) are rare diseases reported within the "Painful lesions of the cranial nerves" section of the International Classification of Headache Disorders-3rd edition (ICHD-3). In case of a first painful attack, differential diagnosis could be challenging and many pitfalls are due to the rarity of the disorders and the lack of information about correct medical management in youngsters.

CASE PRESENTATION

Our main purpose was to report a new case of THS and a new case of RPON describing management and diagnostic investigation at the time of the first episode. In both cases of THS (13 years old) and RPON (14 years old) a unilateral periorbital headache associated with acute onset of ipsilateral third cranial nerve paresis, scarcely responding to non-steroidal anti-inflammatory drugs (NSAID), was present at the beginning of the first attack. Brain MRI with "time-of-flight" (TOF) angiography and the need to administer steroids (after 72 h from onset) in order to stop pain were the most important handles allowing us to adopt the correct management both in THS or RPON since onset and to face recurrences in RPON by avoiding useless therapy during follow-up.

CONCLUSION

Unilateral periorbital headache associated with third-fourth or sixth cranial nerve paresis should ideally be investigated with a full work-up, comprehensive of brain MRI with TOF angiography since the first attack. In cases with negative brain MRI spontaneous resolution should be considered and watchful waiting might be advisable before starting steroid therapy.

A Perplexing case of isolated abducens nerve palsy in a primigravida woman: A case report

Isolated abducens nerve palsy is a rare presentation in women during pregnancy. When an abducens nerve palsy is elicited in a pregnant woman, work-up should start with labs and neuroimaging to rule out mechanical and organic causes such as tumors, preeclampsia, and multiple sclerosis. This case report highlights a 35-year-old woman, gravida 1, para 0, who was sent to the local medical center by her ophthalmologist at 37 weeks of gestation due to a left-sided headache and blurry vision. Upon admission, work-up was negative for preeclampsia. Tick-borne disease panel and lumbar puncture were unrevealing. No other mechanical or lab abnormalities were elicited. Magnetic resonance venography revealed a diminutive left transverse sinus, left sigmoid sinus, and left internal jugular vein in comparison with the right, indicating a possible congenital variant. Labor was induced to see if this would alleviate the patient's abducens nerve palsy. After induction of labor and initiation of dexamethasone, the patient's sixth cranial nerve palsy began to improve.

Recurrent Painful Ophthalmoplegic Neuropathy: A case report with atypical features and a review of the literature

INTRODUCTION

Recurrent Painful Ophthalmoplegic Neuropathy, previously known as Ophthalmoplegic Migraine, is a poorly characterized disorder mainly because there are few cases described. We report a new case of Recurrent Painful Ophthalmoplegic Neuropathy and a review of the literature to contribute to increasing the knowledge of the clinical features of this disorder.

CASE REPORT AND REVIEW OF LITERATURE

A 45-year-old woman presented with adult-onset recurrent attacks of abducens and oculomotor palsy associated with diplopia followed by headache. Most notably, pain always presented many days after oculomotor impairment, a feature never described in the literature. A diagnosis of possible Recurrent Painful Ophthalmoplegic Neuropathy was made after excluding other possible mimicking disorders. Symptoms usually resolved gradually with corticosteroid therapy, albeit without a clear-cut benefit.Clinical data collected from 1989 to 2022 showed that adult onset in Recurrent Painful Ophthalmoplegic Neuropathy is not uncommon. While III cranial nerve palsy is typical, VI and IV nerve palsy have also been described.

PATHOPHYSIOLOGY AND DIAGNOSIS

Several hypotheses have been proposed, including nerve compression, ischemia or inflammation/demyelination, but none has been completely accepted.Diagnosis remains of exclusion; magnetic resonance imaging and blood exams are key in differential diagnosis.

CONCLUSIONS

Our case gives us the possibility to expand the clinical features of Recurrent Painful Ophthalmoplegic Neuropathy, also contributing to updating the pathophysiological hypotheses.

Recurrent Painful Ophthalmoplegic Neuropathy Mistaken for Oculomotor Schwannoma: A Case Report

Recurrent painful ophthalmoplegic neuropathy (RPON) is a headache disorder classified as a cranial neuropathy. It is characterized by episodes of unilateral headache followed by ipsilateral ophthalmoplegia due to ocular cranial nerve palsy. Symptoms usually subside spontaneously within weeks to months. RPON commonly occurs in childhood, though it is overlooked at times as a possible differential diagnosis. The pathophysiology of RPON is not entirely clear. Typical magnetic resonance imaging (MRI) findings in children include nerve thickening and gadolinium enhancement. However, these findings are not specific to this condition. Nerve thickening in RPON can resemble schwannomas, thereby causing a diagnostic dilemma. Here, we present a 13-year-old boy with a history of unilateral headaches associated with ipsilateral ptosis and diplopia. The first MRI indicated thickening and gadolinium enhancement of the right oculomotor nerve, which was interpreted as a schwannoma. However, his symptoms resolved after a few weeks and the follow-up MRI showed resolution of nerve changes. This clinical presentation was consistent with RPON. This case demonstrates the need for a careful follow-up of RPON patients.

Case report recurrent painful ophthalmoplegic neuropathy

Recurrent Painful Ophthalmoplegic Neuropathy (RPON) is a rare condition, previously known as Ophthalmoplegic Migraine, it is characterized by headache ipsilateral to paresis of the III, IV or VI cranial nerve, usually affects children or young adults. This is a report of a case of RPON in a 16-year-old woman treated at the Hospital do Servidor Público Estadual de São Paulo.

[A case of recurrent headache and ophthalmoplegia with a contrast-enhanced lesion of the oculomotor nerve in the cavernous region: an atypical phenotype of recurrent painful ophthalmoplegic neuropathy]

The patient was a 14-year-old boy with two previous episodes of self-remitting right ophthalmoplegia with right temporal pain at ages 9 and 12. In 2019, he developed right eyelid ptosis and diplopia 2 days after a pulsating right-sided temporoparietal headache. Recurrent headaches with ophthalmoplegia responded to high-dose steroid therapy, and the clinical features resembled recurrent painful ophthalmoplegic neuropathy (RPON). RPON generally presents with MRI findings of hypertrophy and inflammation at the root of the oculomotor nerve, a vulnerable site of the blood-brain barrier. However, the imaging features in this case were different from those in typical cases of RPON, and oculomotor nerve inflammation was found in the cavernous sinus. The order of onset of headache and oculomotor nerve palsy differed in each recurrence, suggesting that both autoimmune and vascular mechanisms may have been involved in the onset of the disease in our case.

Recurrent painful ophthalmoplegic neuropathy: a cause for recurrent third nerve palsy in a child

Recurrent painful ophthalmoplegic neuropathy (RPON), previously called ophthalmoplegic migraine, is a rare condition characterised by recurrent episodes of headache and ophthalmoplegia. We report a case of 11-year-old girl with recurrent painful ophthalmoplegia due to isolated right oculomotor nerve involvement. MR brain imaging showed enhancing lesion of cisternal segment of right oculomotor nerve. A possibility of Tolosa Hunt syndrome was considered and she was treated with glucocorticoids, followed by azathioprine due to recurrence. In the fourth episode, she developed migraine headache followed by right third nerve palsy, after which the diagnosis was revised to RPON. She was started on flunarizine along with short-term glucocorticoids. At 1-year follow-up, she remained asymptomatic. RPON should be considered in patients with recurrent third nerve palsy to avoid inadvertent long-term exposure to immunosuppressive agents.

Proposed modified diagnostic criteria for recurrent painful ophthalmoplegic neuropathy: Five case reports and literature review

Background

Recurrent painful ophthalmoplegic neuropathy (RPON) is an uncommon disorder characterized by recurrent unilateral headache attacks associated with ipsilateral ophthalmoplegia. We intend to study the clinical picture in our case series along with the published literature to discuss the pathogenesis and propose modified diagnostic criteria for recurrent painful ophthalmoplegic neuropathy.

Methods

We reported five cases diagnosed as ophthalmoplegic migraine/RPON in our medical centers and reviewed the published literature related to RPON from the Pubmed database between 2000 and 2020. In one of these cases, a multiplanar reformation was performed to look at the aberrant cranial nerve.

Results

The mean onset age for RPON was 22.1 years, and the oculomotor nerve was the most commonly involved cranial nerve (53.9%) in 165 reviewed patients. In most patients, ophthalmoplegia started within 1 week of the headache attack (95.7%, 67/70). Additionally, 27.6% (40/145) of patients presented enhancement of the involved nerve(s) from MRI tests. Finally, 78 patients received corticosteroids, out of which 96.2% benefited from them.

Conclusion

This is the first time multiplanar reformation has been performed to reveal the distortion of the oculomotor nerve. Modified diagnostic criteria are proposed. We hope to expand the current knowledge and increase the detection of recurrent painful ophthalmoplegic neuropathy in the future.

A Case of Recurrent Painful Ophthalmoplegic Neuropathy

Ophthalmoplegic migraine (OM) is characterized by recurrent episodes of headache with unilateral ophthalmoplegia due to paresis of cranial nerve III, IV, or VI. The recent revision to the International Headache Classification has reclassified it as recurrent painful ophthalmoplegic neuropathy (RPON). However, it is of note that the presentation of oculomotor nerve tumors may mimic RPON. Here, we report the case of a patient presenting with recurrent migraine and oculomotor palsy with several specific magnetic resonance imaging (MRI) findings. The patient was initially diagnosed with migraine 15 years ago, but since 10 years ago, his symptoms had evolved to include repeated oculomotor paralyzes. Before this attack, the patient did eventually recover completely each time after the initial episode. MRI performed during this attack revealed a nodular enhancing lesion described as schwannoma of the left oculomotor nerve, and on diffusion-weighted imaging (DWI), the nerve was isointense to the midbrain. The nodular enhancement became weaker, and the nerve's signal on DWI disappeared 3 months later as the patient's symptoms resolved mostly. This is the first case of RPON demonstrating an obvious change in signal of the affected nerve on DWI during the attack and remission.

Facial Pain: A Comprehensive Review and Proposal for a Pragmatic Diagnostic Approach

BACKGROUND

Facial pain, alone or combined with other symptoms, is a frequent complaint. Moreover, it is a symptom situated at, more than any other pain condition, a crosspoint where several disciplines meet, for example, dentists; manual therapists; ophthalmologists; psychologists; and ear-nose-throat, pain, and internal medicine physicians besides neurologists and neurosurgeons. Recently, a new version of the most widely used classification system among neurologists for headache and facial pain, the International Classification of Headache Disorders, has been published.

OBJECTIVE

The aims of this study were to provide an overview of the most prevalent etiologies of facial pain and to provide a generic framework for the neurologist on how to manage patients presenting with facial pain.

METHODS

An overview of the different etiologies of facial pain is provided from the viewpoint of the respective clinical specialties that are confronted with facial pain. Key message: Caregivers should "think outside their own box" and refer to other disciplines when indicated. If not, a correct diagnosis can be delayed and unnecessary treatments might be given. The presented framework is aimed at excluding life- or organ-threatening diseases, providing several clinical clues and indications for technical investigations, and ultimately leading to the correct diagnosis and/or referral to other disciplines.

Are some ophthalmoplegias migrainous in origin?

The 3rd edition of the International Classification of Headache Disorders replaced the term ophthalmoplegic migraine (OM) with Recurrent Painful Ophthalmoplegic Neuropathy (RPON) based on the presence of contrast enhancement of the involved cranial nerves on Gadolinium-enhanced magnetic resonance imaging. We review our experience and publications concerning ophthalmoplegia, migraine, and RPON. Majority of cases of acute ophthalmoplegia are associated with severe migrainous headaches. A positive history of migraine, increased severity of migraine headaches before the onset of ophthalmoplegia, and the close temporal association between migraine attacks and ophthalmoplegia all suggest an important role played by migraine in the causation of ophthalmoplegia. Enhancement of the involved cranial nerves may be due to the neuro-inflammatory cascade associated with migraine. OM should be considered along with RPON in differential diagnoses of painful ophthalmoplegic syndromes.

The Neuralgias

PURPOSE OF REVIEW

Neuralgias are characterized by pain in the distribution of a cranial or cervical nerve. Typically, they are brief, paroxysmal, painful attacks, although continuous neuropathic pain may occur. The most commonly encountered conditions are trigeminal, postherpetic, and occipital neuralgia. Less common neuralgias include glossopharyngeal, superior laryngeal, auriculotemporal, and nervus intermedius neuralgia, among others. The approach to diagnosis and treatment of this group of disorders is reviewed.

RECENT FINDINGS

Recent guidelines of medication administration, the use of botulinum toxin, and more targeted procedures have improved treatment of neuralgias. Patients who present with neuralgias should have imaging studies to investigate for structural abnormalities unless the etiology is apparent. Management of both common and rare neuralgias can be challenging and is best guided by the most recent available evidence.

Monocular diplopia-associated migraine-like headache induced by nicotine withdrawal

We describe an extremely rare case of migraine‐associated monocular diplopia developed in a 23‐year‐old man after sudden cessation of smoking. The physical examination and brain MRI scan were unremarkable. The symptoms resolved after starting nicotine patch. We reviewed the literature and discussed the diagnosis and possible mechanism of this phenomenon.

Facial pain: Overlapping syndromes

Premise This review summarises the pain syndromes that overlap between headache and facial pain and overlap between pain and cranial nerve lesion. Problem These syndromes share two features in common. First, they show both cranial nerve impairment (e.g. palsy, autonomic dysfunction) and pain; second, they have inflammatory (and/or small vessel) processes as the underlying mechanism. A typical representative of these syndromes is recurrent painful ophthalmoplegic neuropathy, which was previously called ophthalmoplegic migraine and was regarded as a migraine subtype. It is now supposed that this syndrome is caused by an inflammation of one of the ocular motor nerves. Other syndromes discussed in this review are optic neuritis, Tolosa-Hunt syndrome, ischaemic ocular motor nerve palsy, and the very rare Raeder's syndrome. Treatment of all these syndromes is mainly based on steroids. Potential solution Management of possibly underlying disorders such as multiple sclerosis or atherosclerosis should also be considered.

"WHICH Headache to Investigate, WHEN, and HOW?"

PREMISE

Headache is a common problem in medical practice. The International Classification of Headache Disorders (ICHD-3 beta)¹ divides all headaches into two broad categories. Most headaches seen in practice belong to the category of primary headaches, where there is no underlying structural cause identifiable. Less than 10% headaches in practice belong to the category of secondary headaches where there is an underlying condition, that can sometimes be ominous and life-threatening.

PROBLEM

Fear of missing a treatable serious secondary headache disorder is the most important reason why we need to investigate headache patients. There is no dilemma in investigating the patient when the clinical presentation is straightforward but when the headache presents differently or with 'red flags,' it can sometimes be quite challenging to order the right investigation and rapidly arrive at the right diagnosis.

POTENTIAL SOLUTIONS

This article looks at some of the elusive headache scenarios and outlines an approach that addresses the issue of 'appropriate' investigation in the headache patient. With advancing technology and increasing expertise, the author feels it is time now to do away with the practice of ordering an exhaustive battery of tests in all headache patients. With experience, clinicians can learn to choose tests judiciously and order specific tests based on a working diagnosis. As the title suggests, knowing 'WHEN to order WHAT test in WHICH headache patient? ' forms the theme of this article.

Headache in a high school student - a reminder of fundamental principles of clinical medicine and common pitfalls of cognition

Primary headache disorders account for the majority of the cases of headache. Nevertheless, the primary objective of a physician, when encountered with a patient with headache is to rule out a secondary cause the headache. This entails a search for specific associated red-flag symptoms or signs that may indicate a serious condition, as well as a heightened suspicion of and evaluation for a don't miss diagnosis.

We present a case of a high-school student whose first manifestation of systemic lupus erythematosus (SLE) was a headache due to cerebral venous and sinus thrombosis, initially misdiagnosed as tension-headache and ‘ophthalmoplegic migraine’ (now known as ‘recurrent painful ophthalmoplegic neuropathy’). The patient made a complete neurological and radiological recovery after systemic anticoagulation and treatment of SLE. An analysis of the clinical errors and cognitive biases leading to delayed referral to hospital is presented. We highlight the fact that adherence to the fundamental principles of clinical medicine and enhancement of cognitive awareness is required to reduce diagnostic errors.