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Last updated: June 14, 2018
Years published: 1987, 1989, 1997, 1998, 2005, 2008, 2012, 2015, 2018
NORD gratefully acknowledges Roman Shinder, MD FACS, Professor of Ophthalmology and Otolaryngology, Director of Oculoplastics, SUNY Downstate Medical Center; and Renelle Pointdujour, MD, Department of Ophthalmology, SUNY Downstate Medical Center, for assistance in the preparation of this report.
Tolosa-Hunt syndrome is a rare disorder characterized by severe periorbital headaches, along with decreased and painful eye movements (ophthalmoplegia). Symptoms usually affect only one eye (unilateral). In most cases, affected individuals experience intense sharp pain and decreased eye movements. Symptoms often will subside without intervention (spontaneous remission) and may recur without a distinct pattern (randomly). Affected individuals may exhibit signs of paralysis (palsy) of certain cranial nerves such as drooping of the upper eyelid (ptosis), double vision (diplopia), large pupil, and facial numbness. The affected eye often abnormally protrudes (proptosis). The exact cause of Tolosa-Hunt syndrome is not known, but the disorder is thought to be associated with inflammation of specific areas behind the eye (cavernous sinus and superior orbital fissure).
Many individuals with Tolosa-Hunt syndrome experience the sudden onset of severe periorbital headache, followed by painful and decreased eye movements (ophthalmoplegia). In some cases of severe ophthalmoplegia, the eye itself is unable to move or look in various directions (frozen globe).
The major symptoms of Tolosa-Hunt syndrome include chronic periorbital headache, double vision, paralysis (palsy) of certain cranial nerves, and chronic fatigue. Affected individuals may also exhibit protrusion of the eye (proptosis), drooping of the upper eyelid (ptosis) and diminished vision. In most cases, symptoms associated with Tolosa-Hunt syndrome affect only one side (unilateral). Symptoms will usually subside without intervention (spontaneous remission) and may recur without a distinct pattern (randomly).
While the exact cause of Tolosa-Hunt syndrome is unknown, one theory is an abnormal autoimmune response linked with an inflammation in a specific area behind the eye (cavernous sinus and superior orbital fissure). In some cases, inflammation may be due to a clumping of a certain type of cell (granulomatous inflammation). Autoimmune disorders are caused when the bodyโs natural defenses against โforeignโ or invading organisms (e.g., antibodies) begin to attack healthy tissue for unknown reasons. Other possible causes may include generalized inflammation and constricted or inflamed cranial blood vessels.
Tolosa-Hunt syndrome is a rare neuro-immunological disorder that occurs in males and females in equal numbers. The average age of onset is 41 years, but there have been cases reported among people younger than age 30. In rare cases, children under the age of 10 have been diagnosed with Tolosa-Hunt syndrome.
The diagnosis of Tolosa-Hunt syndrome has been codified by the International Headache Society. The following criteria must be met for a definitive diagnosis of this disorder: Eye pain on one side of the head that persists for at least eight weeks if untreated; associated irritation or damage to the third, fourth, or sixth cranial nerves; relief of pain within 48 hours upon the administration of steroids; and specialized testing that rules out other conditions such as neoplasm, infection or aneurysm.
The diagnosis of Tolosa-Hunt syndrome is suspected based upon the presence of characteristic physical features (e.g., pain, headache, ophthalmoplegia). The diagnosis may be confirmed by a thorough clinical evaluation, detailed patient history, and a variety of specialized radiologic tests including computed tomography (CT) scan, and magnetic resonance imaging (MRI). These examinations may reveal characteristic enlargement or inflammation of the areas behind the eye (cavernous sinus and superior orbital fissure).
Treatment
In most cases, the pain associated with Tolosa-Hunt syndrome subsides with short-term use of steroid drugs. Pain is usually reduced in untreated cases within fifteen to twenty days. With steroid treatment, pain typically briskly subsides within twenty-four to seventy-two hours โ and this brisk steroid response aids in the diagnosis. Affected individuals may be vulnerable to recurrent future attacks.
Information on current clinical trials is posted on the Internet at www.clinicaltrials.gov. All studies receiving U.S. government funding, and some supported by private industry, are posted on this government web site.
For information about clinical trials being conducted at the NIH Clinical Center in Bethesda, MD, contact the NIH Patient Recruitment Office:
Tollfree: (800) 411-1222
TTY: (866) 411-1010
Email: [email protected]
Some current clinical trials also are posted on the following page on the NORD website:
https://rarediseases.org/living-with-a-rare-disease/find-clinical-trials/
For information about clinical trials sponsored by private sources, contact:
www.centerwatch.com
For information about clinical trials conducted in Europe, contact:
https://www.clinicaltrialsregister.eu/
Researchers have been studying various additional treatment options for individuals who do not respond to, or develop resistance to, corticosteroid treatment. Radiation therapy has demonstrated long-term improvement in several subjects. Immunosuppressive drugs such as methotrexate are being studied as a potential treatment for individuals with Tolosa-Hunt syndrome. Some researchers have advocated the use of acupuncture. More research is necessary to determine the long-term safety and effectiveness of these potential treatments for individuals with Tolosa-Hunt syndrome.
Contacts for additional information about Tolosa-Hunt syndrome:
Roman Shinder, MD
Professor of Ophthalmology, Otolaryngology
Director of Oculoplastics
SUNY Downstate Medical Center
541 Clarkson Ave, E Bldg, 8th Fl, Suite C
Brooklyn, NY 11203
Phone: 718-270-1961
and
Renelle Pointdujour, MD
SUNY Downstate Medical Center
Department of Ophthalmology
450 Clarkson Ave, Box 58
Brooklyn, NY 11203
Phone: 718-288-6818
Tolosa Hunt Syndrome Resources
TEXTBOOKS
Naderi A, Ahmadi MA, Esmaeli B. Tolosa Hunt Syndrome. In: NORD Guide to Rare Disorders. Philadelphia, PA: Lippincott Williams & Wilkins; 2003:664.
Rowland LP, ed. Merrittโs Neurology. 10th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2000.
Kanski JJ, ed. Clinical Ophthalmology. 4th ed. Oxford, UK: Butterworth-Heinemann; 1999.
Adams RD, Victor M, Ropper AA, eds. Principles of Neurology. 6th ed. New York, NY: McGraw-Hill Companies; 1997.
Newell FW, ed. Ophthalmology: Principles and Concepts. 7th ed. St. Louis, MO: Mosby Year Book; 1991
JOURNAL ARTICLES
Foubert-Samier A, Sibon I, Maire JP, Tison F. Long-term cure of Tolosa-Hunt syndrome after low-dose focal. Headache. 2005;45:389-91.
Haque TL, Miki Y, Kashii S, et al. Dynamic MR imaging in Tolosa-Hunt syndrome. Eur J Radiol. 2004;51:209-17.
Mandrioli J, Frank G, Sola P, et al. Tolosa-Hunt syndrome due to actinomycosis of the cavernous sinus: the infectious hypothesis revisited. Headache. 2004;44:806-11.
Gladstone JP, Dodick DW. Painful ophthalmoplegia: overview with a focus on Tolosa-Hunt syndrome. Curr Pain Heachache Rep. 2004;8:321-29.
Yeung MC, Kwong KL, Wong YC, et al. Paediatric Tolosa-Hunt syndrome. J Paediatr Child Health. 2004;40:410-13.
Chmielewska B, Leszek Kaminski M. Progression of preexisting trigem-inalgia to Tolosa-Hunt-like syndrome. The importance of neuroimaging for early differential diagnosis. Neurol Sci. 2003;24:281-85.
Nepp J, Jandrasits K, Schauersberger J, et al. Is acupuncture a useful tool for pain-treatment in ophthalmology? Acupunct Electrother Res. 2002;27:171-82.
Sugano H, Iisuka Y, Arai H, et al. Progression of Tolosa-Hunt syndrome to a cavernous dural arteriovenous fistula: a case report. Headache. 2003;43:122-26.
INTERNET
Taylor DC, Mankowski K. Tolosa-Hunt Syndrome.Medscape. https://emedicine.medscape.com/article/1146714-overview Updated: Dec 06, 2017. Accessed June 12, 2018.
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The Genetic and Rare Diseases Information Center (GARD) has information and resources for patients, caregivers, and families that may be helpful before and after diagnosis of this condition. GARD is a program of the National Center for Advancing Translational Sciences (NCATS), part of the National Institutes of Health (NIH).
View reportOrphanet has a summary about this condition that may include information on the diagnosis, care, and treatment as well as other resources. Some of the information and resources are available in languages other than English. The summary may include medical terms, so we encourage you to share and discuss this information with your doctor. Orphanet is the French National Institute for Health and Medical Research and the Health Programme of the European Union.
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