What is the recommended treatment for a patient with a history of migraines with aura, recent MRI findings of two lesions, and episodes of painful shoulder and leg spasms?

Recommended Treatment Approach

This patient requires urgent neurological evaluation to rule out multiple sclerosis or other demyelinating disease, given the combination of migraine with aura, two brain lesions, and recurrent focal neurological symptoms (painful limb spasms) that suggest possible CNS pathology rather than simple migraine progression. 1

Immediate Diagnostic Priorities

Neuroimaging Re-evaluation

• The two previously missed left-sided lesions require immediate reassessment with dedicated brain MRI to characterize their nature, location, and any interval changes 1
• The combination of migraine with aura and white matter lesions is well-documented, as migraine patients frequently have cerebellar and deep white matter lesions on MRI 1
• However, the temporal relationship between lesion discovery and new focal neurological symptoms (shoulder and leg spasms) raises concern for alternative diagnoses 1

Spinal Cord Imaging

• Obtain MRI of the cervical and thoracic spine given the sequential limb involvement (left shoulder, then right leg) and the nature of symptoms (painful spasms with functional impairment) 2
• Dorsal column lesions can present with sensory disturbances and may be longitudinally extensive, spanning ≥3 vertebral segments 2
• This is critical because sensory neuronopathies and demyelinating conditions can present with similar focal symptoms 2

Differential Diagnosis Considerations

Multiple Sclerosis vs. Migraine-Related Lesions

• White matter lesions occur in both migraine patients and MS, making differentiation challenging 1, 3
• Red flags suggesting MS over migraine include:
  • Progressive neurological symptoms between episodes (the painful spasms lasting days) 1
  • Focal motor symptoms (the spasms causing inability to work/drive) 1
  • Sequential involvement of different body regions over months 1

Vestibular Migraine Consideration

• While the patient has migraine with aura, the limb spasms do not fit typical vestibular migraine patterns 1
• Vestibular migraine typically presents with vertigo, not painful limb spasms 1

Treatment Strategy

Acute Symptom Management

• For the painful spasms: Consider gabapentin or pregabalin for neuropathic pain and spasm control 4
  • Pregabalin has FDA approval for neuropathic pain conditions and may address both pain and spasm components 4
  • Start with lower doses and titrate based on response and tolerability 4

Migraine-Specific Treatment

Acute Treatment:

• Start with NSAIDs (ibuprofen 400-800mg or naproxen 500-1000mg) or acetaminophen 1000mg as first-line for migraine attacks 1, 5
• Initiate treatment during the aura phase to prevent or diminish headache 6
• Avoid triptans if cardiovascular risk factors are present due to vasoconstrictive properties 5
• Never use opioids or butalbital due to dependency risk and medication overuse headache 1, 5

Preventive Treatment:

• Given the progression to aura-only migraines, consider preventive therapy 1
• First-line options include:
  • Candesartan or telmisartan (angiotensin receptor blockers) 1
  • Topiramate 1
  • Propranolol 1
• CGRP antagonists (erenumab, fremanezumab, galcanezumab) are strongly recommended for episodic or chronic migraine prevention 1

Stroke Risk Mitigation

• This patient has migraine with aura, which significantly increases ischemic stroke risk 6, 7, 3
• Absolutely contraindicate combined hormonal contraception with estrogens if the patient is using it, as this significantly increases stroke risk in women with migraine with aura 6
• Address all modifiable cardiovascular risk factors 3

Critical Caveats

Medication Overuse Headache

• Monitor acute medication use carefully: ≥15 days/month with NSAIDs or ≥10 days/month with triptans can cause medication overuse headache 1, 5

Diagnostic Pitfalls

• Do not attribute all symptoms to migraine without excluding structural or inflammatory CNS disease 1
• The "painful spasms" lasting days are atypical for migraine and warrant thorough investigation 1
• Rapidly increasing frequency of neurological symptoms is a red flag requiring neuroimaging 1

Follow-up Imaging

• If inflammatory or demyelinating disease is confirmed, serial MRI studies can assess treatment response 2
• Dorsal column lesions, if present, may show partial resolution with appropriate immunotherapy 2

Lifestyle Modifications

• Maintain regular sleep schedule, adequate hydration, and regular meals 1, 5
• Engage in regular moderate-to-intense aerobic exercise 1
• Identify and avoid individual migraine triggers 1, 5
• Implement stress management techniques 1