Ophthalmoplegic Migraine

Ophthalmoplegic migraine is rare and is no longer considered to be a form of migraine. It usually occurs in children or young adults. Patients usually experience pain around one eye, which may go away in hours or last for weeks. They also experience double-vision (diplopia) which can last from hours to months. Often the double-vision lasts long after the headache has subsided. After repeated attacks, a patient may not completely recover from the double-vision (due to permanent nerve injury).

What causes the double-vision?

The double-vision is caused by dysfunction of the nerves that control eye movements. The most commonly involved is cranial nerve III (the Oculomotor Nerve). When this nerve is damaged (in the setting of ophthalmoplegic migraine) the affected eye will tend to point down and to the side (due to the unopposed action of the other nerves that control eye movement). The pupil may also be very large on that same side (pupillary dilation) and the eye may be partially closed (ptosis).

Occasionally other cranial nerves that affect eye movement will be the cause of double-vision including cranial nerve IV (also called Trochlear) and cranial nerve VI (also called Abducens).

Why is it no longer considered to be a migraine?

Recent studies of patients with this condition demonstrate (on brain MRI) that there is inflammation around the nerve; something that wouldn't occur in the case of migraine.

Thus, most likely this condition is actually due to inflammation of the affected cranial nerve (III, IV, or VI), leading to double-vision and pain around the eye. The inflammation may be due to a viral infection of the nerve, though this has not been proven.

How should it be evaluated?

Many potentially dangerous conditions can also cause headaches and cranial nerve dysfunction, it is therefore very important to see a physician emergently if you have these symptoms.

Evaluation by that physician will include ruling out the following: tumors or other mass lesions which compress the nerves anywhere along their course (this includes intracranial aneurysms), infections (including HIV, Lyme disease, syphilis, fungal infections), and other inflammatory conditions (sarcoidosis, Tolosa-Hunt syndrome, Miller-Fisher Syndrome).

Treatment

Treatment will depend on your physician's thinking, after serious conditions have been eliminated as possibilities. This physician might consider having you take oral steroids or antiviral medications.

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