Hemiplegic Migraines; A Barrage on the Mind

Abstract

Hemiplegic migraines (HM) are a rare type of migraine with an aura phase that includes muscle weakness. This form of migraine can either occur sporadically or can be seen in patients with familial hemiplegic migraine which is an autosomal dominant subtype that runs in families. Migraines are classically accompanied by phonophobia, photophobia, neurological symptoms, nausea or vomiting. The subcategory of hemiplegic migraine involves a transient wave of motor weakness and muscle spasms secondary to decreased threshold of excitation in the neurologic system. The etiology of Hemiplegic Migraines is either idiopathic condition or genetic mutation in the CACNA1A, ATP1A2 and SCN1A encoding proteins involved in ion transport. Our case outlines a 72 year old Caucasian female with past medical history of transient ischemic attack (TIA) and paroxysmal atrial fibrillation, presenting to the emergency department with sudden onset of headache, slurred speech and numbness and tingling in the left hand and leg. Tissue plasminogen activor t-PA) was administered within the 45 minute window, and a computed tomography angiography(CTA) of the head and neck was negative. Diagnosis of Hemiplegic Migraine was suggestive given the neurologic signs and symptoms with negative neurologic imaging. The expedited movement of neuronal depolarization down the easily excitable neurons causes a high amplitude wave of energy down the muscle fibers. Other hemiparesis syndrome differentials include MELAS, hereditary hemorrhagic telangiectasia, amyloidosis, and familial infantile convulsions. This case highlights the rarity of hemiplegic migraines and although genetic testing was not performed in our patient, it has been shown that some patients have a genetic predisposition. Strong clinical skills are needed to match the concurrent neurologic symptoms with migraines.