Headache and the Eye

Other Cranial Nerves

The presentation of headache and ptosis will most likely unveil a painful cranial nerve III palsy that is usually of microvascular or aneurysmal etiology. Vascular risk factors, such as diabetes and hypertension, predispose to microcvascular palsies. The pupil is involved in only about 10% of microvascular palsies.^[39,48] If the palsy does not remit within about 12 weeks, further testing is indicated to rule out mass lesion or myasthenia gravis.^[39,49,50]

The sudden onset of painful, complete (with pupillary involvement) cranial nerve III palsy is a posterior communicating artery aneurysm until proven otherwise. The pupil may be spared initially, but it then becomes involved in the first 24 hours. Such cases require emergency medical resonance imaging or medical resonance angiography.^[39]

Isolated, painful cranial nerve IV or VI palsy may also be microvascular. Rheumatoid arthritis and other inflammatory disorders cause trochleitis.^[51] Patients present with restricted elevation on adduction and tenderness in the superomedial orbit that may respond to local corticosteroid injections.^[51] Sudden, painful cranial nerve VI palsy in an adult is most commonly of microvascular origin.^[52,53] Work-up with neuroimaging, lumbar puncture, and/or edrophonium testing is warranted when there is bilaterality, progression, a history of malignancy, or no resolution within 3 months. Other indications for imaging are persistent pain or age less than 40 years.^[53,54]

Painful abducens palsy with loss of tearing and/or involvement of second division of the trigeminal nerve may be caused by nasopharyngeal or metastatic carcinoma in the sphenopalatine fossa.^[39] In the cavernous sinus, cranial nerve VI is vulnerable and is also affected by lesions mentioned in Table 5 .

Compr Ophthalmol Update. 2004;5(4) © 2004 Comprehensive Ophthalmology Update, LLC

Cite this: Headache and the Eye - Medscape - Jul 01, 2004.