Ophthalmoplegic Migraine

Administrator: Vivek Lal

Ophthalmoplegic Migraine 
Vivek Lal

Acute onset painful ophthalmoplegia is a vital sign and requires a systematic approach in order to rule out ominous aetiologies. Ophthalmoplegic migraine (OM) is an important medical cause of acute painful ophthalmoplegia in childhood characterised by migrainous headaches and multiple attacks of 3rd or 6^th cranial nerve palsies. Gd MRI of the involved cranial nerve may disclose reversible enhancement. There is ongoing debate about whether ophthalmoplegia  in patients with migraine is directly attributable to migraine (ophthalmoplegic migraine [OM]) or is due to an inflammatory neuropathy (recurrent painful ophthalmoplegic neuropathy [RPON]). Given the treatment and prognostic implications it is important  to identify patients of OM. 

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. Further, enhancement of the involved cranial nerves may be due to the neuro- inflammatory cascade associated with migraine. This is most pronounced during an attack and often resolves on follow-up. Serum and CSF CGRP levels have been noted to be elevated during acute episodes suggesting the role of migrainous neuroinflammation in OM.

The objectives of the presentation will be to identify the key features of OM and differentiate it from other infectious, vascular, inflammatory and neoplastic causes. The importance of a systematic approach, detailed history taking and thorough examination will be underscored based upon case based discussions.  Further clinical implications of OM, available diagnostic modalities and management strategies will be discussed in detail based upon the existent evidence.