13.7 Headache attributed to ischaemic ocular motor nerve palsy

Identification: Male patient, 65 years old, diabetic and hypertensive, with acute headache and diplopia for 3 days.

History of Present Illness:
Ocular Symptoms:
Diplopia:
- Binocular, horizontal (worse on dextroversion)
- Absent when closing one eye

Pain:
- Location: Right retro-orbital and frontal
- Characteristic:
- Constant (5-7/10 VAS)
- Pulsatile during exacerbations
- No photophobia/phonophobia

Associated Signs:
- Incomplete right eyelid ptosis
- History of proliferative diabetic retinopathy

Comorbidities:
- Type 2 Diabetes Mellitus (HbA1c 9.2%)
- Uncontrolled Hypertension (BP 170/95 mmHg on admission)

Physical/Neurological Examination:
Ocular Motility (Right Eye):
- Sixth Nerve Palsy:
- Limited abduction (≤30% of normal range)
- Convergent strabismus in primary position
- Pupils isocoric and reflexes preserved

Fundoscopy:
- Cotton wool spots
- Flame-shaped hemorrhages

General Examination:
- No other focal neurological deficits

Complementary Exams:
Brain and Orbit MRI (with diffusion):
- Absence of ischemic/compressive lesions
- Increased signal in the intracavernous course of the sixth nerve

Cerebral Arteries MR Angiography:
- Mild stenosis (<30%) of the basilar artery

Laboratory:
- Fasting glucose: 210 mg/dL
- LDL: 160 mg/dL