Hemiplegic Migraine: Symptoms, Causes and Treatments

January 26, 2024
September 26, 2022
Hemiplegic Migraine: Symptoms, Causes and Treatments

Hemiplegic migraine (HM) is a rare subtype of migraine with aura, associated with one-sided motor weakness during the aura phase. The motor weakness is often present with other aura symptoms such as impairment of vision, sensation, or speech. There are two categories of hemiplegic migraines; familial hemiplegic migraine (FHM) where there is a family history in first and second degree relatives, and sporadic hemiplegic (SHM) migraine where there is no family history.

While migraine affects about 15-20% of the population, the overall prevalence of hemiplegic migraine is much more rare. It occurs in about .01%, reported in a population study from Denmark. It usually starts in the first and second decade of life. Hemiplegic migraine is also is more prevalent in females than males.

Causes of Hemiplegic Migraine

The aura of HM is most likely to be caused by cortical spreading depression across the brain.

Genetic studies have shown the involvement of a few genes - CACNA1A, ATP1A2, PRRT2, and SCN1A. Other genetic mechanisms may play a role although further studies are necessary. The pathophysiology of HM is similar to migraine with aura although we do see a lower migraine threshold and increase in severity of migraine episodes.

Symptoms of Hemiplegic Migraine

HM is characterized by recurrent migraine episodes associated with motor weakness. Motor aura is the hallmark of HM. However, typically there are two or more auras present during a HM attack. Each aura can evolve over 20 to 30 minutes and may also take hours to improve. Often an episode can begin with visual aura then followed by sensory, motor, speech changes, and brainstem symptoms. The aura symptoms associated with brainstem aura include vertigo, speech changes, balance and coordination impairments, bilateral visual symptoms, sensory or motor symptoms, sensitivity to sounds, tinnitus, and diminished alertness. Motor symptoms often start in the hand and gradually spread into the arm and then the face. Although episodes are one-sided this can switch sides between or during attacks. Most patients will have headaches with each attack. Additionally, motor and aura symptoms are fully reversible. We do see that the frequency and severity of episodes improve with age typically after age 50, and can evolve into more typical migraine episodes without hemiparesis. Most common triggers reported include acute stress, bright lights, changes in sleep patterns, exertion, and mild head trauma although episodes can also occur without being exposed to triggers.

Symptoms associated with HM are similar to stroke and epilepsy, so it is absolutely crucial that other neurological conditions are ruled out. It is important to be seen by a healthcare provider (in person or via video visit) for a complete neurological exam in addition to the review of family and medical history. Imaging may also be necessary to look at the brain and the blood vessels.

To receive this diagnosis, the patient should have at least two episodes meeting criteria for migraine with aura. A person must also have experienced temporary symptoms involving motor weakness, visual, sensory, or speech changes. In addition, the aura symptoms are fully reversible.

Treatments for Hemiplegic Migraine

Treatment is always considered based on severity and frequency of episodes. Symptom management is essential for those experiencing HM. Since HM is a subtype of migraine with aura, similar preventive treatment is considered. This includes blood pressure agents, anti-seizure medications, and antidepressants. For acute treatment, NSAIDS may often be prescribed and anti-nausea medications. We generally avoid triptans and ergotamine derivatives because they constrict blood vessels and may increase the risk of stroke in this population.

If you think you may be experiencing hemiplegic migraine, it's important to speak with a doctor. Neura's headache specialists treat many hemiplegic migraine cases, and would be glad to meet with you via video consultation. Click here to start your trial and book a visit.

For more great content, follow us:
Instagram IconFacebook Icon
Jasmine Bhasin, PA-C
Jasmine Bhasin is a Physician Assistant specializing in headache medicine, based in the San Francisco Bay Area.
About the Author
Jasmine Bhasin is a Physician Assistant specializing in headache medicine, based in the San Francisco Bay Area. Prior to joining Neura Health, she worked in the Department of Neurology at UW (University of Wisconsin) Health where she specialized in migraine and headache disorders. Jasmine began her career in family practice and aesthetics where she adopted an interest in alternative medicine. She continues to focus patient care based on preventative medicine with a holistic approach, where treatment plans are incorporated with non-pharmacologic management such as lifestyle changes, alternative medicine, physical therapy, and supplements. She also performs botox injections, supraorbital nerve blocks, occipital nerve blocks, and trigger point injections. Jasmine completed her undergraduate degree in Human Development at UC San Diego. She went on to receive her Master of Science in Physician Assistant studies from Western University.

Share this article

Looking for expert neurology care?

Video visits within days

Talk with neurologists

Get Rx delivered

Learn More

Finally, expert neurology care at your fingertips

Neura Health is a comprehensive virtual neurology clinic. Meet with a neurology specialist via video appointment, and get treatment from home.

Phone and Leaf Mockup