A 38-Year-Old Man With Double Vision, Numbness, and Headache

Olusegun John Oluwole, MBBS

Disclosures

July 28, 2020

Management of hemiplegic migraine entails acute treatment as well as prophylaxis. The options for acute treatment include acetaminophen, nonsteroidal anti-inflammatory drugs, steroids, intravenous magnesium sulfate, and intravenous fluids in various combinations, depending on headache severity and response to treatment.

Some experts suggest that ergotamine and triptans should be avoided in the treatment of hemiplegic migraine, owing to concerns that these classes of medications may increase the risk for ischemic stroke.[5]

After successful acute treatment, prophylactic treatment always deserves serious consideration in patients with hemiplegic migraine because of the catastrophic nature of the hemiparesis associated with it, which often takes considerable time to resolve. In some patients, complete recovery may take over a week, which can have important implications for work and other aspects of life. Available choices of prophylactic treatment range from nonspecific medications (eg, propranolol, topiramate, amitriptyline, acetazolamide, flunarizine) to more recent migraine-specific monoclonal antibodies, such as erenumab and galcanezumab, which are already in use many countries.[2,7,8]

The patient in this case received a combination of intravenous fluid, intravenous acetaminophen, and intravenous ketorolac for acute treatment. He was subsequently started on migraine prophylaxis with erenumab. His weakness, numbness, and hand coordination slowly improved. He was discharged on day 3 of hospitalization. He recovered full strength in his limbs within 3 weeks and continued on once-monthly erenumab.

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