User:Ifreckle/Ophthalmoplegic Migraine

Ophthalmoplegic Migraine is a rare eye disorder, previously called a “complicated migraine”, which is also recognized as cranial neuralgia by the International Classification of Headache Disorders (HIS II) (5). This disorder most commonly presents itself in early childhood or infancy (1, 3, 4).

To date, there is no conclusive hypothesis as to the etiology of this disorder (3, 4). Ophthalmoplegic migraines are characterized by headaches and a weakening of muscles around the eye. Moreover, these headaches commonly precede episodes of partial paralysis of one or more ocular nerve (most commonly the third cranial nerve), drooping of the eyelid, double vision, and dilation of pupils (1, 2, 3, 4, 6). The occurrence of the disorder is very rare, with an incidence rate of .7 per million people annually (2, 4).

Age group
Multiple attempts have been made to determine the average age of onset. In one study conducted by Diana X. Bharucha, the first episode of ophthalmoplegic migraine ranged from 9 months to 19 years, with an average of 5.38 years (4, P.62).

In addition, other studies conducted by Thomas J. Carlow showed the onset to occur from 7 months to 19 years with an average of about 6 years. (1, P.217)

Although ophthalmoplegic migraines occur more commonly in younger people, they do occur at any age.

Accompanying problems
In the study conducted by Bharucha, all subjects complained of a headache. In addition, 26 out of the 52 subjects had a dilated pupil (50%), and 23 exhibited involvement of extraocular movement, or involuntary eye movement (44%). Lastly, this study showed that many exhibited an enhancement of the cranial nerve 3, although other abnormalities included focal thickening (this is where damage results in inflammation in the brain) or swelling of the fourth or sixth cranial nerve (constriction of blood vessels in the brain, followed by dilation of the vessels. When the vessels dilate and become swollen, the migraine occurs).

Additionally, Dr. Carlow showed that 15 out of 16 cases exhibited a dilated pupil (94%), and that headaches preceded the onset of oculomotor paresis (paralysis of muscles surrounding the eye) by an average of 3.3 days in 15 out of 23 cases. B. Todd Troost, MD has conjectured that the “enhancement of the third nerve [may] represent a type of inflammation, and, therefore, more characteristic of what is seen with facial nerve palsy than with any form of migraine.”

Disorder recession
In Bharucha’s research, MRI studies were performed from 1-8 months. In this study, after 8 months, 81.8% of people showed a decrease in the enhancement of the 3rd nerve, 2.3% showed persistent enhancement, and 9.1% showed complete resolution (4).

Moreover, Dr. Carlow showed that the resolution of oculomotor paresis ranged from four days to twelve weeks, with an average of 4.1 weeks (1, p. 218).

Lastly, in a study conducted by Dr. Alexander Mark, all six patients showed a complete recession of symptoms after 9 weeks (3).

Symptoms
People experiencing ophthalmoplegic migraine often exhibit the following symptoms involving the eyes. Symptoms may last up to a couple weeks at a time. Not all symptoms will be felt by each person, and the severity of each accompanying symptom may vary on an individual basis (1, 2, 3, 4, 6, 7).


 * Double vision
 * Ptosis, aka droopy eyelids
 * Eye paralysis
 * Various other vision changes (link)
 * Head pain
 * Severe migraine

Causes
As previously mentioned, the exact etiology of Ophthalmoplegic migraines is unknown. Previous explanations of the etiology include ischemia, allergic reaction, swelling of blood vessels surrounding the eye, swelling of the pituitary gland, vascular anomaly, and pressure on the third cranial nerve, although no explanation has been conclusive. (4, 7) Regardless, some factors that may cause a recurrence of ophthalmoplegic migraine are noise, light, too much or too little sleep, fatigue, changes in individual hormone levels, weather changes, and foods such as chocolate, some cheeses, food additives, foods containing tyramine, alcohol, red wine, and meats from body organs (6, 7). In addition, in one study, there was a family history of the disorder in 10 out of 15 cases, indicating the possibility that this disorder may be hereditary (1).

Diagnosis
Headaches lasting more than a couple of days may be indicative of ophthalmoplegic migraines (7). In order to diagnose this disorder, it is suggested that you visit your physician or health care provider. The doctor will take a complete medical history, as well as perform a physical exam. In addition, an MRI or an MRA may be taken to ensure that problems are not caused by a brain tumor or any other neurological abnormality. The doctor will then take the results, and, if diagnosis is made, try to determine what triggered the ophthalmoplegic migraine. Once diagnosed, treatment may begin.

Treatment
Many methods have been used in effort to treat or prevent ophthalmoplegic migraine with variable results depending on severity. Initially, doctors prescribe ibuprofen and acetaminophen to relieve symptoms. If pain is too intense, doctors may prescribe barbiturates (7).

Drug treatment
Doctors may prescribe antidepressants (such asamitriptyline and nortriptuline) (7).

Among alternate methods are the use of steroids such as prednisolone, prednisone, and dexamethasone (which are all administered after disorder onset), and flunarizine, propranolol, verapamil, cyproheptadine, and acetazolamide (all administered prophylactically) (4, 7). It is believed that rapid administration of steroids at the time of onset can minimize residual weakness of the 3rd cranial nerve and papillary dysfunction. In Dr. Carlow’s study, 6 out of 12 subjects who were prescribed corticosteroids exhibited a beneficial response. With the early administration, both the headache and the ophthalmoplegia resolved early in all subjects. In these six, the resolution of the disorder was typically measured in days, as opposed to months (1).

Non-drug treatment

 * Acupuncture
 * Exercise
 * Hypnosis
 * Relaxation
 * Chiropractic techniques

Lastly, combinations of any of the previous methods may be suggested by a physician in individual circumstances.

Long term use of over-the-counter drugs
Long-term use of over-the-counter drugs, and other common prescribed medication to treat migraines may cause a resistance to pain killers, rebound headaches, drowsiness, and allergic reactions.

Long term use of steroids

 * Masculinization
 * Feminization
 * Cardiovascular problems
 * Growth defects
 * Kidney problems
 * Liver problems
 * Skin problems
 * Neuropsychiatric problems

The use of any medication is accompanied by inherent risks. Individual side effects may vary, and not all side effects will be experienced by every individual.

Risk to Others
Ophthalmoplegic migraine is not contagious, therein posing no risk to others (6, 7).

Prevention
To prevent recurrent issues with opthalmoplegic migraines, it is important to recognize your personal triggers. Since ophthalmoplegic migraines are most common in children and infants, it is necessary to watch your child’s intake. Once the trigger has been identified, it is important to either completely remove or limit the presence of that substance in the individual’s intake.

Prognosis
Usually, ophthalmoplegia only affects people for a short time (6), although it can become permanent, especially with repeated attacks.