Ophthalmoplegic migraine and recurrent sinus arrest.

Cardioinhibitory vagovagal reflex, induced by pain, is well known. We are unaware, however, from the literature, of recurrent sinus arrest episodes in the setting of ophthalmoplegic migraine, a rare entity in itself (0 16% in a large series).' A 34 year old female was admitted to the intensive cardiac care unit on 19 July 1987 following three events of dizzy spells, malaise and near fainting. The day before she sustained a recurrent throbbing pain in her left temple. Recurrent episodes of sinus arrest were seen, lasting 2-4 s, without syncope (fig). Her physical examination was otherwise noncontributory and other laboratory data were normal. Her history revealed only occasional headache, either unilateral or bilateral, sometimes accompanied by nausea. She did not smoke or take any medication. We found no family history of headache, seizure, sudden death or chronic diseases. During six consecutive days in the intensive cardiac care unit, she sustained recurrent pain in her left temple and almost every time a sinus arrest was recorded on the monitor, 10-20 times per day. On the sixth day, the headache began to recede and gradually left sixth nerve palsy and diplopia became apparent as the only neurological deficit. EEG and brain CT, as well as LP, performed when a sixth nerve palsy appeared, were normal. Her double vision completely cleared three weeks later. A trial of atropine treatment (iv) was given, resulting in a switch from extreme sinus bradycardia to regular nodal rhythm. The patient refused invasive electrophysiological study ofthe heart. Autonomic functions were normal: her blood pressure ranged between 110/70 and 120/70 mmHg. Orthostatic hypotension was absent. Her diaphoresis was not disturbed and bowel movement was regular. Limited tests were done. Eyeball pressure did not change the heart rhythm in the interictal periods; carotid massage did not reveal hypersensitivity of the carotid sinus. Valsalva manoeuvre showed a normal "overshoot" of blood pressure in the fourth phase. The diagnosis was based on the clinical course, outcome, physical examination, normal CSF and brain CT. On CT with enhancement, no aneurysm was visualised. The patient refused carotid angiography. Tolosa-Hunt painful ophthalmoplegia is another possibility. Hunt's criteria' were almost totally fulfilled. It is, however, difficult to differentiate between the two conditions.' The short duration of pain and the benign self-limiting course favoured the diagnosis of ophthalmoplegic migraine.4 The speculative explanation of the mechanism in the two entities indicates that they may share common features."6 Symptoms of autonomic dysfunction are well known in migraine, and an ophthalmoplegic variant is not an exception in this case.7 This autonomic dysfunction was an isolated episode. Abnormalities in the sympathetic nervous system in those with migraine headache are well known,8 but cause arrhythmias, and not sinus arrest. The right vagus is supposed to innervate the sinoatrial node; its stimulation causes sinus arrest.9 It is not clear how it was stimulated by a presumed left extra-axial process. Perhaps the pain acts as the "non-localised" trigger of multiple sinus arrest spells. A follow up over two years found the patient healthy, except for her "habitual" headache, and no focal signs have been detected. ISAAC BAZAK* TAMARA MARGULIS HANAN SHNAIDER AVRAHAM PALANT Department of Neurology* and Heart Institute, Lady Davis Carmel Hospital, Haifa, Israel.