A 12‐year‐old girl with history of migraines and seizures presented for evaluation of aphasia and right‐sided hemiplegia. The symptoms began five days prior to admission and preceded a migraine headache. A day later she was completely aphasic and paralyzed on the right side. Prior to this event she had no history of recent illness, fever, rashes or change in personality. At baseline she had migraines several times per month. Physical exam was remarkable for facial droop and weakness on the right side, as well as expressive and mild receptive aphasia. Headaches persisted throughout admission and were treated successfully with Tylenol and ibuprofen; however, these agents did not resolve her neurologic symptoms. An extensive workup was sent to rule out stroke, inflammatory processes, or autoimmune conditions. CSF studies were normal and a comprehensive rheumatologic workup was unremarkable. CT showed no evidence of stroke or any other acute process. EEG showed no epileptiform discharges. MRA/MRS were normal, and MRI showed cortical swelling in the left frontoparietal and temporal lobes, thought to be post‐ictal in nature. She was started on a three‐day course of high dose solumedrol, as well as verapamil, used for prevention of hemiplegic migraines. She also had intensive physical therapy and occupational therapy while in the hospital. Over one week after symptom onset, the hemiplegia and aphasia began to steadily improve, particularly after the initiation of steroids. At the time of discharge she could walk without assistance and speak in full sentences, though had word finding difficulties. Now, many months after hospitalization, her language is nearly back to baseline. She still has difficulties concentrating. Since she was started on verapamil, she has not had a single migraine headache.
Hemiplegic migraines are characterized by motor weakness with or without a speech disturbance that begins during the aura phase. It is uncommon for symptoms to last more than several days, and for the most part they will resolve completely. In rare circumstances, severe attacks can lead to permanent neurologic deficits including cerebral atrophy and cognitive decline. We describe a case in which the acute attack persisted for weeks, with some long‐lasting cognitive sequelae. In such instances it is critical to rule out other diagnoses and consider prophylactic therapy for prevention of future attacks. The most well‐studied agents for this purpose include verapamil, flunarizine, and acetazolamide. Vasocontrictors such as triptans are felt to be contraindicated for prophylaxis of hemiplegic migraines.
It is critical for hospitalists to consider hemiplegic migraines as a diagnosis for someone who presents in this manner. It is also important for providers to be cognizant of migraine preventative agents, as severe attacks with neurologic symptoms, though rare, can lead to lasting neurologic deficits.