Journal of Pain & Palliative Care Pharmacotherapy. 2014;28:311–313. ISSN: 1536-0288 print / 1536-0539 online DOI: 10.3109/15360288.2014.943384
EUROPEAN PERSPECTIVES ON PAIN AND PALLIATIVE CARE
J Pain Palliat Care Pharmacother Downloaded from informahealthcare.com by Biblioteka Uniwersytetu Warszawskiego on 03/13/15 For personal use only.
Reversible Hemiparesis in a Patient With Migraine Michael Bjørn Russell A B STRA CT A third of patients with migraine may experience accompanying aura, and when this includes motor weakness, the condition is described as hemiplegic migraine. Young women who suffer from migraine with aura have a 6.2-fold increased risk of ischemic stroke. The slow progression and succession of symptoms help to provide the diagnosis of hemiplegic migraine. This report is adapted from paineurope 2014; Issue 1, ©Haymarket Medical Publications Ltd., and is presented with permission. paineurope is provided as a service to pain management by Mundipharma International, Ltd., and is distributed free of charge to health care professionals in Europe. Archival issues can be accessed via the Web site: http://www.paineurope.com at which European health professionals can register online to receive copies of the quarterly publication. KEYWORDS aura, headache, migraine, triptan
BACKGROUND
CASE ASSESSMENT
Migraine is a common disorder that causes disabling headaches. A third of patients may experience accompanying aura. When this includes motor weakness, the condition is described as hemiplegic migraine. Headache can last for more than 3 days in 2% of patients with hemiplegic migraine and can cause excruciating pain.1 Hemiparesis is often caused by stroke, which usually affects elderly and middle-aged people. However, young women who suffer from migraine with aura have a 6.2-fold increased risk of ischemic stroke, and the risk is even higher in women with migraine who also use oral contraceptives or in those who are heavy smokers.2 This case describes a patient with reversible hemiparesis who suffers from migraine with aura.
A 23-year-old woman was admitted to hospital with slurred speech and paresis of her arm and leg. When she arrived at the emergency ward, she was awake but unable to speak or follow simple commands. Her husband provided the medical history. The attack started about 1 hour prior to admission. She had suffered with migraines for several years, usually experiencing one or two attacks per month. During these episodes the pain was severe and she often sought a dark and quiet room. The migraines were usually treated effectively with a nasal triptan. She was also taking oral contraceptives. She had no family history of stroke or myocardial infarction (MI). Neurological examination revealed a right-sided hemiparesis and slight stiffness of the neck. Her temperature was normal, and blood pressure (BP) was 140/100 mm Hg. Routine blood tests showed no abnormal findings. An acute computed tomographic (CT) scan of the brain revealed no abnormal findings. The patient was reexamined after the CT scan, approximately 1 hour after admission. She was now able to speak and was able to move her right arm and leg. She explained that she is right-handed and has suffered from migraine attacks with visual disturbances once or twice per month since 12 years of age. The
Michael Bjørn Russell, PhD, Dr Med Sci, is Professor of Neurology and Consultant Neurologist, Akershus University Hospital, Oslo, Norway. This report is adapted from paineurope 2014; Issue 1, ©Haymarket Medical Publications Ltd., and is presented with permission. paineurope is provided as a service to pain management by Mundipharma International, Ltd., and is distributed free of charge to health care professionals in Europe. Archival issues can be accessed via the Web site: http://www.paineurope.com at which European health professionals can register online to receive copies of the quarterly publication. Address correspondence to: Michael Bjørn Russell (E-mail: m.b.russell@ medisin.upi.no).
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Journal of Pain & Palliative Care Pharmacotherapy
visual disturbances usually last about 20 minutes, and after 10–20 minutes she is left with a headache associated with photo- and phonophobia, sometimes accompanied with nausea and, rarely, vomiting. The visual disturbances were usually unilateral, starting as a hazy spot in the center of the visual field, gradually progressing toward the periphery as a semicircular flickering zigzag. The headache that followed was usually contralateral to the visual disturbance. On a few occasions, she had experienced attacks with visual disturbances followed by speech and/or sensory disturbances and headache. The speech disturbance usually lasted 30–60 minutes. The sensory disturbance was always unilateral, starting as a tingling in one of the fingers, then spreading to the other fingers, moving up the arm, cheek, and tongue. A feeling of deadness followed the tingling. The sensory disturbances usually lasted 30–60 minutes. Her father also suffers from migraine with visual aura. The patient had never experienced hemiparesis prior to the current attack. At the time of investigation she had a mild left-sided headache without accompanying symptoms. The attack that caused the admission started with a right-sided visual disturbance that gradually progressed, followed by speech disturbance, a mild left-sided headache, and rightsided sensory disturbances that gradually progressed to a right-sided hemiparesis. The hemiparesis resolved spontaneously; therefore, there was no need for acute thrombolysis.
DISCUSSION The majority of patients with sporadic and hemiplegic migraine also have attacks of typical migraine with aura (visual, aphasic, and/or sensory aura, but no motor symptoms).7 These attacks can be treated with triptans. The mild migraine headache can be treated with standard doses of mild analgesics, such as paracetamol and/or nonsteroidal anti-inlfammatory drugs (NSAIDs). If accompanied by nausea and vomiting, metoclopramide suppositories can be helpful. The use of triptans in the treatment of sporadic and familial hemiplegic migraine attacks is contraindicated.3 However, in a retrospective study of 76 patients with sporadic or familial hemiplegic migraine, who had used triptans at least once to treat their migraine attack, triptans were found to be well tolerated and effective. One patient, however, had a prolonged attack that lasted several months after triptan treatment.4 Information about the gradual progression of visual and sensory disturbances, as well as the succession of visual, aphasic, sensory, and motor symptoms,
is crucial for the right diagnosis.1,5,6 Epileptic aura is short-lived, lasting only a few seconds. Stroke is usually of sudden onset and not associated with gradual progression of visual, sensory, and motor symptoms. The patient had an attack of sporadic hemiplegic migraine, causing a reversible hemiparesis. The diagnosis is familial hemiplegic migraine if one or several first-degree relatives have these symptoms.
REFERENCE [1] Russell MB, Ducros A. Lancet Neurol. 2011;10:457–470. [2] Tzourio C, Tehindrazanarivelo A, et al. BMJ. 1995;310:830–833. [3] Almogran (almotriptan) SPC. 2013. Available at: www.medicines.org.uk. Accessed 29 January 2014. [4] Artto V, Nissil¨a M, et al. Eur J Neurol. 2007;14:1053–1056. [5] Russell MB, Iversen HK, et al. Cephalalgia. 1994;14:107–117. [6] Russell MB, Olesen J. Brain. 1996;119(Pt 2):355–361. [7] Headache Classification Committee of the International Headache Society (IHS). Cephalalgia. 2013;33:629–808.
COMMENTARY FROM BELGIUM Jan Versijpt The pain caused by (hemiplegic) migraine can indeed be relieved by paracetamol, NSAIDs, or acetylsalicylic acid. If these do not work, triptans can be used. The warning to not use triptans in hemiplegic migraine patients or in patients with cardiovascular disease stems merely from the fact that these two patient groups were all excluded from the initial triptan studies. This occurred because at that time, the false belief still existed that (hemiplegic) aura was related to vasoconstriction and triptans can significantly worsen preexisting vasoconstriction. Indeed, a retrospective case-control study indicated that triptans do not increase the risk of ischemic complications, even in those patients who overuse triptans and in those concomitantly taking cardiovascular drugs.1 This case puts emphasis on the association of migraine with aura and stroke risk. Whether the stroke risk is indeed 6.2 times greater might, however, be an overstatement. After all, some studies have failed to show this increased risk, and a recent meta-analysis revealed a relative risk of stroke of 2.2 in patients with migraine with aura.2 However, it seems wise for now to refer all patients with migraine with aura who are using combined oral contraceptives to their general practitioner (GP) or gynecologist to discuss their current contraceptive use. Apart from the risk of stroke, comJan Versijpt, MD, PhD, is Professor of Neurology, University Hospital, Brussels, Belgium (E-mail: [email protected]).
Journal of Pain & Palliative Care Pharmacotherapy
European Perspectives on Pain and Palliative Care
bined oral contraceptives could also have a detrimental effect on both migraine frequency and intensity of symptoms. However, recent evidence suggests a possible benefit of progestogen-only contraceptives.3
J Pain Palliat Care Pharmacother Downloaded from informahealthcare.com by Biblioteka Uniwersytetu Warszawskiego on 03/13/15 For personal use only.
References [1] Wammes-van der Heijden EA, Rahimtoola H, et al. Neurol. 2006;67:1128–1134. ¨ [2] Schurks M, Rist PM, et al. BMJ. 2009;339:b3914. [3] Nappi RE, Merki-Feld GS, et al. J Headache Pain. 2013;14:66.
COMMENTARY FROM THE UNITED KINGDOM Mark Weatherall The author presents a case of transient hemiparesis in a young woman with a history of migraine with more typical visual, sensory, and dysphasic manifestations of aura. In such cases the diagnosis may not be difficult, provided the history of migraine is apparent at the time of presentation. In the absence of a clear history, however, neuroimaging is advisable to rule out alternative diagnoses, particularly where, as here, weakness has not hitherto been characteristic of the patient’s migraines. In many cases hemiplegic migraine is a diagnosis of exclusion and will often remain a working diagnosis until the patient has further similar attacks.
Mark Weatherall, MB, BC, FRCP(Edin), is a consultant neurologist at the Charing Cross and Ealing hospitals, London, UK (E-mail: [email protected]).
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Hemiplegic migraine attacks are frightening and debilitating. In some cases it can take many days or even weeks for the weakness to resolve fully. Although the acute treatment of the pain phase of hemiplegic migraine is, as the author points out, essentially the same as for other forms of migraine with aura, we have no treatments that abort, alleviate, or ameliorate migraine aura. Therefore, for patients with recurrent attacks, preventive treatment is almost always indicated. Standard migraine preventives may be used for patients with hemiplegic attacks; where available, flunarizine is said to be a particularly effective preventive treatment in hemiplegic migraine.1 Patients with recurrent attacks (particularly those who have a tendency to dysphasia) should wear a MedicAlert bracelet or similar information device to inform medical and paramedical professionals of their diagnosis. This is particularly important now that systems for rapid access to thrombolysis for acute stroke are becoming more widespread.
Reference [1] Mohamed PB, Goadsby PJ, et al. Dev Med Childhood Neurol. 2012;54:274–277.
Declaration of interest: The author reports no conflicts of interest. The author alone is responsible for the content and writing of the paper.
EUROPEAN PERSPECTIVES ON PAIN AND PALLIATIVE CARE
J Pain Palliat Care Pharmacother Downloaded from informahealthcare.com by Biblioteka Uniwersytetu Warszawskiego on 03/13/15 For personal use only.
Reversible Hemiparesis in a Patient With Migraine Michael Bjørn Russell A B STRA CT A third of patients with migraine may experience accompanying aura, and when this includes motor weakness, the condition is described as hemiplegic migraine. Young women who suffer from migraine with aura have a 6.2-fold increased risk of ischemic stroke. The slow progression and succession of symptoms help to provide the diagnosis of hemiplegic migraine. This report is adapted from paineurope 2014; Issue 1, ©Haymarket Medical Publications Ltd., and is presented with permission. paineurope is provided as a service to pain management by Mundipharma International, Ltd., and is distributed free of charge to health care professionals in Europe. Archival issues can be accessed via the Web site: http://www.paineurope.com at which European health professionals can register online to receive copies of the quarterly publication. KEYWORDS aura, headache, migraine, triptan
BACKGROUND
CASE ASSESSMENT
Migraine is a common disorder that causes disabling headaches. A third of patients may experience accompanying aura. When this includes motor weakness, the condition is described as hemiplegic migraine. Headache can last for more than 3 days in 2% of patients with hemiplegic migraine and can cause excruciating pain.1 Hemiparesis is often caused by stroke, which usually affects elderly and middle-aged people. However, young women who suffer from migraine with aura have a 6.2-fold increased risk of ischemic stroke, and the risk is even higher in women with migraine who also use oral contraceptives or in those who are heavy smokers.2 This case describes a patient with reversible hemiparesis who suffers from migraine with aura.
A 23-year-old woman was admitted to hospital with slurred speech and paresis of her arm and leg. When she arrived at the emergency ward, she was awake but unable to speak or follow simple commands. Her husband provided the medical history. The attack started about 1 hour prior to admission. She had suffered with migraines for several years, usually experiencing one or two attacks per month. During these episodes the pain was severe and she often sought a dark and quiet room. The migraines were usually treated effectively with a nasal triptan. She was also taking oral contraceptives. She had no family history of stroke or myocardial infarction (MI). Neurological examination revealed a right-sided hemiparesis and slight stiffness of the neck. Her temperature was normal, and blood pressure (BP) was 140/100 mm Hg. Routine blood tests showed no abnormal findings. An acute computed tomographic (CT) scan of the brain revealed no abnormal findings. The patient was reexamined after the CT scan, approximately 1 hour after admission. She was now able to speak and was able to move her right arm and leg. She explained that she is right-handed and has suffered from migraine attacks with visual disturbances once or twice per month since 12 years of age. The
Michael Bjørn Russell, PhD, Dr Med Sci, is Professor of Neurology and Consultant Neurologist, Akershus University Hospital, Oslo, Norway. This report is adapted from paineurope 2014; Issue 1, ©Haymarket Medical Publications Ltd., and is presented with permission. paineurope is provided as a service to pain management by Mundipharma International, Ltd., and is distributed free of charge to health care professionals in Europe. Archival issues can be accessed via the Web site: http://www.paineurope.com at which European health professionals can register online to receive copies of the quarterly publication. Address correspondence to: Michael Bjørn Russell (E-mail: m.b.russell@ medisin.upi.no).
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J Pain Palliat Care Pharmacother Downloaded from informahealthcare.com by Biblioteka Uniwersytetu Warszawskiego on 03/13/15 For personal use only.
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Journal of Pain & Palliative Care Pharmacotherapy
visual disturbances usually last about 20 minutes, and after 10–20 minutes she is left with a headache associated with photo- and phonophobia, sometimes accompanied with nausea and, rarely, vomiting. The visual disturbances were usually unilateral, starting as a hazy spot in the center of the visual field, gradually progressing toward the periphery as a semicircular flickering zigzag. The headache that followed was usually contralateral to the visual disturbance. On a few occasions, she had experienced attacks with visual disturbances followed by speech and/or sensory disturbances and headache. The speech disturbance usually lasted 30–60 minutes. The sensory disturbance was always unilateral, starting as a tingling in one of the fingers, then spreading to the other fingers, moving up the arm, cheek, and tongue. A feeling of deadness followed the tingling. The sensory disturbances usually lasted 30–60 minutes. Her father also suffers from migraine with visual aura. The patient had never experienced hemiparesis prior to the current attack. At the time of investigation she had a mild left-sided headache without accompanying symptoms. The attack that caused the admission started with a right-sided visual disturbance that gradually progressed, followed by speech disturbance, a mild left-sided headache, and rightsided sensory disturbances that gradually progressed to a right-sided hemiparesis. The hemiparesis resolved spontaneously; therefore, there was no need for acute thrombolysis.
DISCUSSION The majority of patients with sporadic and hemiplegic migraine also have attacks of typical migraine with aura (visual, aphasic, and/or sensory aura, but no motor symptoms).7 These attacks can be treated with triptans. The mild migraine headache can be treated with standard doses of mild analgesics, such as paracetamol and/or nonsteroidal anti-inlfammatory drugs (NSAIDs). If accompanied by nausea and vomiting, metoclopramide suppositories can be helpful. The use of triptans in the treatment of sporadic and familial hemiplegic migraine attacks is contraindicated.3 However, in a retrospective study of 76 patients with sporadic or familial hemiplegic migraine, who had used triptans at least once to treat their migraine attack, triptans were found to be well tolerated and effective. One patient, however, had a prolonged attack that lasted several months after triptan treatment.4 Information about the gradual progression of visual and sensory disturbances, as well as the succession of visual, aphasic, sensory, and motor symptoms,
is crucial for the right diagnosis.1,5,6 Epileptic aura is short-lived, lasting only a few seconds. Stroke is usually of sudden onset and not associated with gradual progression of visual, sensory, and motor symptoms. The patient had an attack of sporadic hemiplegic migraine, causing a reversible hemiparesis. The diagnosis is familial hemiplegic migraine if one or several first-degree relatives have these symptoms.
REFERENCE [1] Russell MB, Ducros A. Lancet Neurol. 2011;10:457–470. [2] Tzourio C, Tehindrazanarivelo A, et al. BMJ. 1995;310:830–833. [3] Almogran (almotriptan) SPC. 2013. Available at: www.medicines.org.uk. Accessed 29 January 2014. [4] Artto V, Nissil¨a M, et al. Eur J Neurol. 2007;14:1053–1056. [5] Russell MB, Iversen HK, et al. Cephalalgia. 1994;14:107–117. [6] Russell MB, Olesen J. Brain. 1996;119(Pt 2):355–361. [7] Headache Classification Committee of the International Headache Society (IHS). Cephalalgia. 2013;33:629–808.
COMMENTARY FROM BELGIUM Jan Versijpt The pain caused by (hemiplegic) migraine can indeed be relieved by paracetamol, NSAIDs, or acetylsalicylic acid. If these do not work, triptans can be used. The warning to not use triptans in hemiplegic migraine patients or in patients with cardiovascular disease stems merely from the fact that these two patient groups were all excluded from the initial triptan studies. This occurred because at that time, the false belief still existed that (hemiplegic) aura was related to vasoconstriction and triptans can significantly worsen preexisting vasoconstriction. Indeed, a retrospective case-control study indicated that triptans do not increase the risk of ischemic complications, even in those patients who overuse triptans and in those concomitantly taking cardiovascular drugs.1 This case puts emphasis on the association of migraine with aura and stroke risk. Whether the stroke risk is indeed 6.2 times greater might, however, be an overstatement. After all, some studies have failed to show this increased risk, and a recent meta-analysis revealed a relative risk of stroke of 2.2 in patients with migraine with aura.2 However, it seems wise for now to refer all patients with migraine with aura who are using combined oral contraceptives to their general practitioner (GP) or gynecologist to discuss their current contraceptive use. Apart from the risk of stroke, comJan Versijpt, MD, PhD, is Professor of Neurology, University Hospital, Brussels, Belgium (E-mail: [email protected]).
Journal of Pain & Palliative Care Pharmacotherapy
European Perspectives on Pain and Palliative Care
bined oral contraceptives could also have a detrimental effect on both migraine frequency and intensity of symptoms. However, recent evidence suggests a possible benefit of progestogen-only contraceptives.3
J Pain Palliat Care Pharmacother Downloaded from informahealthcare.com by Biblioteka Uniwersytetu Warszawskiego on 03/13/15 For personal use only.
References [1] Wammes-van der Heijden EA, Rahimtoola H, et al. Neurol. 2006;67:1128–1134. ¨ [2] Schurks M, Rist PM, et al. BMJ. 2009;339:b3914. [3] Nappi RE, Merki-Feld GS, et al. J Headache Pain. 2013;14:66.
COMMENTARY FROM THE UNITED KINGDOM Mark Weatherall The author presents a case of transient hemiparesis in a young woman with a history of migraine with more typical visual, sensory, and dysphasic manifestations of aura. In such cases the diagnosis may not be difficult, provided the history of migraine is apparent at the time of presentation. In the absence of a clear history, however, neuroimaging is advisable to rule out alternative diagnoses, particularly where, as here, weakness has not hitherto been characteristic of the patient’s migraines. In many cases hemiplegic migraine is a diagnosis of exclusion and will often remain a working diagnosis until the patient has further similar attacks.
Mark Weatherall, MB, BC, FRCP(Edin), is a consultant neurologist at the Charing Cross and Ealing hospitals, London, UK (E-mail: [email protected]).
313
Hemiplegic migraine attacks are frightening and debilitating. In some cases it can take many days or even weeks for the weakness to resolve fully. Although the acute treatment of the pain phase of hemiplegic migraine is, as the author points out, essentially the same as for other forms of migraine with aura, we have no treatments that abort, alleviate, or ameliorate migraine aura. Therefore, for patients with recurrent attacks, preventive treatment is almost always indicated. Standard migraine preventives may be used for patients with hemiplegic attacks; where available, flunarizine is said to be a particularly effective preventive treatment in hemiplegic migraine.1 Patients with recurrent attacks (particularly those who have a tendency to dysphasia) should wear a MedicAlert bracelet or similar information device to inform medical and paramedical professionals of their diagnosis. This is particularly important now that systems for rapid access to thrombolysis for acute stroke are becoming more widespread.
Reference [1] Mohamed PB, Goadsby PJ, et al. Dev Med Childhood Neurol. 2012;54:274–277.
Declaration of interest: The author reports no conflicts of interest. The author alone is responsible for the content and writing of the paper.
