Migraine that looks like a stroke

There are many different kinds of headache disorders and they’re not all migraine. Up to this point we’ve only covered two of them: migraine and cluster headaches. This month I’d like to share some basic information about other headache disorders to broaden your understanding. One of these headache disorders presents with symptoms that can be alarming to both patient and loved ones.

It looks like a stroke.

Hemiplegic migraine (HM) is a rare form of migraine, similar to migraine with aura. However, the aura of HM has some unique characteristics:

• aura symptoms include both motor weakness (or paralysis) and visual, sensory, and/or aphasia
• one symptom begins gradually over 5 minutes
• other symptoms follow in succession
• each symptom can last for 5-60 minutes
• at least one symptom will be unilateral
• motor symptoms continue for the duration of the attack, up to 72 hours

A headache follows the aura within 60 minutes and lasts up to 72 hours if not treated. Because the aura symptoms closely resemble that of TIA and/or stroke. These must be ruled out first, these patients often undergo extensive medical testing before a diagnosis can be confirmed. This can delay treatment and prolong a patient’s suffering.

There’s a genetic link, too.

Hemilplegic migraine is the one migraine type that has a confirmed genetic link. Researchers have identified 3 different genetic mutations which can each cause hemiplegic migraine.

There are now four familial subtypes:

• Familial hemilplegic migraine (FMH) is diagnosed when at least one first- or second-degree relative also has the symptoms of hemiplegic migraine.
• Familial hemilplegic migraine, type 1 (FHM1) is diagnosed when there is a confirmed causative mutation on the CACNA1A (a calcium channel) gene on chromosome 19 in addition to the symptoms listed above.
• Familial hemilplegic migraine, type 2 (FHM2) is diagnosed when there is a confirmed causative mutation on the ATP1A2 (a K/Na-ATPase) gene on chromosome 1 in addition to the symptoms listed above.
• Familial hemilplegic migraine, type 3 (FHM3) is diagnosed when there is a confirmed causative mutation on the SCN1A (a sodium channel) gene on chromosome 2 in addition to the symptoms listed above.

Treatment can be tricky.

Due to the severity of symptoms, it is critical that patients work with their headache specialists to find an effective preventive treatment protocol. Just like with other forms of migraine, there has never been a medicine designed to prevent hemiplegic migraine. So all migraineurs are faced with the option of trying off-label medicines. Fortunately, this sorry state has been going on long enough that some of these medicines have actually proven to help reduce the severity and frequency of even hemiplegic migraine.

Finding a good aboritive treatment is a bigger challenge. Triptans and ergotamines are both contraindicated for use with hemiplegic migraine. Because of this, patients are usually prescribed a combination of prescription-strength NSAIDs, antiemetics, and/or opioids. None of these options are quite as effective at aborting migraine attacks as triptans.

Resources:
American Headache and Migraine Association (AHMA)
National Headache Foundation (NHF)