Tolosa-Hunt syndrome; a diagnosis of exclusion: a case report

Tolosa-Hunt Syndrome is a rare cause of unilateral headache with painful ophthalmoplegia. Only a limited number of cases are reported in the literature. We present a case of Tolosa-Hunt syndrome in a middle-aged male who presented to Teaching Hospital Anuradhapura. A previously well, hypertensive gentleman presented with gradual onset right-sided headache and diplopia for five days duration. On examination, there were right-sided palsies of right-sided cranial nerves III, IV, V-1, VI  on examination. Magnetic Resonance Imaging (MRI) of the brain with contrast was unremarkable. The patient was treated with steroids after excluding other possible causations of painful ophthalmoplegia. He was started on steroids, to which a dramatic response was observed. Tolosa-Hunt syndrome responds well to steroid therapy even though there is no proven benefit of steroids to reduce recurrence rates. Careful evaluation needs to be carried out to rule out other possible causes of similar clinical and radiological features as they may be masked by steroid therapy.