Abstract
Dear Sir We have read the critisism of Dr Ferrante about our article on ophthalmoplegic migraine (OM) (1).
It is correct that the second edition of the International Classification of Headache Disorders considers the demonstration of cavernous sinus granuloma by magnetic resonance imaging (MRI) or biopsy to be unnecessary for the diagnosis of Tolosa–Hunt syndrome (THS) and we agree with Dr Ferrante that an abnormal MRI is not the only differentiating feature between THS and OM. However, this is not because, as he says, there are cases showing no mass lesion within the cavernous sinus, superior orbital fissure or orbit. Indeed, there are cases showing no abnormality with conventional MRI (2). However, there are reports of different imaging techniques, including dynamic MR imaging (3) and contrast-enhanced three-dimensional constructive interference in steady-state MRI (4), which can be more convenient for the diagnosis of diseases involving the cavernous sinuses, such as THS. Therefore, we think one cannot rule out THS just by obtaining a normal conventional MRI, as this does not mean that the cavernous sinus or the superior orbital fissure are completely normal. With advancing techniques we will be more capable of visualizing those tissues.
Coming to blood biochemistry of the cases, we performed erythrocyte sedimentation rate and C-reactive protein level tests in both of our patients, with normal results, but antinuclear antibody concentration was not studied.
The other point raised was treatment. None of the patients was given corticosteroid treatment. As they had both experienced similar attacks before (case 1 had four and case 2 had one previous attack) which resolved spontaneously, our primary diagnosis was OM and they were not given steroids. It took 2 weeks for case 1 and 3 weeks for case 2 to recover.