Case Presentation:

A 28–year–old nonsmoker female with a history of migraines and OCP use presented to the hospital with acute onset confusion, disorientation and right–sided focal neurologic deficits. The patient had migraines since age 12 and had been placed for the past year on topamax daily and sumatriptan as needed. Her typical aura consisted mainly of dizziness and nausea, without localizing neurologic deficits. On the morning of the admission she felt confused and dizzy. She had a headache as well and took a dose of sumatriptan 50 mg. Her boyfriend noticed that she was acting strange, and having difficulty with memory; he noted a slight drop of her mouth on the right. She then developed mild ataxia and weakness in her right arm. She presented to the ER that evening after her symptoms did not improve. On physical exam, vitals were stable and she appeared in no acute distress, but was slightly confused and could not recite the time or date. Neurologic exam revealed right facial numbness, right lower facial droop and right upper extremity weakness and dysmetria. Cranial nerves, strength and reflex testing were grossly normal. Head CT and subsequent MRI showed a left thalamic infarct. MRA and MRV imaging of the neck and head showed no vascular anomalies and a full hyper–coagulation work up was negative. The patient was discharged on aspirin and statin for outpatient rehabilitation, her weakness has improved but she continued to have episodes of confusion.

Discussion:

This patient’s stroke was in the posterior circulation, a common distribution for migraine–associated strokes, and the aura on this day was not typical for her. The added symptom of “confusion” can be attributed to the focal thalamic stroke. This suggests that focal thalamic ischemia preceded the sumatriptan use, but raises the question if sumatriptan converted what may have been a reversible complicated migraine into a completed stroke. This question cannot be answered with certainty. It is also important to add that cerebrovascular ischemic events can be an inciting event for a migraine attack, which further complicates this diagnosis. Finally, the incidence of ischemia with triptan use may be underestimated given that they are contraindicated in patient’s at higher risk for cardiovascular disease and stroke.

Conclusions:

his case illustrates the challenge of educating a patient prospectively to recognize a subtle variation from the usual aura – in this case the added confusion—as a contraindication to triptan use. The internist must be cautious when prescribing triptans and avoid their use in patients at higher risk for ischemic strokes The internist must also recognize the broad differential diagnosis in patients presenting with a headache and associated neurologic findings – (complex migraine vs stroke vs migraine). Although ischemia is a rare complication of both migraines and triptan use, this potential serious risk should not be ignored and further studies are needed to determine the relationship