A 55-year-old woman with history of adrenal insufficiency on chronic prednisone, hypertension, Hashimoto’s disease, migraine, obesity status post gastric bypass surgery presented in October 2024 with a year-long history of episodic, severe right-sided retro-orbital throbbing pain accompanied by ipsilateral ptosis, mydriasis, photophobia, facial paresthesia (V2), bilateral pulsatile tinnitus, nausea, and restlessness. Each attack lasted four to twenty-four hours, occurring three times per week.
Both neuro-ophthalmological and neurological examinations were normal. CTA head/neck, and MRI brain/orbit revealed bilateral PACs, more prominent on the right. Lumbar puncture revealed an opening pressure of 38cm H2O, with a normal CSF analysis. MR venogram revealed hypoplastic left transverse and sigmoid sinuses. Acetazolamide was poorly tolerated, and topiramate did not improve her symptoms. The patient was evaluated by neurosurgery and successfully underwent right transverse sinus stenting following venous pressure manometry. Post-procedure, her right-sided facial symptoms resolved.