From the Guidelines
Hemiplegic migraine should be managed with a focus on preventive therapy, including calcium channel blockers like verapamil, and avoiding triggers that can exacerbate symptoms, as recommended in the most recent guidelines 1. The management of hemiplegic migraine involves both acute and preventive approaches. For acute treatment, standard migraine medications like NSAIDs or acetaminophen can help manage pain, though triptans and ergotamines are generally avoided due to concerns about vascular effects, as noted in a study on the management of stroke in infants and children 1.
Key Considerations
- Preventive medications include calcium channel blockers like verapamil (120-360 mg daily), antiepileptic drugs such as topiramate (25-200 mg daily) or lamotrigine (25-200 mg daily), and sometimes flunarizine (5-10 mg daily) where available.
- During an attack, patients should rest in a quiet, dark room and apply cold compresses if helpful.
- Hemiplegic migraine can be familial (with genetic mutations affecting CACNA1A, ATP1A2, or SCN1A genes) or sporadic, and diagnosis requires ruling out other conditions like stroke or seizures.
- Triggers often include stress, sleep disturbances, certain foods, and hormonal changes, so identifying and avoiding personal triggers is an important part of management, as emphasized in guidelines for the diagnosis and management of migraine 1.
Treatment Evaluation
- Evaluate treatment responses shortly after initiation (after 2–3 months) or a change of treatment and regularly thereafter (every 6–12 months) 1.
- Evaluate the effectiveness of treatment by assessing attack frequency, attack severity, and migraine-related disability.
- When outcomes are suboptimal, review the diagnosis, treatment strategy, dosing, and adherence, and consider specialist referral if all treatment fails 1.
From the Research
Definition and Diagnosis of Hemiplegic Migraine
- Hemiplegic migraine (HM) is a rare subtype of migraine with aura, characterized by transient hemiparesis during attacks 2.
- Diagnosis is based on the International Classification of Headache Disorders criteria (ICHD-II) 2, 3.
- Two types of HM are recognized: familial (FHM) and sporadic hemiplegic migraine (SHM) 2.
Clinical Features and Genetics
- HM is genetically heterogeneous, with three identified genes (CACNA1A, ATP1A2, and SCN1A) but more unknown genes involved 2.
- Clinically, attacks of the 3 subtypes cannot be distinguished 2.
- Motor symptoms usually last <72 hours and are associated with visual or sensory manifestations, speech impairment or brainstem aura 4.
Treatment and Management
- The treatment of HM is based on empirical data, personal experience of the treating neurologist, and involves a trial-and-error strategy 2.
- Acetaminophen and NSAIDs often are the first choice in acute treatment 2.
- Triptans can be prescribed when headaches are not relieved sufficiently with common analgesics, although their use is controversial in HM 2, 3, 5.
- Prophylactic treatment can be considered when attack frequency exceeds 2 attacks per month, or when severe attacks pose a great burden that requires reduction of severity and frequency 2, 6.
- Flunarizine, sodium valproate, lamotrigine, verapamil, and acetazolamide can be tried for prophylactic treatment, while topiramate, candesartan, and pizotifen can also be considered 2, 6.