Case Diagnosis: Familial Hemiplegic Migraine with Concurrent Meningioma
Case Description: 69-year-old female with FHM complicated by ataxia and dysarthria who presented with worsening migraines and ataxia associated with left sided numbness. A diagnosis of FHM was made in her teens, with multiple negative head CTs throughout her lifetime, the last one being 10 years prior. From her family history of FMH, our patient knew that attacks usually decrease with age, but her attacks were increasing in frequency and magnitude. MRI revealed a right-sided parasagittal meningioma, which was surgically resected. She was subsequently admitted to acute rehabilitation.
Our patient symptoms quickly resolved after surgery, suggesting her recent symptoms were caused by her meningioma rather than her FMH. After 4 weeks of inpatient rehabilitation, she returned to her baseline functional status. She had mild residual ataxia and dysarthria with resting tremor but was independent with ambulation and ADLs.
Discussion: Hemiplegic migraine (HM) is a rare subtype of migraine, which presents with a motor aura. Motor auras consist of reversible unilateral motor weakness that occurs concurrently or prior to a headache. In severe forms, patients suffer from prolonged hemiparesis, permanent cerebellar ataxia, epilepsy or mental retardation. HM can occur in families or sporadically. Approximately 75% of FHM cases are linked to a mutation in CACNA1A, ATP1A2 or SCN1A. Treatment of HM includes avoiding triggers, such as stress and bright lights. Preventative treatment with sodium valproate, lamotrigine, verapamil or acetazolamide may be indicated in patients with frequent attacks.
FHM aura can mimic TIA, epilepsy, brain tumors and stroke. CFS analysis, MRI or EEG may be indicated based on presentation. A throughout history can prompt quicker diagnosis and treatment, thus improving morbidity and mortality. Conversely, HM should be kept in the differential of patients who present with persistent attacks of motor weakness and a negative neurological workup.