The Hidden Trap: Tolosa–Hunt Syndrome Masking Entrapped Great Occipital Nerve—A Case of Headache Surgery

Summary:

Headache syndromes may coexist with peripheral nerve entrapment, which can obscure the true pain generator and delay effective treatment. Tolosa–Hunt syndrome is a rare, painful ophthalmoplegia syndrome characterized by unilateral orbital pain and cranial nerve palsy, often showing a marked response to corticosteroids. We report the case of a 56-year-old woman with a long history of migraine who developed recurrent right-sided orbital pain, maxillary pain, and ophthalmoplegia. She was diagnosed with Tolosa–Hunt syndrome by an experienced neurologist after skull magnetic resonance imaging and clinical evaluation. Because steroids and anti-inflammatory treatment produced only partial relief, and because she also had occipital pain with a positive Tinel sign over the greater occipital nerve, occipital neuralgia was suspected. A diagnostic block of the right greater occipital nerve provided partial improvement, after which right-sided surgical decompression of the nerve was performed. At 1-year follow-up, the patient had no residual surgical sensory deficit, no recurrent severe orbital or maxillary pain, and a marked reduction in attack frequency and intensity. Her Migraine Disability Assessment score improved from 18 to 4, and medication use decreased to sporadic use of simple analgesics and triptans. In selected patients, rare headache syndromes may coexist with occult peripheral nerve entrapment. Persistent symptoms despite appropriate medical treatment should prompt reconsideration of the diagnosis and targeted evaluation for occipital neuralgia.