XI Congress of the International Headache Society

Painful ophthalmoplegia of the right eye in a 20-year-old man

BACKGROUND

Painful ophthalmoplegia is an infrequent but very important presentation in the acute care setting and requires a thorough neurologic evaluation to determine its cause. This clinical sign has a large differential and generally indicates a serious cerebrovascular process.

CASE REPORT

We describe a patient with a subacute presentation of painful ophthalmoplegia, ultimately diagnosed as Tolosa-Hunt syndrome, a rare inflammatory process of the cavernous sinus.

CONCLUSION

This case highlights the importance for the Emergency Physician to quickly recognize painful ophthalmoplegia and rapidly elucidate the cause to prevent further complications for the patient.

ICHD-II Diagnostic Criteria for Tolosa—Hunt Syndrome in Idiopathic Inflammatory Syndromes of the Orbit and/or the Cavernous Sinus

A bibliographical search was conducted for papers published between 1999 and 2007 to verify the validity of International Classification of Headache Disorders (ICHD)-II criteria for the Tolosa-Hunt syndrome (THS) in terms of (i) the role of magnetic resonance imaging (MRI); (ii) which steroid treatment should be considered as adequate; and (iii) the response to treatment. Of 536 articles, 48, reporting on 62 patients, met the inclusion criteria. MRI was positive in 92.1% of the cases and it normalized after clinical resolution. There was no evidence of which steroid schedule should be considered as adequate; high-dose steroids are likely to be more effective both to induce resolution and to avoid recurrences. Pain subsided within the time limit required by the ICHD-II criteria, but signs did not. We conclude that THS diagnostic criteria can be improved on the basis of currently available data. MRI should play a pivotal role both to diagnose and to follow-up THS.