What is the treatment for hemiplegic migraines?

Treatment of Hemiplegic Migraines

For hemiplegic migraines, acetaminophen and NSAIDs should be used as first-line acute treatments, while flunarizine, sodium valproate, lamotrigine, verapamil, or acetazolamide are recommended as first-line preventive options. 1

Acute Treatment

• Acetaminophen and NSAIDs are the first choice for acute treatment of hemiplegic migraine attacks 1
• When common analgesics provide insufficient relief, triptans may be considered, although their use in hemiplegic migraine remains controversial 1
• Prokinetic antiemetics (domperidone, metoclopramide) can be used as adjunct medications when nausea and vomiting are present 2
• Avoid ergot alkaloids, opioids, and barbiturates due to questionable efficacy and risk of dependency 2
• Limit use of acute medications to no more than twice weekly to prevent medication overuse headache 2

Preventive Treatment

Preventive treatment should be considered when:

• Attack frequency exceeds 2 per month 2, 1
• Attacks produce significant disability 2
• Acute treatments fail or are contraindicated 2
• The patient has hemiplegic migraine (which is considered an uncommon migraine condition requiring prevention) 2

First-line preventive options for hemiplegic migraine:

• Flunarizine 1
• Sodium valproate (800-1,500 mg/day) 2, 1
• Lamotrigine 1
• Verapamil 1
• Acetazolamide 1

Second-line preventive options:

• Topiramate 1
• Candesartan 1
• Pizotifen 1

Special considerations:

• The use of propranolol in hemiplegic migraine is controversial, though recent evidence suggests it may be effective in some cases 1, 3
• Beta-blockers without intrinsic sympathomimetic activity (like propranolol, timolol) are generally effective for migraine prevention, but their use in hemiplegic migraine requires careful consideration 2, 1
• For chronic migraine transformation, topiramate, onabotulinumtoxinA, and CGRP monoclonal antibodies have demonstrated effectiveness 2

Treatment Algorithm

1. Diagnosis confirmation: Ensure diagnosis meets International Classification of Headache Disorders criteria for hemiplegic migraine 4
2. Acute treatment:
   • Start with acetaminophen or NSAIDs 1
   • Add antiemetics if nausea/vomiting present 2
   • Consider triptans only if other options fail and after careful risk assessment 1
3. Preventive treatment:
   • Initiate when attacks exceed 2 per month or cause significant disability 2
   • First choice: Select from flunarizine, sodium valproate, lamotrigine, verapamil, or acetazolamide 1
   • Evaluate efficacy after 6-8 weeks at therapeutic doses 5
   • If ineffective, try an alternative first-line agent or consider second-line options 1

Important Considerations

• Hemiplegic migraine is rare and requires exclusion of other causes of focal neurological symptoms with headache 4
• Treatment recommendations are largely based on empirical data and expert opinion due to limited clinical trials in this specific population 1, 4
• Manage comorbidities such as depression, anxiety, and sleep disorders, which can worsen migraine 6
• Educate patients about avoiding triggers and maintaining regular sleep patterns 6
• Consider referral to specialist care for difficult-to-manage cases 2