Immediate Evaluation and Management in Primary Care
This patient requires urgent neuroimaging (MRI brain) today to exclude stroke or TIA, as the new isolated speech disturbance represents a change in her typical hemiplegic migraine pattern and cannot be assumed to be migraine-related without excluding cerebrovascular events. 1, 2
Critical Distinction: Why This Requires Urgent Workup
- Hemiplegic migraine aura symptoms typically spread gradually over ≥5 minutes and occur in succession, whereas TIA symptoms have sudden, simultaneous onset 1
- However, a 2-minute isolated speech episode three days ago in a patient with known motor aura represents a NEW symptom pattern that was not part of her typical attacks 2
- Migraine with aura (especially hemiplegic migraine) increases stroke risk, making it imperative to exclude cerebrovascular events when new focal neurological symptoms occur 1, 2
Immediate Actions in Primary Care Today
Neuroimaging
- Order MRI brain with diffusion-weighted imaging (DWI) urgently to exclude stroke, TIA, or other structural causes 2, 3
- MRI is preferred over CT for detecting acute ischemia and excluding other causes of focal neurological symptoms with headache 2
- Avoid conventional cerebral angiography as it may provoke hemiplegic migraine attacks 4, 3
Additional Diagnostic Workup
- Obtain EEG to rule out epilepsy, which can present with similar transient focal symptoms 2, 3
- Consider CSF analysis if encephalitis or other inflammatory conditions are in the differential 2
- Document detailed characteristics of this new speech episode: exact duration, type of speech disturbance (expressive aphasia, dysarthria, word-finding difficulty), associated symptoms, and how it differed from her typical motor weakness aura 2, 4
If Neuroimaging and Workup Are Normal
Confirm Hemiplegic Migraine Diagnosis
- Verify she meets ICHD-3 criteria: at least two attacks with fully reversible motor weakness lasting 5-72 hours, motor aura spreading gradually over ≥5 minutes, accompanied by or followed by headache within 60 minutes 2
- Determine if familial (first-degree relative with hemiplegic migraine) or sporadic 4, 3
Acute Treatment Plan Going Forward
- NSAIDs (ibuprofen 400-800 mg or naproxen sodium 275-550 mg) should be taken early in the headache phase for maximum effectiveness 1, 2
- Add prokinetic antiemetics (metoclopramide or domperidone) for nausea and to improve gastric motility 1, 2
- Avoid ergot alkaloids as they are poorly effective and potentially toxic in hemiplegic migraine 2, 4
- Avoid opioids and barbiturates due to questionable efficacy, risk of dependency, and medication overuse headache 1, 2
- Triptans are controversial but can be used off-label when headaches are not relieved with NSAIDs, despite historical contraindication 4, 5
Preventive Treatment Consideration
- Initiate preventive therapy if she has ≥2 attacks per month or if severe attacks pose significant burden 1, 2, 4
- First-line options for hemiplegic migraine include:
- Alternative options: topiramate, candesartan 4
- Assess efficacy after 2-3 months of preventive therapy 1, 2
Critical Monitoring Points
Red Flags Requiring Urgent Attention
- Seizures during attacks 2
- Altered consciousness during attacks 2
- Prolonged weakness lasting >72 hours 3, 5
- Any new neurological symptoms different from typical pattern 2, 3
Medication Overuse Headache Prevention
- Educate patient that frequent use of acute medications (>10 days/month for triptans, >15 days/month for NSAIDs) can cause medication overuse headache 1, 2
- Monitor acute medication use with headache calendars 1
Common Pitfalls to Avoid
- Do not assume new neurological symptoms are "just migraine" without excluding stroke/TIA, especially in a patient with known migraine with aura who has increased stroke risk 1, 2
- Do not delay neuroimaging – the 3-day window does not eliminate the need for urgent evaluation 2, 3
- Do not use conventional angiography if vascular imaging is needed; use MRA or CTA instead 4, 3