Ophthalmoplegic migraine is a recurrent paroxysmal cephalgia of a migraine nature, accompanied by transient paresis of one or more nerves of the oculomotor group without signs of their intracranial lesion. Ophthalmoplegic migraine is characterized by a long duration of headache and even longer preservation of oculomotor dysfunction (strabismus, double vision, ptosis, mydriasis). Diagnosis involves conducting an MRI of the brain with contrast, angiography or MR angiography. Triptans, nonsteroidal anti–inflammatory drugs, ergot preparations, antidepressants, b-blockers, anticonvulsants, glucocorticoids are used in the treatment. Individually, the patient is selected drugs for the relief of a migraine attack and means for its prevention.
General information
Ophthalmoplegic migraine is a form of associative migraine. The latter is characterized by the occurrence at the beginning or at the height of a migraine attack of a transient neurological deficit, usually observed some time after the cessation of cephalgia. Other forms of associative migraine include: aphatic, hemiplegic, cerebellar, dysphrenic, vestibular, basilar.
Ophthalmoplegic migraine is quite rare. Some experts in the field of neurology suggest not to attribute the ophthalmoplegic form to migraine, since the typical cephalgia lasts for more than 1 week, and ophthalmoplegia occurs after a certain latent period, usually on the 1-4 day of the attack. This approach is supported by the fact that in some cases ophthalmoplegic migraine is detected on MRI with contrast accumulation in the cisternal part of the oculomotor nerve, which indicates the presence of a demyelinating process in it.
Causes
To date, the exact genesis of both migraine-like headache and transient oculomotor disorders that accompany ophthalmoplegic migraine has not been established. The alleged causes of transient oculomotor disorders include the following periodically developing conditions: spasm or swelling of the artery providing blood supply to the oculomotor nerve; expansion of the cavernous sinus; swelling and/or expansion of the internal carotid artery.
It is known that triggers that cause hyperstimulation of the senses (noise, sharp sound, bright light or flickering, unpleasant odor), as well as mental overstrain, lack of sleep, irritation can provoke a migraine attack. It should be noted that for these causal factors, there is a direct dependence of their influence on the subjective perception of a person. A more calm and friendly attitude to the current situation allows you to avoid an oversensitive and mental reaction, which can transform into a migraine attack.
Symptoms
The basis of the attacks characterized by ophthalmoplegic migraine is a typical migraine—like cephalgia – a headache of a pressing or pulsating type that spreads to half of the head. Its peculiarity in the ophthalmoplegic form of migraine is a long, for 7 or more days, course. At the beginning of a migraine attack, and more often delayed — on the 1-4 day of the attack — ipsilateral, i.e. localized on the side of cephalgia, disorders of the movements of the eyeball and the resulting diplopia (double vision) occur.
Basically, there are symptoms of oculomotor nerve dysfunction (III pair of cranial nerves). These include: drooping of the upper eyelid, divergent strabismus, mydriasis (pupil dilation), diplopia. Less common is ophthalmoplegic migraine with symptoms of damage to the block nerve (IV pair of CN) or the abductor nerve (V pair of CN). In the first case, there is a double image when looking down and converging strabismus, in the second — diplopia and converging strabismus. In some cases, ophthalmoplegic migraine may be accompanied by a combined dysfunction of several of these nerves.
The oculomotor disorders mentioned above are exclusively transient in nature. They can persist for up to several months after the end of the paroxysm of cephalgia, but eventually they are completely leveled with 100% restoration of previously impaired functions. Such a long-term preservation of oculomotor dysfunction makes it necessary to carefully differentiate the ophthalmoplegic form of migraine from organic cerebral pathology and, above all, from vascular disorders.
Diagnostics
The combination of migraine headache with ophthalmoplegia requires a cautious diagnostic approach. Perhaps the disease is not an ophthalmoplegic migraine, but a combination of cephalgia with recurrent oculomotor neuropathy, which may be based on many pathological processes (inflammation, intracerebral tumor, cerebral vascular aneurysm, small hemorrhage, arteriovenous malformation of the Willis circle).
Accurately differentiate these pathological conditions helps MRI of the brain with additional contrast. CT of the brain has no diagnostic value, because it does not visualize a small hematoma, aneurysm or vascular anomaly. In the diagnosis of vascular malformations, angiography of cerebral vessels is the most informative. Recently, it has been replaced by a safer tomographic analogue — MR angiography.
Ophthalmoplegic migraine is diagnosed by a neurologist in the presence of 2 or more paroxysms of migraine-like cephalgia with paresis of several or one CN from the oculomotor group that occurs during the period from 1 to 4 days of the attack, provided that pathological processes of the posterior cranial fossa, upper orbital fissure and parasellar region are excluded.
Treatment
Treatment of any form of migraine includes the relief of seizures and their prevention. Since ophthalmoplegic migraine is characterized by a long duration of attacks, serotonin 5HT1 receptor agonists – triptans (naratriptan, sumatriptan, zolmitriptan, eletriptan, etc.) are usually used in the treatment. They not only reduce the intensity of cephalgia, but also relieve symptoms such as phonophobia and photophobia, nausea. Ophthalmoplegic migraine occurs without an aura, so patients have no way to prevent an attack by taking medication. However, the earlier the drug is taken, the greater its effectiveness will be. If necessary, it is possible to take the pill again.
Contraindications to taking triptans are: high arterial hypertension, coronary heart disease, pregnancy, atherosclerosis of the vessels of the lower extremities, sepsis, CRF, liver failure, age over 65 years. If there are contraindications, ergot preparations (ergotamine, dihydroergotamine) or nonsteroidal anti-inflammatory drugs (naproxen, diclofenac) may be prescribed instead of triptans. The preservation of oculomotor dysfunction after the cessation of cephalgia is an indication for the appointment of glucocorticoids. As a rule, prednisone is used in a daily dose of 40 mg, then the dosage is gradually reduced.
Drug prevention of recurrent seizures is carried out by individual selection of one or more drugs from the following groups: calcium channel blockers, b–blockers, nonsteroidal anti-inflammatory, antidepressants (venlafaxine, amitriptyline, duloxetine), anticonvulsants (valproates, carbamazepine, topiramate). In addition, normalization of sleep and wakefulness, reduction of psychoemotional load, avoidance of stressful moments, revision of attitudes to various life situations is of no small importance.
Forecast
Ophthalmic migraine, like other forms of migraine, often does not respond well to therapy. The success of treatment, and, consequently, the prognosis, largely depends on the efforts of the patient himself, his ability to change his own attitude to people and situations to a more benevolent and calm. In most cases, ophthalmoplegic migraine eventually begins to intersperse with migraine attacks with aura or completely transforms into a classic migraine.