435 - Unmasking Migraine Hemiplegia: A Challenging Diagnosis and Effective Treatment Approach

Thursday, February 22, 2024

5:00 PM – 6:30 PM EDT

Presenting Author(s)

JS

Jasmine Sidhu, MD

Resident Physician/ MD
Larkin Community Hospital
Miami, Florida, United States

Co-Author(s)

TJ

Trevor P. Jackson, DO

Resident Physician
Larkin Community Hospital PSC
Pembroke Pines, Florida, United States

Case Diagnosis: Hemiplegic migraine, a rare subtype of migraine with aura, manifests as unilateral weakness and sensory disturbances. This report discusses the diagnostic challenge of identifying its etiology and the successful use of migraine-specific therapies.

Case Description: A 25-year-old female with a medical history of migraines and Guillain-Barre syndrome (without lasting deficit), presented to the hospital with a one-day history of headache, phonophobia, photophobia, and left-sided weakness. Initially, Miller Fisher’s Syndrome, a variant of Guillain-Barre syndrome, was suspected, leading to IVIG treatment. However, extensive diagnostic assessments, including CT and MRI imaging, lumbar puncture, and serological studies, yielded largely unremarkable results, excluding acute vascular events, multiple sclerosis, and other potential causes. Paraneoplastic and autoimmune markers were also negative. On examination, the patient was alert and oriented, following commands, without aphasia, hemineglect, or gaze preference. Significant left-sided diplopia persisted unchanged, along with hemiparesis, where left upper extremity muscle strength was at 1/5, and left lower extremity muscle strength at 1/5. The patient's migraines were managed with Topamax, resulting in significant symptom relief and noticeable strength improvement, especially in the left upper extremity.

Discussions: This case highlights the diagnostic challenge of identifying the etiology of hemiplegia in a patient with a complex medical history. While Guillain-Barre syndrome and other potential causes were considered, the patient's improvement with migraine-specific therapy suggested that her symptoms were likely related to chronic migraine. Migraine-related hemiplegia, though rare, should be considered in patients with recurrent hemiparesis and a history of migraines.

Conclusions: Migraine-related hemiplegia can present with a wide range of neurological symptoms, making it a diagnostic challenge. Clinicians should consider this rare condition, especially in patients with a history of migraines, when evaluating cases of unexplained hemiparesis. Migraine-specific therapies may provide significant relief and improvement in such cases, as demonstrated in this report.