What is the management approach for a patient with a history of migraines, presenting with headache and weakness for one week?

Management of Headache with Weakness in a Patient with Migraine History

This patient requires immediate evaluation to rule out secondary causes of headache before attributing symptoms to migraine, as the combination of headache with weakness lasting one week represents a red flag that demands urgent assessment for stroke, intracranial hemorrhage, or other life-threatening conditions. 1

Critical First Step: Rule Out Secondary Headache

Patients presenting with headache must first be evaluated for secondary causes through careful history and examination, particularly when red flags are present. 1 The presence of weakness is a critical red flag that distinguishes this presentation from typical migraine and mandates urgent evaluation. 1

Red Flags Requiring Immediate Investigation:

• Neurologic signs (including weakness) - this patient's presenting symptom 1, 2
• Progressive headache over one week 3
• New or unusual headache pattern in someone with known migraines 4, 3

Common pitfall: Patients with a history of primary headaches like migraine can also develop new secondary headaches, and assuming all headaches in a migraineur are migraines can lead to missed diagnoses of serious conditions. 5

Urgent Diagnostic Workup Required

Before treating this as migraine, obtain:

• Immediate neuroimaging (CT or MRI) to evaluate for stroke, hemorrhage, mass lesion, or other structural causes 2, 3
• Complete neurologic examination documenting the pattern and distribution of weakness 1, 5
• Assessment for other concerning features: fever, neck stiffness, altered mental status, visual changes 3

This patient warrants either emergency department evaluation or urgent neurologist referral given the combination of headache with neurologic deficit. 4

If Secondary Causes Are Ruled Out: Migraine with Aura Consideration

Only after excluding secondary causes should hemiplegic migraine or migraine with prolonged aura be considered. 1 However, these diagnoses require specialist evaluation:

• Hemiplegic migraine (causing motor weakness) is a contraindication to triptans and requires neurologist management 1, 6
• Patients with migraine associated with motor weakness should be referred to a neurologist 4
• Persistent aura lasting one week is atypical and warrants neurologist evaluation 4

Acute Treatment Approach (Only After Ruling Out Secondary Causes)

For Typical Migraine Without Motor Weakness:

First-line acute treatment:

• NSAIDs (ibuprofen 400-800 mg, naproxen 500-825 mg) for mild-to-moderate attacks 7, 2
• Triptans (sumatriptan 50-100 mg) for moderate-to-severe attacks, but absolutely contraindicated if hemiplegic migraine 7, 6, 2
• Combination therapy (triptan + NSAID) provides superior efficacy to either agent alone 7, 8

Parenteral options for severe attacks:

• IV metoclopramide 10 mg plus IV ketorolac 30 mg for severe refractory migraine 7, 8
• Subcutaneous sumatriptan 6 mg provides highest efficacy with 15-minute onset, but contraindicated in hemiplegic migraine 7, 8

Critical Medication Frequency Limitation:

Limit all acute migraine medications to no more than 2 days per week to prevent medication-overuse headache, which can lead to daily headaches. 7, 2

Preventive Therapy Consideration

Given the one-week duration of this headache, preventive therapy should be strongly considered:

• Preventive therapy is indicated for patients with attacks producing disability lasting 3+ days or requiring acute treatment more than twice weekly 7
• First-line preventive options include propranolol 80-240 mg/day, topiramate, or amitriptyline 30-150 mg/day 1, 7
• Preventive therapy reduces attack frequency and can restore responsiveness to acute treatments 7

Mandatory Next Steps

This patient requires:

1. Immediate neurologic evaluation to exclude stroke, hemorrhage, or other secondary causes 1, 2, 3
2. Neuroimaging before attributing symptoms to migraine 2, 3
3. Neurologist referral for definitive diagnosis and management, particularly given the motor weakness 1, 4
4. If hemiplegic migraine is diagnosed, avoid all triptans and ergot derivatives permanently 1, 6

Do not treat this as routine migraine without first excluding secondary causes - the presence of weakness with headache lasting one week demands urgent evaluation. 1, 2, 3