Reversible Hemiparesis in a Patient With Migraine

ABSTRACT

A third of patients with migraine may experience accompanying aura, and when this includes motor weakness, the condition is described as hemiplegic migraine. Young women who suffer from migraine with aura have a 6.2-fold increased risk of ischemic stroke. The slow progression and succession of symptoms help to provide the diagnosis of hemiplegic migraine.

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KEYWORDS :

• aura
• headache
• migraine
• triptan

COMMENTARY FROM BELGIUM

Jan Versijpt

The pain caused by (hemiplegic) migraine can indeed be relieved by paracetamol, NSAIDs, or acetylsalicylic acid. If these do not work, triptans can be used. The warning to not use triptans in hemiplegic migraine patients or in patients with cardiovascular disease stems merely from the fact that these two patient groups were all excluded from the initial triptan studies. This occurred because at that time, the false belief still existed that (hemiplegic) aura was related to vasoconstriction and triptans can significantly worsen preexisting vasoconstriction. Indeed, a retrospective case-control study indicated that triptans do not increase the risk of ischemic complications, even in those patients who overuse triptans and in those concomitantly taking cardiovascular drugs.¹

This case puts emphasis on the association of migraine with aura and stroke risk. Whether the stroke risk is indeed 6.2 times greater might, however, be an overstatement. After all, some studies have failed to show this increased risk, and a recent meta-analysis revealed a relative risk of stroke of 2.2 in patients with migraine with aura.²

However, it seems wise for now to refer all patients with migraine with aura who are using combined oral contraceptives to their general practitioner (GP) or gynecologist to discuss their current contraceptive use. Apart from the risk of stroke, combined oral contraceptives could also have a detrimental effect on both migraine frequency and intensity of symptoms. However, recent evidence suggests a possible benefit of progestogen-only contraceptives.³

COMMENTARY FROM THE UNITED KINGDOM

Mark Weatherall

The author presents a case of transient hemiparesis in a young woman with a history of migraine with more typical visual, sensory, and dysphasic manifestations of aura. In such cases the diagnosis may not be difficult, provided the history of migraine is apparent at the time of presentation. In the absence of a clear history, however, neuroimaging is advisable to rule out alternative diagnoses, particularly where, as here, weakness has not hitherto been characteristic of the patient's migraines. In many cases hemiplegic migraine is a diagnosis of exclusion and will often remain a working diagnosis until the patient has further similar attacks.

Hemiplegic migraine attacks are frightening and debilitating. In some cases it can take many days or even weeks for the weakness to resolve fully. Although the acute treatment of the pain phase of hemiplegic migraine is, as the author points out, essentially the same as for other forms of migraine with aura, we have no treatments that abort, alleviate, or ameliorate migraine aura. Therefore, for patients with recurrent attacks, preventive treatment is almost always indicated. Standard migraine preventives may be used for patients with hemiplegic attacks; where available, flunarizine is said to be a particularly effective preventive treatment in hemiplegic migraine.¹ Patients with recurrent attacks (particularly those who have a tendency to dysphasia) should wear a MedicAlert bracelet or similar information device to inform medical and paramedical professionals of their diagnosis. This is particularly important now that systems for rapid access to thrombolysis for acute stroke are becoming more widespread.

Declaration of interest: The author reports no conflicts of interest. The author alone is responsible for the content and writing of the paper.

Notes

Jan Versijpt, MD, PhD, is Professor of Neurology, University Hospital, Brussels, Belgium (E-mail: [email protected]).

Mark Weatherall, MB, BC, FRCP(Edin), is a consultant neurologist at the Charing Cross and Ealing hospitals, London, UK (E-mail: [email protected]).