Monthly Case

A 35-year-old male patient suffers for 8 years from recurrent stereotyped episodes with initial double vision for 2 to 3 min., followed by paresis of facial and then upper extremity musculature, in each case on the right. Duration of paresis is 20 to 30 min., followed by slow recovery over another 10 min. During these episodes, articulation is slurred which obviously is the consequence of right facial weakness. The patient’s wife has video-taped one of these episodes, clearly confirming the specifications. The paroxysmal events are not accompanied or followed by headaches. Frequency is two to three attacks per year. Cranial MRI and EEG examinations were normal.

The patient’s brother and mother suffer from migraine with visual aura, so far both of them did not experience motor deficits in association with headache.

Before the patient presented to us the first time, the diagnosis of transient ischemic attacks was made and a secondary prophylaxis with Aspirin was started. Later another hospital allocated these attacks to focal epileptic seizures. The – assumed – epilepsy was treated with levetiracetam which however was not able to influence occurrence of these episodes.

When the patient presented in our epilepsy outpatient clinic at the Charité for the first time, we again took a detailed history from the patient and his wife regarding these events. The main argument against transient ischemic attacks is the progressive development of motor deficits which is expected to occur suddenly with cerebrovascular accidents. The main argument against focal epileptic seizures is the long duration of the events, epileptic seizures commonly do not last longer than 2 min.

After exclusion of these two differentialdiagnoses, we made the diagnosis of sporadic hemiplegic migraine which shows an atypical course due to lack of headache. We stopped treatment with Aspirin and levetiracetam.

Secondary prophylaxis for recurrent episodes of hemiplegic migraine is lamotrigine which we currently titrate to 150 mg daily.

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