Migraine presenting as recurrent ophthalmoplegia: The wolf in sheep's clothing

Abstract

Ophthalmoplegic migraine or recurrent painful ophthalmoplegic neuropathy is a rare condition with childhood onset. Adult onset is extremely rare. A 43-year-old hypothyroid lady presented with right-sided ptosis and diplopia. She had right ocular motility restriction in elevation and adduction with pupillary involvement. Initially, neuroimaging was suggestive of dysthyroid optic neuropathy for which she received oral steroids with incomplete recovery. She underwent strabismus surgery in the right eye for diplopia. After 2 years, she presented with a recurrence of third nerve palsy with ptosis. Neuroimaging and systemic investigations were inconclusive. Based on clinical presentation, diagnosis of ophthalmoplegic migraine was made by the neurologist, and prophylactic treatment was started to abort further attacks. Ophthalmoplegic migraine, although rare, should be considered a differential for painful ophthalmoplegia after excluding the presence of intracranial lesion, infectious, inflammatory and vascular pathology.