Project Title

Hemiplegic Migraine Presenting as Acute Cerebrovascular Accident: A Difficult Differentiation

Authors' Affiliations

Amanda Cecchini, DO, Department of Internal Medicine, East Tennessee State University, Johnson City, TN Arthur Cecchini, DO, Department of Internal Medicine, East Tennessee State University, Johnson City, TN Martin Litman, DO, Department of Internal Medicine, East Tennessee State University, Johnson City, TN

Faculty Sponsor’s Department

Internal Medicine

Type

Oral Non-Competitive

Classification of First Author

Medical Resident or Clinical Fellow

Project's Category

Healthcare and Medicine

Abstract Text

Cerebrovascular accidents (CVAs) are a leading cause of morbidity and mortality in the United States. Metabolic derangements such as hypoglycemia, infections, brain masses or lesions, neurodegenerative disorders, neuropathies, myelopathies, seizures, syncope, types of migraines, and many other disorders may mimic CVA. Our case presents a 38-year-old female who was evaluated in the emergency department with a three- hour history of headache, lethargy, left- sided upper extremity weakness, facial droop, and dysarthria. A CVA workup was initiated and she immediately underwent a computed tomography (CT) scan of the head which revealed no intracranial hemorrhage. She was unable to provide a thorough medical history due to lethargy, however she was able to answer yes/no questions to screen for tissue plasminogen activator (tPA) qualification. She qualified based on her screening results and was administered tPA for her presumed ischemic CVA. She was then monitored in the intensive care unit for twenty-four hours. Due to reoccurrence of headache and left-sided weakness, as well as recent administration of tPA increasing risk of hemorrhage, she underwent two subsequent negative non- contrast head CT scans to rule out bleeding during that time. On hospital day two, magnetic resonance imaging (MRI) of the head, neck, and spine were performed which were also negative for infarct or hemorrhage. A more detailed history from our patient revealed previous migraine headaches, but her left sided weakness and dysarthria were new symptoms. With this information, it was suspected that she was suffering from a hemiplegic migraine, a rare mimic of CVA. Prochlorperazine, diphenhydramine, valproic acid, and corticosteroids were administered for migraine treatment, which aborted her symptoms entirely. Topiramate was then started for migraine prophylaxis. Daily low-dose aspirin was also initiated due to inability to fully rule out CVA/transient ischemic attack (TIA). An outpatient neurology follow up was scheduled on discharge. In clinical practice, hemiplegic migraines and CVA/TIA may be difficult to differentiate as symptoms often overlap. A detailed history and physical exam with careful attention to associated symptoms and timing of symptom onset is essential to formulating a correct diagnosis. This must be done quickly, as tPA is a high-risk medication with a narrow time window for administration. In conclusion, not all disease processes have an available “gold standard” diagnostic test to differentiate similar diagnoses. MRI of the brain is usually performed to differentiate ischemic CVA from TIA; however, imaging is not useful to differentiate hemiplegic migraine from TIA. Therefore, performing a thorough history, physical exam, and chart review is paramount to provide patients with the correct treatment as well as prevent adverse outcomes. It is the responsibility of the clinician to make difficult decisions weighing the risks and benefits of providing various treatments or interventions, and to know the complications of those treatments. Disease processes mimicking CVA must be considered in all patients, as treating an incorrect diagnosis can have devastating effects.

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Hemiplegic Migraine Presenting as Acute Cerebrovascular Accident: A Difficult Differentiation

Cerebrovascular accidents (CVAs) are a leading cause of morbidity and mortality in the United States. Metabolic derangements such as hypoglycemia, infections, brain masses or lesions, neurodegenerative disorders, neuropathies, myelopathies, seizures, syncope, types of migraines, and many other disorders may mimic CVA. Our case presents a 38-year-old female who was evaluated in the emergency department with a three- hour history of headache, lethargy, left- sided upper extremity weakness, facial droop, and dysarthria. A CVA workup was initiated and she immediately underwent a computed tomography (CT) scan of the head which revealed no intracranial hemorrhage. She was unable to provide a thorough medical history due to lethargy, however she was able to answer yes/no questions to screen for tissue plasminogen activator (tPA) qualification. She qualified based on her screening results and was administered tPA for her presumed ischemic CVA. She was then monitored in the intensive care unit for twenty-four hours. Due to reoccurrence of headache and left-sided weakness, as well as recent administration of tPA increasing risk of hemorrhage, she underwent two subsequent negative non- contrast head CT scans to rule out bleeding during that time. On hospital day two, magnetic resonance imaging (MRI) of the head, neck, and spine were performed which were also negative for infarct or hemorrhage. A more detailed history from our patient revealed previous migraine headaches, but her left sided weakness and dysarthria were new symptoms. With this information, it was suspected that she was suffering from a hemiplegic migraine, a rare mimic of CVA. Prochlorperazine, diphenhydramine, valproic acid, and corticosteroids were administered for migraine treatment, which aborted her symptoms entirely. Topiramate was then started for migraine prophylaxis. Daily low-dose aspirin was also initiated due to inability to fully rule out CVA/transient ischemic attack (TIA). An outpatient neurology follow up was scheduled on discharge. In clinical practice, hemiplegic migraines and CVA/TIA may be difficult to differentiate as symptoms often overlap. A detailed history and physical exam with careful attention to associated symptoms and timing of symptom onset is essential to formulating a correct diagnosis. This must be done quickly, as tPA is a high-risk medication with a narrow time window for administration. In conclusion, not all disease processes have an available “gold standard” diagnostic test to differentiate similar diagnoses. MRI of the brain is usually performed to differentiate ischemic CVA from TIA; however, imaging is not useful to differentiate hemiplegic migraine from TIA. Therefore, performing a thorough history, physical exam, and chart review is paramount to provide patients with the correct treatment as well as prevent adverse outcomes. It is the responsibility of the clinician to make difficult decisions weighing the risks and benefits of providing various treatments or interventions, and to know the complications of those treatments. Disease processes mimicking CVA must be considered in all patients, as treating an incorrect diagnosis can have devastating effects.

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