What is the first line of treatment for patients with hemiplegic migraines?

Treatment of Hemiplegic Migraines

The first-line treatment for hemiplegic migraines includes acetaminophen and NSAIDs for acute attacks, while preventive therapy should be considered with flunarizine, sodium valproate, lamotrigine, verapamil, or acetazolamide when attacks occur frequently or are severe. 1

Diagnosis and Clinical Features

Hemiplegic migraine (HM) is a rare subtype of migraine with aura characterized by:

• Transient hemiparesis/hemiplegia during attacks
• Often accompanied by other aura symptoms (visual, sensory, speech disturbances)
• Motor symptoms typically lasting <72 hours
• Can be familial (FHM) or sporadic (SHM)

Diagnosis is based on the International Classification of Headache Disorders criteria, with genetic testing potentially confirming but not ruling out the condition 1, 2.

Acute Treatment

For acute management of hemiplegic migraine attacks:

1. First-line options:

   • Acetaminophen (safest option)
   • NSAIDs (ibuprofen, naproxen) 3, 1

2. Controversial options:

   • Triptans: While generally contraindicated in hemiplegic migraine due to theoretical risk of vasoconstriction, some experts suggest they can be prescribed when headaches are not sufficiently relieved with common analgesics 1
   • Consider adding an antiemetic when nausea is prominent 3

Important caveat: Begin treatment as soon as possible after migraine onset to optimize effectiveness 3. Avoid opioids and butalbital due to risk of medication overuse headache 3.

Preventive Treatment

Preventive therapy should be considered when:

• Attack frequency exceeds 2 per month
• Attacks are severe and debilitating
• Quality of life is significantly impacted 1, 4

Recommended preventive medications (in no strict order):

1. First-line options for hemiplegic migraine:

   • Flunarizine
   • Sodium valproate (500-1500 mg/day)
   • Lamotrigine
   • Verapamil
   • Acetazolamide 1

2. Second-line options with less evidence:

   • Topiramate (100 mg/day) 3, 5
   • Candesartan
   • Pizotifen 1

3. Controversial option:

   • Propranolol: While traditionally considered controversial in hemiplegic migraine, recent evidence suggests it may be effective 1, 6

Clinical pearl: A recent 2024 case report demonstrated successful prophylactic treatment of sporadic hemiplegic migraine with propranolol, with no recurrent paralysis over a 2-year follow-up period 6.

Complementary Approaches

Consider evidence-based supplements:

• Magnesium (400-600 mg daily)
• Riboflavin (400 mg daily)
• Coenzyme Q10 (100-300 mg daily)
• Feverfew 3, 4

Lifestyle Modifications

Implement these non-pharmacologic strategies:

• Regular sleep schedule
• Consistent meal times
• Adequate hydration
• Regular physical activity
• Stress management techniques
• Identification and avoidance of personal triggers 3

Important Considerations and Monitoring

• Avoid conventional cerebral angiography as it may provoke an attack 1
• Target 50% reduction in attack frequency for preventive therapy
• Allow 6-8 weeks at therapeutic dose to assess effectiveness 3
• Monitor for medication side effects, particularly with anticonvulsants
• Valproate should be avoided in women of childbearing potential due to teratogenic effects 3

Warning: Hemiplegic migraine can mimic stroke and other serious neurological conditions. Appropriate diagnostic workup including neuroimaging is essential to rule out other causes before confirming diagnosis 2.