Oculomotor Ophthalmoplegic Migraine Associated with Schwannoma
Shaza N. Al-Holou; Richard H. Legge
Truhlsen Eye Institute, University of Nebraska Medical Center
Introduction: To describe the clinical and MRI findings of two pediatric patients with oculomotor ophthalmoplegic migraines associated with schwannoma, review the literature, and consider the relationship of migraine to schwannoma.
Methods: Retrospective case series identifying two patients with migraine affecting the oculomotor nerve and MRI findings consistent with schwannoma of the oculomotor nerve.
Results: Two patients were identified with migraine-associated oculomotor nerve paresis. They began exhibiting transient episodes of unilateral cranial nerve III paresis at 1-2 years of age, with lid ptosis, exotropia, and limited extraocular motility. On presentation no anisocoria was noted for either patient. MRI and MRA demonstrated a mass of the oculomotor nerve with MRI signal consistent with schwannoma. Patients were treated with prednisone during the acute phase and propranolol for migraine prophylaxis.
Discussion: We report two cases of pediatric oculomotor ophthalmoplegic migraine associated with schwannoma. Ophthalmoplegic migraine is typically found without a structural lesion and only demonstrates oculomotor nerve enhancement on imaging. The symptoms are transient with pupillary mydriasis, though our cases were pupil-sparing. Treatment typically includes corticosteroid therapy. Oculomotor nerve schwannoma may be an etiology of ophthalmoplegic migraine. Controversy exists regarding whether the schwannoma precedes, or results from, transient migrainous ischemia. Surgery or radiation therapy have been considered for treatment, but risk complete oculomotor nerve palsy. Our patients improved with steroid therapy and migraine prophylaxis.
Conclusion: We recommend brain MRI for children with oculomotor ophthalmoplegic migraine in order to detect the presence of schwannoma.
References: Carlow TJ. Oculomotor ophthalmoplegic migraine: is it really migraine? J Neuroophthalmol. 2002 Sep;22(3):215-21.
Cho YH, Sung KS, Song YJ, Kim DC, Choi S, Kim KU. Oculomotor nerve schwannoma: a case report. Brain Tumor Res Treat. 2014 Apr;2(1):43-7.
Kawasaki A. Oculomotor nerve schwannoma associated with ophthalmoplegic migraine. Am J Ophthalmol. 1999 Nov;128(5):658-60.