How should I manage a patient with migraine and functional neurological disorder who presents with weakness and a positive Hoover sign on neurologist examination?

Management of FND with Weakness and Positive Hoover Sign

This patient requires multidisciplinary rehabilitation centered on occupational therapy and physical therapy using a biopsychosocial framework, with concurrent appropriate migraine management, as the positive Hoover sign confirms the functional nature of the weakness and guides treatment away from traditional neurological rehabilitation approaches. 1

Immediate Management Framework

Diagnosis Confirmation and Patient Education

The positive Hoover sign is a positive clinical sign that confirms FND diagnosis—this is not a diagnosis of exclusion 1. The neurologist's examination has already established this, which is critical for moving forward with appropriate treatment.

Key educational points to discuss with the patient:

• FND is a real, common, and disabling condition causing neurological symptoms outside their control
• Symptoms result from potentially reversible miscommunication between brain and body
• The diagnosis was made using positive clinical signs (the Hoover sign in this case), not by ruling out other conditions
• FND can coexist with other neurological conditions like migraine 1
• Self-directed attention worsens symptoms; redirecting attention can temporarily reduce them
• The body's stress response influences nervous system functioning and therefore FND symptoms

Core Treatment Strategy

Occupational therapy should be the primary rehabilitation intervention 1. The approach must differ fundamentally from standard neurological rehabilitation:

Essential OT components:

• Retraining normal movement within functional activities (not isolated muscle strengthening)
• Graded reintroduction to daily activities with patient-set goals in their own words
• Self-management strategy development to establish internal locus of control
• 24-hour approach: implementing rehabilitation strategies throughout daily routine
• Anxiety management techniques
• Reestablishment of structure and routine 1

Critical Pitfall to Avoid

Do not use typical neurorehabilitation strategies designed for structural neurological conditions like stroke. FND requires a distinct approach focusing on function rather than impairment, with emphasis on self-management and understanding that recovery follows a pattern of symptom remission and exacerbation 1.

Migraine Management

Treat the migraine aggressively and appropriately, as migraine is highly prevalent in FND patients and may be a predisposing factor that can predate FND by up to 10 years 2, 3. Importantly, treating migraine may improve functional symptoms 2.

Preventive Therapy Options (in order of recommendation strength):

Strong recommendations:

• Candesartan or telmisartan 4
• Erenumab, fremanezumab, or galcanezumab 4

Weaker but reasonable options:

• Topiramate (also helps chronic migraine) 4
• Propranolol 4
• Valproate 4

Acute Treatment:

• First-line: Eletriptan, rizatriptan, sumatriptan (oral/subcutaneous), or sumatriptan-naproxen combination 4
• Alternative: Aspirin-acetaminophen-caffeine combination 4

Critical Medication Consideration

Screen for medication overuse headache given the patient has both migraine and FND. High-risk factors include:

• Headache frequency ≥7 days/month
• Migraine diagnosis (already present)
• History of anxiety or depression (common in FND)
• Physical inactivity 4

Practical Implementation

Week 1-2:

• Provide structured education about FND and migraine relationship
• Initiate migraine preventive therapy
• Begin OT assessment focusing on functional activities, not isolated weakness
• Establish patient-directed goals

Weeks 3-12:

• Supervised exercise and functional activity practice through OT
• Progressive reduction of attention to weakness
• Development of self-management strategies
• Continue migraine optimization

Avoid:

• Prolonged use of adaptive equipment (crutches, wheelchairs) unless absolutely necessary—these can cause secondary problems like shoulder pain and muscle deconditioning 1
• Excessive focus on the weakness itself rather than functional activities
• Time-dependent rigid goals (recovery is often non-linear)

Prognosis

Studies show promising outcomes with this approach: improvements in physical function scales and quality of life both immediately after treatment and at 12-25 month follow-up 1. The combination of appropriate migraine treatment with FND-specific rehabilitation addresses both conditions' contributions to disability 2, 3.