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Tolosa-Hunt syndrome presenting with features of a trigeminal autonomic cephalalgias and pituitary enlargement
  1. Nicholas Keyi Sim1,
  2. Sze Yii Liew2,
  3. Daniel J Warren3 and
  4. Ahamad Hassan4
  1. 1Neurology, Calderdale and Huddersfield NHS Foundation Trust, Halifax, UK
  2. 2School of Medicine, University of Leeds School of Medicine, Leeds, UK
  3. 3Neuroradiology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
  4. 4Neurology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
  1. Correspondence to Dr Nicholas Keyi Sim; nicholas.sim1{at}


Tolosa-Hunt syndrome is understood as a steroid-responsive, relapsing-remitting, unilateral headache disorder associated with ipsilateral cranial neuropathies, of a probable granulomatous aetiology. The diagnosis is made clinically from the history and examination, supported by appropriate imaging. Here the authors report a case of Tolosa-Hunt syndrome with a headache phenotype mimicking a trigeminal autonomic cephalalgias (hemicrania continua), and serial MRI studies showing a stable enlarged pituitary. Due to her initial lack of clinical signs, she was diagnosed with chronic migraine, revised to hemicrania continua based on indomethacin response, then revised back to chronic migraine. Her final diagnosis was achieved after she developed a left cavernous sinus syndrome 4 years into her disease course. This case shows that Tolosa-Hunt syndrome may present with a non-side-locked headache and delayed development of clinical signs. Clinicians should also maintain a high degree of suspicion when faced with incidental MRI findings.

  • pituitary disorders
  • headache (including migraines)
  • pain (neurology)
  • neuroimaging
  • cranial nerves

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  • Contributors NKS drafted the manuscript, edited the manuscript and prepared the images. SYL made significant revisions to the manuscript. DJW provided the images and drafted the radiology sections and image legend. AH conceptualised the manuscript and made significant revisions. All authors commented on the final manuscript and approved it for publication.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Case reports provide a valuable learning resource for the scientific community and can indicate areas of interest for future research. They should not be used in isolation to guide treatment choices or public health policy.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.