What is the appropriate management and diagnosis for a patient experiencing stroke-like symptoms, including dizziness, migraines, speech impairments, and bipolar symptoms?

Urgent Stroke Evaluation Required

This patient requires immediate emergency department evaluation with urgent brain imaging (CT or MRI) and vascular imaging (CTA/MRA) within 24 hours, as the combination of stroke-like symptoms (dizziness, speech impairment) places them at very high risk for acute ischemic stroke, regardless of the presence of migraines or bipolar disorder. 1

Immediate Triage and Assessment

Priority Actions

• Treat as highest priority emergency equivalent to acute myocardial infarction, regardless of symptom severity 1
• Establish time of symptom onset - defined as when patient was last at baseline or symptom-free (if awakened with symptoms, use time last known well) 1
• Activate stroke team/pathway immediately upon arrival 1

Critical Initial Evaluation

• Perform validated stroke screening using FAST (Face, Arm, Speech, Time) assessment 1, 2
• Obtain capillary blood glucose immediately to exclude hypoglycemia as stroke mimic 1
• Assess ABCs (airway, breathing, circulation) first 1

Essential Urgent Investigations (Within 24 Hours)

Neuroimaging

• Non-contrast CT or MRI brain to exclude hemorrhage and confirm ischemia 1
• CTA or MRA from aortic arch to vertex to assess extracranial and intracranial vasculature 1
• Carotid imaging to identify symptomatic stenosis requiring revascularization 1

Laboratory Tests

• Complete blood count, electrolytes, renal function, coagulation studies (aPTT, INR), random glucose, troponin 1
• 12-lead ECG to assess for atrial fibrillation or other cardiac arrhythmias 1
• Lipid profile and HbA1c (can be deferred to outpatient if needed) 1

Addressing the Migraine-Stroke Diagnostic Challenge

Why Migraine Cannot Exclude Stroke Here

• Migraine is a common stroke mimic accounting for approximately 18% of patients incorrectly treated with thrombolysis, but represents only 1.79% of all stroke evaluations 3, 4
• However, migraine with aura increases stroke risk, particularly in young women, making it a risk factor rather than an alternative diagnosis 5, 6
• Speech impairment is atypical for migraine aura - migraine aura typically presents with positive visual phenomena (scintillations, fortification spectra) spreading gradually over 5-20 minutes, not acute speech deficits 3

Critical Distinguishing Features

• Acute onset favors stroke over migraine aura, which typically develops gradually 3
• Negative symptoms (weakness, speech loss) favor stroke; positive symptoms (visual scintillations, paresthesias) favor migraine 3
• Dizziness with speech impairment suggests posterior circulation involvement, a stroke pattern not typical of migraine 1, 7

Bipolar Disorder Considerations

Comorbidity Recognition

• Bipolar disorder and migraine frequently coexist with 30.7% of bipolar patients having migraine, particularly bipolar II subtype 8
• This comorbidity does not change acute stroke evaluation but affects subsequent prophylactic treatment choices 8

Medication Implications

• Avoid antidepressants alone for migraine prophylaxis in bipolar patients as they may precipitate mood episodes 8
• Consider mood-stabilizing anticonvulsants (valproate, lamotrigine, topiramate) or atypical antipsychotics (olanzapine, quetiapine) that treat both conditions if prophylaxis needed 8

Common Pitfalls to Avoid

Do Not Delay Imaging for These Reasons

• Presence of migraine history - migraine increases stroke risk and can coexist with stroke 5, 6
• Psychiatric comorbidity - does not exclude cerebrovascular disease 8
• Young age - migraine with aura increases stroke risk particularly in younger patients 6

Stroke Mimics to Consider (After Imaging)

• Hypoglycemia - check glucose immediately 1
• Seizure with postictal state - look for witnessed seizure activity 1
• Complicated migraine - but only after excluding stroke 1, 3

Risk Stratification

If symptoms began within 48 hours: Patient is at very high risk for recurrent stroke (up to 36% at 7 days with multiple risk factors) and requires immediate ED transfer with stroke capabilities 2, 7

If symptoms began 48 hours to 2 weeks ago: Still requires comprehensive evaluation by stroke specialist within 24 hours 1

If symptoms began >2 weeks ago: Lower urgency but still needs neurologist evaluation within one month 1