Ophthalmoplegic migraine refers to the uncommon form of cranial nerve palsy in a patient with migraine. It may occur as a result of ischemic neuropathy caused by closure of the ostia of vasa nervosum supplying the intracranial ocular motor nerves.


The condition tends to have an onset during childhood or adolescence. An initial onset after the age of 20 is unusual and should raise doubts about the diagnosis.


Clinical features:

(1) The patient has a history of migraine (see below).

(2) Opthalmolegia occurs that may reflect involvement of the third, fourth and/or sixth cranial nerves.

(3) Slight mydriasis may occur in the pupil of the affected eye.

(4) Cerebral angiography is normal.

(5) exclusion of other explanations


The migraine headache may:

(1) precede the onset of the ophthalmoplegia by hours or days

(2) be diminished or gone by the onset of the ophthalmoplegia


The ophthalmoplegia usually resolves in a few days without residua. With repeated or prolonged episodes it may become permanent.


When to consider another diagnosis:

(1) initial onset after 20 years of age

(2) change in the level of consciousness

(3) signs and symptoms of subarachnoid hemorrhage

(4) absence of a history of migraine or family history of migraine

(5) severe, persistent headache with total ophthalmoplegia

(6) abnormal cerebral angiography


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