Orbital Mass in a Patient With Exacerbation of Chronic Migraine – A Case Report

A 62-year-old female with chronic migraine diagnosed in her late teens presented to the neurology clinic after noticing a gradual change over the last 3 months in the character of her headaches from “vice-like” to “dull.” There was concomitant intermittent blurry vision, dizziness, and a sensation of increased pressure behind the eyes, left greater than right. Ocular examination revealed 2 mm of left enophthalmos and was otherwise unremarkable. Due to the patient’s new onset of symptoms, a contrast-enhanced MRI of the head was obtained, which revealed a left inferomedial orbital mass in direct communication with the superior ophthalmic vein (Fig. 1). A B-scan ultrasound of the left orbit showed an echogenic mass measuring approximately 7 mm located just nasal to the globe (Video S1 in Supporting Information). The mass had high vascularity with multiple low-flow venous channels and no arterialization. These imaging characteristics were consistent with an orbital varix – a dilated malformation of existing vasculature, in this case the superior ophthalmic vein. Upon this incidental finding on imaging, the patient was referred to oculoplastics and interventional neuroradiology for discussion of treatment options. The classic presentation of orbital varix is a progressive, painless proptosis as the vascular channels expand and displace surrounding soft tissue. A paradoxical enophthalmos may be seen if a previously expanded lesion later involutes, leaving behind room for the globe to sink posteriorly, as in this patient. However, if the orbital varix enlarges significantly, it may put pressure on the orbital contents, commonly leading to painful proptosis, diplopia, and retroorbital discomfort. It is this orbital pressure that patients may commonly interpret as headache. As such, the clinical suspicion for orbital varix should increase if headache or unilateral proptosis can be exaggerated by increasing venous pressure, including putting the head in a dependent position or performing a Valsalva maneuver. Moreover, eye strain or squint Headache doi: 10.1111/head.13698 © 2019 American Headache Society Published by Wiley Periodicals, Inc. ISSN 0017-8748