What is the recommended evaluation and management for a patient with left-sided weakness, daily headaches, extreme fatigue, possible focal seizures or aura migraines, tinnitus, and depression, triggered by stress and overexertion?

Evaluation and Management of Left-Sided Weakness, Daily Headaches, Extreme Fatigue, Possible Focal Seizures or Aura Migraines, Tinnitus, and Depression

This patient requires urgent neuroimaging with brain MRI to rule out structural pathology, given the combination of focal neurological deficits (left-sided weakness), daily headaches, and possible seizure activity—red flags that mandate immediate evaluation before attributing symptoms to primary headache or psychiatric disorders. 1, 2

Immediate Red Flag Assessment

Your patient presents with multiple concerning features that require urgent evaluation:

• Left-sided weakness is a focal neurological deficit that demands immediate investigation for stroke, mass lesion, or other structural pathology 1, 2
• Daily headaches (≥15 days/month) combined with focal deficits cannot be assumed benign 1
• Possible focal seizures require EEG and neuroimaging to exclude secondary causes 1
• The combination of these symptoms triggered by stress and overexertion does not exclude serious pathology 1

Diagnostic Workup Priority

Neuroimaging (First-Line)

Brain MRI with and without contrast is the appropriate initial study given focal weakness and concern for seizures, as it provides superior sensitivity for structural abnormalities, stroke, inflammatory conditions, and mass lesions compared to CT 1. Noncontrast head CT is insufficient when focal neurologic deficits are present unless MRI is contraindicated 1.

Electroencephalogram (EEG)

EEG is mandatory for any unprovoked seizure or suspected focal seizure activity, performed alongside neuroimaging 1. The distinction between focal seizures and migraine aura can be challenging, but EEG abnormalities during events support seizure activity 3.

Laboratory Evaluation

Check for metabolic triggers that can cause both seizures and neurological symptoms 1:

• Serum calcium and magnesium (hypocalcemia/hypomagnesemia can provoke seizures)
• Complete metabolic panel
• Thyroid function
• Complete blood count

Audiologic Assessment for Tinnitus

Comprehensive audiometric examination including pure tone audiometry, speech audiometry, and acoustic reflex testing should be performed, especially given unilateral symptoms 1, 4. However, imaging takes priority given the focal weakness.

Differential Diagnosis Considerations

Distinguishing Focal Seizures from Migraine Aura

Both conditions can present with transient focal neurological symptoms 5, 3:

• Migraine aura typically involves positive visual phenomena (scintillations, zigzag lines), gradual spread over 5-60 minutes, and is followed by headache 2, 3
• Focal seizures tend to have more rapid onset (<2 minutes), may involve motor manifestations like jerking, and can have post-ictal confusion 1
• The presence of left-sided weakness is more concerning for seizure activity or structural pathology than typical migraine aura 1, 3

Chronic Migraine vs. Secondary Headache

Daily headaches (≥15 days/month) meet criteria for chronic migraine if 8+ days have migraine features 1. However, new focal neurological deficits mandate exclusion of secondary causes before accepting a primary headache diagnosis 1, 2.

Management Algorithm

If Neuroimaging/EEG Reveals Structural Pathology or Seizure Activity

• Refer immediately to neurology or neurosurgery depending on findings 1
• Initiate antiepileptic therapy if seizures confirmed 1
• Address underlying structural cause

If Workup is Negative (Primary Headache/Seizure Disorder)

For Chronic Migraine Management

Initiate preventive therapy immediately given daily headaches 1:

• First-line: Topiramate 50-200mg daily (only preventive with proven efficacy in chronic migraine in randomized controlled trials, and has dual benefit for seizure prophylaxis if seizures are confirmed) 1, 6
• Alternative options: Propranolol 80-240mg daily, amitriptyline 30-150mg daily (also treats comorbid depression), or divalproex sodium 500-1500mg daily 1

Acute treatment for breakthrough headaches:

• NSAIDs (ibuprofen, naproxen sodium) for mild-moderate attacks 1, 2
• Add triptan (sumatriptan, rizatriptan) if NSAID fails or for moderate-severe attacks 1, 2
• Antiemetics (metoclopramide, prochlorperazine) as adjunctive therapy 2

For Seizure Management (if confirmed)

Antiepileptic drugs with dual benefit for migraine prophylaxis are preferred 6:

• Topiramate (as above)
• Valproate/divalproex sodium
• Avoid medications that lower seizure threshold

For Tinnitus

Education and counseling about management strategies for persistent tinnitus 4. If bothersome:

• Cognitive behavioral therapy to reduce distress and improve quality of life 4
• Sound therapy for auditory masking 4
• Rule out TMJ dysfunction (can cause unilateral tinnitus worsening with jaw movements and coexist with headache) 4

For Depression

Screen and treat aggressively—depression is highly comorbid with both migraine and epilepsy and significantly impacts outcomes 1, 5:

• Amitriptyline 30-150mg daily serves dual purpose for migraine prevention and depression 1, 5
• Alternative: Venlafaxine (SNRI with evidence in migraine with comorbid depression) 5
• Assess for suicidal ideation—suicide risk is elevated in patients with tinnitus and psychiatric comorbidity 1

For Fatigue

Investigate underlying causes given multisystem presentation 1:

• Sleep study to rule out obstructive sleep apnea (common with chronic headache) 1
• Optimize treatment of depression and anxiety 1, 5
• Address metabolic/cardiac etiologies if suspected 1

Stress and Trigger Management

Stress reduction methods are evidence-based adjunctive therapy for both migraine and epilepsy 7:

• Recommend specific techniques: progressive muscle relaxation, mindfulness meditation, biofeedback
• Establish consistent sleep schedule and avoid overexertion 1, 7
• Screen for anxiety disorder (highly comorbid with stress-triggered seizures) 7

Critical Pitfalls to Avoid

• Never attribute focal weakness to migraine or functional disorder without neuroimaging 1, 2
• Do not assume chronic daily headache is benign migraine when focal deficits are present 1
• Avoid medication overuse—frequent acute medication use (>10-15 days/month) can cause medication overuse headache, worsening the chronic headache pattern 1
• Screen for and treat comorbid depression/anxiety—these significantly worsen outcomes and quality of life in both migraine and epilepsy 1, 5, 7
• Do not use triptans if hemiplegic migraine or basilar migraine is suspected (contraindicated due to stroke risk) 1