Is It All In My Head? Recurrent Right-sided Hemiparesis in a Young Female. A Case Report.

Case Diagnosis: A 22-year old female with right-sided hemiparesis secondary to hemiplegic migraine.

Case Description or Program Description: The patient presented with a 4-day history of right hemiparesis and hemianesthesia that was preceded by headache. These episodes have occurred multiple times over the past 7 years and follow the same pattern. The patient has had about 7 concussions in the past. In this episode, she developed symptomatic bradycardia with a 2.5-second heart stop. On day 10, the patient was admitted to IPR to improve strength and balance. Physical exam was significant for right hemisomal myelopathic changes and corticobulbar signs. Imaging and labs were unremarkable. She was discharged from IPR on day 7 with a resolution of hemianesthesia and near complete resolution of hemiparesis.

Setting: Inpatient Rehabilitation Hospital

Assessment/Results: At IPR admission, Strength testing revealed she was minimally able to move her right extremities against gravity. Therapy evaluations showed that she could ambulate 20 feet using a four-wheeled walker with minimal assistance but needed moderate assistance with transfers and bed mobility. At discharge from IPR, the patient was able to ambulate independently.

Discussion (relevance): The differential diagnosis in this case was recurrent hemiplegic migraines vs functional neurologic disorder (FND). Both disorders are not detectable on imaging and require extensive workup to rule out other causes for neurologic symptoms. Rapport with the patient is essential because both diagnoses can be alarming and debilitating. Treatments for these conditions are widely different. Hemiplegic migraine can be treated medically with migraine abortives and education regarding trigger avoidance, whereas FND requires education regarding the diagnosis, CBT, and PT/OT to have positive outcomes.

Conclusions: Complicated migraines and FND can present similarly, but interventions for these conditions vary. In both cases, rehabilitation services can be an effective component of the treatment plan.