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Unusual Symptoms Warrant Prompt Medical Attention

Q. I had a migraine yesterday morning and took my medication to get rid of it. It got rid of my pounding pain, but about 2 hours later a portion of the right side of my face became numb. Within another 3 hours, the entire right side of my face was numb, my mouth was drooping, and my right arm and leg were heavy. As you can imagine, we thought I could be having a stroke. I am 43. We went to the emergency room, and by the time I arrived, even my speech was affected.

All CT scans came back clear. The doctors decided I was having a complex migraine and explained the headaches can present as though the patient is having a stroke. They gave me a migraine “cocktail” and massive steroids and within a half hour, my symptoms were much improved. I am still regaining more control even today.

What was so odd was that I had no pain.  Have you heard of this kind of migraine before?

A. You were right to go to an emergency room for your symptoms because migraine and stroke can appear very similar, even in the absence of head pain. The very slow onset of symptoms would favor migraine, but stroke has to be considered, no matter how young you are. A migraine attack can certainly be painful, but not all migraines produce pain. When symptoms seem atypical, evaluation is essential. If a series of stroke-like symptoms, which are not due to migraine, persist less than 24 hours, it is called a transient ischemia attack (TIA). A TIA is a warning for future strokes.

Although hemiplegic migraine (previously called complex migraine) is a strong possibility with the symptoms you described, a proper neurological work up should include a detailed history, neurological examination, MRI scan, and blood tests to rule out any tendency to clot abnormally in your blood vessels. If the MRI reveals more than just routine migraine findings, additional testing might also include a transesophageal echocardiogram (TEE) to look for areas in the heart where clots might be thrown into the cerebral circulation. CT scanning is useful in the emergency room because it is fast, but it is not nearly as accurate as an MRI scan, which should be read by a certified neuroradiologist.

It is very important to know that the type of neurological deficits you described, whether from stroke, TIA, or migraine, are a contraindication to using any type of constricting medicines such as the triptans (sumatriptan, naratriptan, rizatriptan, eletriptan, zolmitriptan, almotriptan, etc,) or the ergotamines (like DHE-45, ergotamine tartrate or methylergonovine). Also, women with stroke, TIA, hemiplegic migraine, or migraine with any type of aura, should avoid estrogens because of increased stroke risk.

Edmund Messina M.D., F.A.H.S.
Medical Director
Michigan Headache Clinic
East Lansing, Michigan

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