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  • Updated 04.23.2024
  • Released 08.22.1995
  • Expires For CME 04.23.2027

Recurrent painful ophthalmoplegic neuropathy



Recurrent painful ophthalmoplegic neuropathy, formerly termed “ophthalmoplegic migraine,” is a fascinating and controversial entity. The International Classification of Headache Disorders (ICHD-3) now considers the disorder a cranial neuralgia rather than a type of migraine. Although many cases are typical of a cranial neuralgia, with enhancement of the involved cranial nerve on MRI and improvement using corticosteroids, other cases are more suggestive of a migraine variant. The third nerve is the nerve most frequently involved. Most cases appear in childhood and may persist into adulthood, but onset in adulthood may also occur. The episodes of ophthalmoplegia appear spontaneously and then resolve over days to weeks. As the etiology for recurrent painful ophthalmoplegic neuropathy is likely multifactorial and remains uncertain, the condition may more appropriately be considered a syndrome rather than a distinct diagnosis.

Key points

• The International Classification of Headache Disorders version 3 classifies recurrent painful ophthalmoplegic neuropathy as a cranial neuralgia.

• MRI of the brain with contrast is recommended for all new cases.

• Although a clinical diagnosis, recurrent painful ophthalmoplegic neuropathy may show enhancement of the involved cranial nerve on post-gadolinium magnetic resonance imaging.

• The third cranial nerve is the most frequently involved nerve in recurrent painful ophthalmoplegic neuropathy.

• Most of the cases start in childhood or early adulthood.

• Episodes of recurrent painful ophthalmoplegic neuropathy appear spontaneously and resolve without treatment.

• Ocular motor nerve schwannomas may produce identical symptoms and resolve spontaneously.

• The etiology for recurrent painful ophthalmoplegic neuropathy is controversial and likely multifactorial, and although a number of treatments have been proposed (eg, steroids, anti-migraine agents), none have proven to be a consistently effective therapy.

Historical note and terminology

Recurrent ocular motor palsies associated with a headache were previously termed “ophthalmoplegic migraine.” The syndrome most commonly affects the oculomotor (third) nerve, but abducens (sixth) and trochlear (fourth) nerve palsies may occur. The original 1860 report was by Gubler (16; 08), and Charcot first used the term "ophthalmoplegic migraine" in 1890. Gubler's patient subsequently died, and autopsy showed a fibrous mass embedding the third nerve. The patient had no history of migraine but was afflicted with syphilis 10 years earlier. Gowers believed that diplopia was a rare symptom of migraine, and Liveing only briefly alluded to diplopia in his monograph (29; 15). Prior to Charcot's use of the expression "ophthalmoplegic migraine," other synonymous terms included "recurring ocular palsy," "periodic oculomotor paresis," and "recurring third nerve palsy."

Prior to the modern imaging era, authors suggested that ophthalmoplegic migraine represented a congenital anomaly whereby an arteriole at the base of the brain perforated the third nerve or, less commonly, the sixth nerve (19). Alternatively, the involved nerve harbored an occult cavernous hemangioma or other occult vascular malformation. Walsh and O'Doherty cited 200 cases from the literature and postulated that edema of the wall of the carotid within the confines of the cavernous sinus caused pressure on the third nerve, thereby producing an oculomotor nerve palsy involving the pupil (43; 34). In addition to the cavernous sinus, the other potential location for vascular compression is the locus where the third nerve passes between the posterior cerebral and superior cerebellar arteries (32).

Ultimately, demonstrable contrast enhancement of the involved ocular motor nerve on brain MRI in many cases led to replacing the term “ophthalmoplegic migraine” with “recurrent painful ophthalmoplegic neuropathy,” a definable, albeit rare, clinical condition.

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