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LETTER TO EDITOR
Year : 2016  |  Volume : 64  |  Issue : 2  |  Page : 328-330

Facial paretic migraine — A rare migraine variant


Department of Neurology, Pushpagiri Medical College, Tiruvalla, Kerala, India

Date of Web Publication3-Mar-2016

Correspondence Address:
Mohan Madhusudanan
Department of Neurology, Pushpagiri Medical College, Tiruvalla, Kerala
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.177624

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How to cite this article:
Madhusudanan M. Facial paretic migraine — A rare migraine variant. Neurol India 2016;64:328-30

How to cite this URL:
Madhusudanan M. Facial paretic migraine — A rare migraine variant. Neurol India [serial online] 2016 [cited 2019 Dec 10];64:328-30. Available from: http://www.neurologyindia.com/text.asp?2016/64/2/328/177624


Sir,

Migraine variant (or migraine equivalent) is the term applied to a migraine that exhibits itself in a form other than cranial pain. The usual migraine variants are cheiro-oral migraine with atypical motor, sensory, and visual aura; acute confusional migraine; vertiginous migraine; hemiplegic migraine; cyclical vomiting and paroxysmal torticollis in infants; and benign episodic vertigo in childhood. Here, a case of migraine presenting with transient unilateral facial paralysis ipsilateral to the hemicranial headache, that was manifesting every time the headache occurred, is presented. To the best of my knowledge, this presentation has not yet been described.

A 55-year-old woman had been having paroxysmal episodic left hemicranial headache since the age of 25 years. The headache sometimes shifted sides, but most of the times, it remained on the left side. The left-sided hemicranial headache was preceded by the complaint of a pulling sensation of the left side of the face, followed by facial deviation to the right. The facial paresis used to develop to its maximum over a period of 5–10 minutes and would last from 30 minutes upto an hour, followed by vomiting. There was no photophobia or sonophobia. The episodes used to occur two to four times a month.

There was a strong family history of migraine, but none of the other family members had similar episodes of recurrent facial palsy during their attacks.

Examination of the patient in between the attacks did not reveal any abnormality. During the attack of migraine, she developed lower facial weakness on the left side along with deviation of the angle of the mouth to the right, accompanied by normal eye closure on the left side [Figure 1] and [Figure 2]. Rest of the central nervous system examination, even during the attack, was normal. Her brain magnetic resonance (MR) imaging with contrast study, that included the diffusion weighted images, the apparent diffusion coefficient (ADC) maps, and the MR angiogram, was performed immediately after the attack, and was found to be normal. The routine blood chemistry and antinuclear antibody panel were within normal limits.
Figure 1: Left lower facial weakness during the attack of migraine

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Figure 2: The facial weakness spares the upper part of the face

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Propranolol therapy, 40 mg twice daily, was initiated. With this treatment, her episodic headache and recurrent facial palsy reduced in frequency but continued to recur once or twice a month. Topiramate was added to the previous regimen. Following this addition, she had no further episodes of these manifestations for the next 6 months. On attempting to taper either medication, the attacks returned to the previous levels. On reintroducing the antimigranous medications, she had no further episodes of headache or facial weakness.

The transient facial paresis associated with each episode of migranous headache is a novel entity. Even though facial weakness can occur in other migraine variants such as sporadic hemiplegic migraine or basilar migraine, the clinical features of the present case were quite unlike those present in these entities.

In hemiplegic migraine, the patient experiences recurrent headaches associated with temporary unilateral hemiparesis or hemiplegia.[1] In the case presented, there was no weakness of any of the limbs at any given time. Patients with basilar migraine usually present with symptoms of vertebrobasilar insufficiency associated with the headache. Even though facial weakness can occur in basilar migraine, absence of other features is against the latter possibility in the case presented.

Zachariah and Patel [2] described a case of recurrent Bell's palsy preceded by migraine-like headache and accompanied by a visual aura. However, in their case, the facial palsy was akin to the Bell's palsy lasting for days to months, unlike in the current case, where the facial weakness lasted for less than an hour in each attack.

In the present case, the episodic hemicranial headache with vomiting, a positive family history, the recurrence of headache and facial palsy on stopping the prophylactic antimigrane drugs, and the subsidence of these symptoms on reintroduction of the medications, along with normal neuroimaging and other relevant blood investigations, makes an atypical presentation of migraine, a more plausible diagnosis in our patient.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Benatar M, Ford CC. Familial hemiplegic migraine: More than just a headache. Neurology2005;64:592-3.  Back to cited text no. 1
    
2.
Zachariah J, Patel P. Facial pain with recurrent facial palsy. Headache 2003;43:700-1.  Back to cited text no. 2
    


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