(Kiosk 4) Management of Hemiplegic Migraine in Acute Inpatient Rehabilitation; A Case Report

Case Diagnosis: 57-year-old male with history of migraines presented to the emergency department for acute-onset left-sided headache, right-sided hemiplegia and paresthesia, right visual field deficit, and dysarthria.

Case Description: Non-contrast CT Head showed hyperdense supraclinoid ICA on the left, suspicious for acute stroke. Patient received tPA. MRI Brain, however, was negative for acute stroke. MRI spinal survey was unremarkable. Neurology was consulted and suggested hemiplegic migraine given the negative work-up, though started secondary stroke prevention with aspirin and clopidogrel. On acute inpatient rehabilitation admission, exam was notable for full strength in the left upper and lower extremities and antigravity strength in the right upper and lower extremities. He did not demonstrate cognitive deficits.

Discussion: Hemiplegic migraine is a rare subtype of migraine with aura in which a headache is accompanied by unilateral weakness. It can occur with other aura symptoms including sensory or visual impairments. Classically, motor deficits resolve within 72 hours, though can persist for weeks or longer.

Setting: Academic, acute inpatient rehabilitation facility

Assessment/Results: During his stay, his strength rapidly improved. He could provide resistance with the right upper and lower extremities, except for right ankle dorsiflexion, after seven days of acute inpatient rehabilitation. He was completing activities of daily living at setup to modified independent level and was ambulatory with transfers using a rolling walker. Repeat MRI Brain as an outpatient ruled out pure motor lacunar syndrome. Patient followed with his Neurologist and Neuro-ophthalmologist, both of whom supported diagnosis of hemiplegic migraine. He was continued on his home galcanezumab injections.

Conclusion: This case highlights the benefit of a short acute inpatient rehabilitation stay in those with hemiplegic migraine. These patients typically demonstrate more rapid motor improvement relative to stroke patients, and physiatrists should expect greater prognosis for motor recovery. Patients should be counseled that hemiplegic migraines may recur and to adhere to their migraine prophylaxis regimen.