New-onset cervical pain followed by ophthalmoplegia revealing cavernous sinus meningioma

Abstract

Background: Headache and facial pain may occur in patients with meningioma, but their diagnostic significance is often underestimated when pain resembles a primary headache phenotype or occurs in a patient with a long-standing history of tension-type headache. Cavernous sinus meningiomas are particularly relevant in headache medicine because of their proximity to the oculomotor nerves, trigeminal branches, internal carotid artery, and parasellar structures. Case Report: A 62-year-old woman with a 30-year history of tension-type headache presented with a 1-month history of severe cervical pain, initially interpreted in the context of her previous headache disorder and treated with amitriptyline at a dose of 10 mg/day, administered at bedtime for 2 weeks, without clinical benefit. She subsequently developed acute vertical diplopia. Neurological examination revealed mild left ptosis, left ocular deviation, and impaired elevation of the left eye, consistent with partial left oculomotor nerve palsy. She also reported a transient cold sensation in the left maxillary territory. Contrast-enhanced brain MRI showed a homogeneously enhancing extra-axial lesion in the left cavernous sinus, extending toward the superior orbital fissure and lying close to the intracavernous segment of the internal carotid artery, compatible with cavernous sinus meningioma. No previous brain MRI or CT was available for comparison. Discussion: The association of a new, refractory cervical pain with acute ocular motor dysfunction and ipsilateral trigeminal sensory symptoms supported a secondary pain disorder rather than a simple fluctuation of the patient’s previous tension-type headache. Cavernous sinus meningioma should be considered in the differential diagnosis of new-onset cervical pain followed by ophthalmoplegia, particularly when oculomotor nerve palsy is accompanied by trigeminal sensory symptoms. Conclusions: This case highlights a clinically relevant diagnostic pitfall in headache practice: a new or changed pain phenotype in a patient with a known primary headache disorder should prompt reassessment for secondary causes, especially when cranial nerve signs emerge.