1509 - Uncommon Triggers of Hemiplegic Migraine: A Case Report on Accommodative Spasm and Abducens Nerve Palsy Secondary To Concussion

Thursday, February 22, 2024

5:00 PM – 6:30 PM EDT

Presenting Author(s)

Jing Lin, MD (she/her/hers)

Brain Injury Fellow
Rutgers New Jersey Medical School/ Kessler Institute for Rehabilitation
Jersey City, New Jersey, United States

Co-Author(s)

SS

Samantha Suarez, BS

Sports Medicine Coordinator / Athletic Trainer
RWJ Barnabas Health
Livingston, New Jersey, United States
NS

Nicole Schneider, MS

Athletic Trainer
RWJ Barnabas Health
Livingston, New Jersey, United States
PT

Peter Tumminelli, MD, FAAPMR, CAQSM

Attending Physician
Rutgers New Jersey Medical School/ RWJBarnabas Health
Livingston, New Jersey, United States

Case Diagnosis: Hemiplegic Migraine Secondary to Concussion

Case Description: A 16-year-old girl, with a history of headaches, presented for sports-related concussion without loss of consciousness. Initial evaluation demonstrated headache, cervical strain, diplopia, blurred vision, and photophobia. Initial exam showed nystagmus and left ankle weakness. Her condition worsened three weeks later with acute dysphagia, left sided weakness, and worsening visual symptoms. Follow-up examination revealed restricted eye movements, impaired convergence, and left hemiparesis. Brain MRI showed no abnormalities. She received high-dose non-steroidal anti-inflammatory drugs (NSAIDs) for suspected hemiplegic migraine (HM). Neuro-ophthalmology diagnosed severe accommodative spasm in the right eye and left abducens nerve palsy. Treatment with atropine eye drops and NSAIDs successfully resolved her ocular dysfunction and the deficits caused by her HM.

Discussions: Concussions often lead to headaches, but hemiplegic migraines are rare. HM involves headaches with unilateral weakness, typically lasting 20 to 60 minutes but sometimes weeks. Diagnosis involves ruling out other causes, with stress and head trauma as common triggers.

Our case is unique, featuring HM triggered by extra-ocular dysfunction following a concussion. Abducens nerve palsy, a result of head trauma, rarely occurs with accommodative spasm—a condition from prolonged ciliary muscle contraction. In concussions with cervical injury, it is possible that sympathetic nerves exiting the C2-C3 level are injured, resulting in dysregulation of the accommodative system.

Conclusions: The heterogeneity of post concussion complications emphasizes the importance of treatment by a concussion specialist. HM is a clinical diagnosis, and other diagnoses should be excluded first. This case demonstrates that HM can be a unique complication of concussion with extra-ocular motor dysfunction.