Journal of Postgraduate Medicine Medknow Publications and Staff Society of Seth GS Medical College and KEM Hospital, Mumbai, India ISSN: 0022-3859 EISSN: 0972-2823 Vol. 55, Num. 3, 2009, pp. 231-231

Journal of Postgraduate Medicine, Vol. 55, No. 3, July-September, 2009, pp. 231

Letter

Treatment options for ophthalmoplegic migraine

Granado LIG, Guillén G

Department of Pediatrics, Hospital 12 de Octubre, Madrid, España.

Correspondence Address: Dr. Luis Ignacio Gonzalez Granado, Department of Pediatrics, Hospital 12 de Octubre, Madrid, España.
nachgonzalez@gmail.com

Code Number: jp09069

PMID: 19884756

DOI: 10.4103/0022-3859.57389

Sir,

The article by Borade et al.^[1] provides an excellent description of the clinical picture shown, but regarding short-term and long-term management I would like to present two therapeutic options that were missed in their article, especially when prolonged ophthalmoplegia occurs.

We have to emphasize that ophthalmoplegic migraine is a diagnosis of exclusion, and noninvasive imaging tests such as magnetic resonance angiography (MRA) or magnetic resonance imaging (MRI) should be performed in all cases, to exclude the presence of one aneurysm. Usually ophthalmoplegia is a transient phenomenon. However, it can become permanent, especially after repeated attacks. In this case there are some concerns that longstanding lack of binocularity impedes the recovery of the alignment. For this reason, we can consider botulinum toxin A or surgical realignment (squint surgery) for short- or long-term management, respectively. The injection of botulinum toxin is safe (even for infants) ^[2] and painless, with appropriate topical analgesia, driven optionally with electromyography (we have been using botulinum toxin for the last four years without moderate or severe adverse effects, so - from our point of view - electromyography would be optional). As it is known, paralysis usually peaks two weeks after the injection. Because of the molecular turnover within the neuromuscular junction and neuronal sprouting, neuronal activity begins to return at three months, with restoration of complete function at approximately six months, so it can provide a longlasting, beneficial effect. It is not only safe and painless, even pain relief could be obtained with this strategy, as it has been proven previously. ^[3],[4],[5]

Botulinum toxin has previously been shown to produce longlasting recovery of binocular function in some patients with longstanding deviation. ^[6]

Even though large cohorts of patients are difficult to obtain in such infrequent diseases, we believe that worldwide observational studies could be helpful when deciding if a longlasting therapeutic strategy is needed (and which one) in these patients.

References

1.	Borade A, Prabhu AS, Kumar S, Prasad V, Rajam L. Magnetic resonance imaging findings in ophthalmoplegic migraine. J Postgrad Med 2009;55:137-8.  Back to cited text no. 1  [PUBMED]
2.	Pascual-Pascual SI, Pascual-Castroviejo I. Safety of botulinum toxin type A in children younger than 2 years. Eur J Paediatr Neurol Nov 2008. doi:10.1016/j.ejpn.2008.10.006 PMID: 1903661   Back to cited text no. 2
3.	de Sèze MP, de Sèze M, Dehail P, Joseph PA, Lavignolle B, Barat M, et al. Botulinum toxin A and musculoskeletal pain. Ann Readapt Med Phys 2003;46:329-32.  Back to cited text no. 3
4.	Gajraj NM. Botulinum toxin a injection of the obturator internus muscle for chronic perineal pain. J Pain 2005;6:333-7.  Back to cited text no. 4
5.	Colhado OC, Boeing M, Ortega LB. Botulinum toxin in pain treatment. Rev Bras Anestesiol 2009;59:366-81.  Back to cited text no. 5
6.	Manzouri B, Sainani A, Plant G, Lee J, Sloper J. The aetiology and management of long-lasting sixth nerve palsy in ophthalmoplegic migraine. Cephalalgia 2007;27:275-8.  Back to cited text no. 6

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