Year : 2013 | Volume
: 12 | Issue : 3 | Page : 185--187
Sporadic hemiplegic migraine in a Nigerian woman
Owolabi F Lukman
Department of Medicine, Neurology unit, Aminu Kano Teaching Hospital, Bayero University, Kano, Nigeria
Owolabi F Lukman
Department of Medicine, Aminu Kano Teaching Hospital, Bayero University, PMB 3452, Kano
Sporadic hemiplegic migraine (SHM) is a rare form of migraine. I report a 23-year-old Nigerian lady with SHM. She had recurrent attacks characterized by visual aura that progressed to headache, dysphasia, and hemiplegia. Her motor symptom was always followed by development of nausea and photophobia lasting several hours. Computerized tomography of the brain and electroencephalography were normal. She was treated with carbamazepine, aspirin, and codeine. Differential diagnoses of SHM were highlighted.
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Lukman OF. Sporadic hemiplegic migraine in a Nigerian woman.Ann Afr Med 2013;12:185-187
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Lukman OF. Sporadic hemiplegic migraine in a Nigerian woman. Ann Afr Med [serial online] 2013 [cited 2022 Aug 18 ];12:185-187
Available from: https://www.annalsafrmed.org/text.asp?2013/12/3/185/117631
Hemiplegic migraine is a very rare form of migraine that is considered to be one of the more severe types of migraine. , There are two variants of hemiplegic migraine, namely, familial hemiplegic migraine (FHM) and sporadic hemiplegic migraine (SHM).  Unlike in SHM, FHM can be traced back in the family history and has been linked to mutations of specific genes on chromosomes 1 and 19. Thus, SHM is without the familial connection and that particular genetic mutation. Diagnosing FHM and SHM can be difficult as the symptoms are also indicative of vascular disease and can be thought to be stroke, epilepsy, or other conditions. ,
On account of rarity of this disorder, coupled with its close similarity to transient ischemic attack and stroke, a case of SHM in a Nigerian lady is reported and this to the best of my knowledge is the first of its kind in Nigeria.
A 23-year-old right-handed undergraduate lady who presented for the first time in February 2009 after she has had several episodes of throbbing right hemicranial headaches associated with nausea and photophobia lasting several hours. The hemicranial headache attacks were usually preceded by ipsilateral flashlight sensation in the eye. At first presentation, she has had three prior hemicranial headaches that were associated with hemiplegia. Attacks lasted from 60 min to 7 days. A typical attack would start with a visual aura and then progress to headache and then hemiplegia. The motor symptom was always followed by development of nausea and photophobia lasting several hours. The most severe attack occurred at the age of 23 years; it started with headache and aphasia; however, comprehension remained intact for both spoken and written commands. Subsequently, she developed hemiparesis within 24 hrs of the illness. Aphasia gradually improved but residual right-sided weakness persisted for more than 12 days. There was no associated convulsion or loss of consciousness. There was no family history of similar illness, and she was neither hypertensive nor diabetic. She was not on migraine prophylaxis prior to presentation to the neurology clinic.
The salient findings on physical examination at presentation included left hemiparesis, left-sided facial weakness, and expressive dysphasia. There was no arrhythmia, carotid bruit, or cardiac murmur.
Computerized tomography of the brain, which was done 48 hrs after the onset of symptom as well as during one of the previous attacks, showed no abnormality. Electroencephalography during attack was also normal. However, regional cerebral blood flow study and molecular genetic studies could not be done as facilities were not available.
She was placed on 200 mg control release carbamazepine as migraine prophylaxis and aspirin with low-strength opiate for abortion of migraine. All the symptoms subsided after about 4 h of therapy. She is currently under follow-up.
Migraine variant (MV) or migraine equivalent is the term applied to a migraine that exhibits itself in a form other than head pain. This condition is less recognized, less common, and poorly understood than typical migraines with or without aura. The children and young adults are usually affected.
MV is characterized by paroxysmal episodes of prolonged visual auras (atypical sensory, motor, or visual aura) confusion, dysarthria, focal neurologic deficits, gastrointestinal manifestations, or other constitutional symptoms with or without a headache.
The diagnosis of MV is determined by a history of paroxysmal signs and symptoms with or without headache and a previous history of migraine with aura, in the absence of other medical disorders that may contribute to the symptoms. Many of these patients usually have a family history of migraine.
Many MVs have been defined by the International Classification of Headache Disorders (ICHD-II) 2004 classification.  These include hemiplegic migraines, basilar migraine, childhood periodic syndromes, retinal migraine, complicated migraines, and ophthalmoplegic migraine. Less common forms of migraine, such as vertiginous migraine, acute confusional migraine of childhood, and nocturnal migraine, remain unclassified by ICHD-II. 
The index case fulfilled the diagnostic criteria of SHM (1.2.5) of the International Headache Society (ICHD-2). , Structural brain lesions including congenital and vascular anomalies were excluded by imaging studies.
Regarding hemiplegic variants, FHM and SHM share the same symptoms, which vary among different Migraineurs. The difference between the two is that FHM can be traced back in the family history and has been linked to mutations of specific genes on chromosomes 1 and 19. ,,
Symptoms of SHM include episodes of prolonged aura (up to several days or weeks), hemiplegia (paralysis on one side of the body), fever, meningismus (symptoms of meningitis without the actual illness and accompanying inflammation), headache, which may begin before the hemiplegia or be absent ataxia (defective muscle coordination), nausea and/or vomiting phonophobia, and/or photophobia. The index patient had visual aura, hemicranial headache, hemiplegia, and photophobia; these findings are in keeping with the manifestations of SHM reported elsewhere. ,,,
The typical feature of presence of visual aura, which has been previously reported to occur in all cases of SHM, , was present in this patient. In SHM onset of the hemiplegia may be sudden, thereby simulating a stroke.  In the index patient, onset of hemiplegia was rather gradual; however, stroke was excluded during attack on two separate occasions by neuroimaging.
A close differential of SHM is basilar migraine. Thomsen and Olesen  stated that 72% of SHM patients fulfill the IHS diagnostic criteria for basilar migraine. Nevertheless, on clinical grounds, the absence of visual symptoms, which was present in this case, and presence of other brain stem features such as vertigo, dysarthria, diplopia, and ataxia, which were absent in the patient in question, would clinch the diagnosis of SHM. ,
The patient was managed with carbamazepine, aspirin, and opiate. The choice of carbamazepine as prophylactic drug had been somewhat arbitrary, but Valproate had been avoided because of her sex and age and because of theoretical arguments against use of beta-blockers in hemiplegic migraine.  Migraine-specific abortive, such as the triptans and ergotamines, are currently contraindicated in the treatment of hemiplegic migraine because of their vasoconstrictive properties and concerns about stroke. One small study was conducted, safely using triptans with patients with hemiplegic migraine, but more trials are needed before they are considered a safe option.  Since the triptans and ergotamines are not options in this category of patients, other treatments such as nonsteroidal anti-inflammatory drugs, antiemetic, and narcotic analgesics are generally used for relief of hemiplegic migraine.  Given the severity of the symptoms, preventive regimens are considered especially important in the treatment of SHM.
SHM is reported in a Nigerian woman. Consideration of SHM as a differential diagnosis in a patient with recurrent hemiparesis associated with hemicranial headache as well as the need for careful clinical documentation and cranial neuroimaging cannot be overemphasized.
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