A Case of Recurrent Benign Episodic Unilateral Mydriasis and Decreased Visual Acuity and Review of the Literature

Jane T Caty, Michael Kogan, J James Reidy, Adnan H Siddiqui, Osman Farooq, Ping Li


Unilateral mydriasis has a variety of causes, some of which are life-threatening. Migraine with benign episodic unilateral mydriasis is a nonsurgical cause of anisocoria, with unknown underlying pathophysiology. This disorder is thought to be caused by an Adie’s pupil triggered by migraine due to overactivation of the sympathetic nervous system or hypoactivity of the parasympathetic nervous system. We present the case of a 47-year-old patient who had recurrent benign episodic unilateral mydriasis associated with migraine headaches. Other vascular causes of mydriasis were investigated and excluded. Ultimately, the patient’s symptoms of blurred vision and pupillary dilation resolved over the 2 weeks after onset. We reviewed all 50 cases of benign episodic unilateral mydriasis reported in the literature and summarized common presentations of this disorder. The case presented here is typical in its progression and associated symptom of blurred vision, which is reported in 56% of cases in the literature. 


anisocoria, migraine headache, unilateral mydriasis

Full Text:



Alkhalil M, Lewis S, Hawker M, et al. Persistent unilateral mydriasis and headache (doi: 10.1136/bcr.11.2008.1260). BMJ Case Rep. 2009;2009 epub March 17.

Caglayan HZ, Colpak IA, Kansu T. A diagnostic challenge: dilated pupil. Curr Opin Ophthalmol. 2013;24:550-557.

Kerr FW, Hollowell OW. Location of pupillomotor and accommodation fibres in the oculomotor nerve: experimental observations on paralytic mydriasis. J Neurol Neurosurg Psychiatry. 1964;27:473-481.

Nam KH, Choi CH, Lee JI, et al. Unruptured intracranial aneurysms with oculomotor nerve palsy : clinical outcome between surgical clipping and coil embolization. J Korean Neurosurg Soc. 2010;48:109- 114.

Ault J. Teaching case: migraine and pupil dilation. Headache. 2011;51:324-326.

Barriga FJ, Lopez de Silanes C, Gili P, et al. Ciliary ganglioplegic migraine: migraine-related prolonged mydriasis. Cephalalgia. 2011;31:291-295.

Blaik Z, Hiremagular S. Episodic unilateral mydriasis and headaches. Tenn Med. 1998;91:107-108.

Evans RW, Jacobson DM. Transient anisocoria in a migraineur. Headache. 2003;43:416-418.

Ishikawa H, Yoshihara M, Mizuki K, et al. A pediatric case of ophthalmoplegic migraine with recurrent oculomotor nerve palsy. Jpn J Ophthalmol. 2000;44:576.

Jacobson DM. Benign episodic unilateral mydriasis. Clinical characteristics. Ophthalmology. 1995;102:1623-1627.

Leone M, Grazzi L, Moschiano F, et al. Internal ophthalmoplegia associated with migraine attacks. Cephalalgia. 1994;14:461-462.

Maggioni F, Mainardi F, Malvindi ML, et al. The borderland of migraine with aura: episodic unilateral mydriasis. J Headache Pain. 2011;12:105-107.

Purvin VA. Adie's tonic pupil secondary to migraine. J Neuroophthalmol. 1995;15:43-44.

Simonetto M, Zanet L, Capozzoli F, et al. Unilateral headache with bilateral internal ophthalmoplegia. Neurol Sci. 2012;33:1185-1187.

Skeik N, Jabr FI. Migraine with benign episodic unilateral mydriasis.

Int J Gen Med. 2011;4:501-503.

Sobreira I, Sousa C, Raposo A, et al. Ophthalmoplegic migraine with

persistent dilated pupil. J Child Neurol. 2013;28:275-276.

Woods D, O'Connor PS, Fleming R. Episodic unilateral mydriasis and

migraine. Am J Ophthalmol. 1984;98:229-234.

Tomsak RL. Ophthalmologic aspects of headache. Med Clin North Am.



  • There are currently no refbacks.