Case Studies in Headache: Hemiplegic Migraine

By Anne Walling, M.D.
Professor, Family and Community Medicine, University of Kansas School of Medicine – Wichita


Al was a very healthy 28-year-old lawyer. The only indication of a potential health problem was a history of migraine in his mother and several family members. Al himself had never suffered from headaches.

One day at work, Al felt unusually tired and had trouble concentrating. He found writing difficult and noticed he was “dropping things and tripping over my feet.” At the insistence of his boss, Al made an emergency appointment with his family physician. By then he had developed a headache on his left side and felt nauseated and tired. His arm and leg were weaker on the right side than the left. A neurological assessment, including MRI and other tests, was performed because of the possibility of a stroke.

The tests were normal, but while they were being completed, Al appeared to have a typical left-sided migraine. The weakness disappeared as the headache, nausea and exhaustion progressed. After taking pain pills and a long nap, Al was completely back to normal within a few hours. Al’s physicians concluded that the weakness was a migraine aura.

About 20% of migraine sufferers have distinctive neurological symptoms called “aura” before the headache, nausea and other migraine symptoms begin. The aura usually lasts for less than an hour and patients typically do not have a break between the aura and the migraine attack. Many patients use their aura symptoms as a warning of an impending migraine.

Changes in vision are by far the most common aura symptoms. Patients report seeing flashes of light or “floaters” of long zigzag lines drifting across their field of vision. Sometimes they have areas of lost or hazy vision. Patients often say that the junction between their normal vision and the lost or hazy area is scintillating or sparkling. Less common aura symptoms are tingling, “pins and needles,” or numbness sensations, especially in the hands, face or tongue, and difficulty speaking.

Muscle weakness is a rare symptom of aura. When it is present, the diagnosis is hemiplegic migraine. Hemiplegic means weakness on one side of the body, i.e., both the arm and leg on the same side become weak. Rarely, several members of a family have migraines with an aura of weakness on one side of the body. This is called familial hemiplegic migraine and has been associated with inherited chromosomal changes.

In hemiplegic migraine, the muscle weakness is usually only on one side but can be on both sides of the body. It usually starts in one area and spreads to other muscles. Al’s case is very typical, as he first noticed feeling clumsy and that he was dropping things due to hand weakness. Within a few hours, he had weakness in both his arm and leg on the right side. In retrospect, he also had difficulty in speaking or “finding the right words” during his aura.

Sudden weakness is usually caused by a stroke. Al was treated as an emergency until the physicians knew that the brain imaging and other tests were normal, that he had developed a migraine attack, and that his symptoms went away within an hour or so. The possibility of a stroke in any patient is a medical emergency requiring urgent expert assessment. In Al’s words, “hemiplegic migraine is not pleasant, but it sure beats the alternatives.”

The diagnosis of hemiplegic migraine is usually best done by a neurologist or headache specialist very familiar with this rare headache form. Because there is some concern that the triptan medications may lead to stroke in patients with hemiplegic migraine, they are contraindicated. Healthcare providers should also help patients address any additional risk factors for stroke and other cardiovascular diseases.

Since Al’s first episode, he has had migraines about every six weeks. He only notices muscle weakness before about half of the attacks. He manages his migraines with analgesics and rest and always reminds his physician of the day he had everyone in a panic over his “stroke.”



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