Hemiplegic Migraine: The One-sided Perspective

The Burgundy Interlude

Watson walks into the restaurant late... Watson’s colleague has a birthday and has invited Watson for dinner. To Watson’s surprise, his colleague has not yet arrived; a glass of 2012 Albert Bichot Cote de Nuits Villages Burgundy (of course!) is ordered. 

Watson’s colleague arrives, apologising profusely, “I have just come from the hospital visiting my niece.” 

“Is everything OK?”

“Well, it is now, but initially it looked like she had a CVA, but all the tests are negative, and she has been diagnosed with ‘Hemiplegic Migraine’(HM),” explains Watson’s colleague. “I have heard of this before, but what is it?” 

Hemiplegic Migraine: The Entity

“Hemiplegic migraine is a subtype of migraine with aura characterised by the presence of motor weakness or paralysis on one side of the body,” explains Watson. “The aura in HM includes not only visual disturbances but also sensory changes—paraesthesia and anaesthesia—and speech difficulties seen in other types of migraine with aura. It can also cause temporary hemiplegic paralysis or weakness.”

“So, what causes this?” replies Watson’s concerned colleague. “Well, it is thought to be genetic associated with mutations in specific genes that affect ion channels in the brain,” comes Watson’s furtive reply. “Why the covert reply?” enquires Watson’s colleague.

Hemiplegic Migraine: Non-Genetic?

“Well, HM is one of my favourite conditions to treat – it responds readily to specific upper cervical spine mobilisation. I’m not sure I am changing the genetic composition,” explains Watson’s ‘tongue-in-cheek’ reply.  Watson’s colleague almost chokes on the pinot, grabbing his serviette to mop up. “Do you mean you could help my niece?”

“Yes!” comes Watson’s confident reply. “In my experience, it’s worth looking at her neck because, otherwise and unnecessarily, she will be destined for a lifetime of pharmaceutical management. Despite advances in genetic research, the majority (75 per cent) of HM remains unexplained, suggesting that additional genetic factors contributing to the disorder are yet to be identified.1  Or perhaps there are other factors(?),” questions Watson

Watson’s colleague dismisses the waiter who has come for their order...

Empirical Evidence

Watson continues, “Coincidentally, I have just discharged a patient with HM.  She experienced her first episode, in which the acute phase comprised loss of speech and anaesthesia starting in the [R] leg and radiating to include the [R] arm and face ten weeks before seeing me. These episodes were associated with [R] cervical symptoms and mild [R] sided-headache followed by significant nausea; at best, she could no longer than three days between episodes.”

“Wow, that is significant.”  “Yes, and she was hiding these from her two young children because of the effect it might have on them to see their Mum in this state,” explains Watson.

“I’ll abbreviate the journey: in all, five treatments with decreasing frequency, duration, and intensity of episodes with increasing intervals between treatments, with the last interval being three weeks without any episodes.” “That’s impressive,” Watson’s colleague excitedly replies.

The Default Button

“Ah, let me take you through a rare spontaneous opportunity that presented... at the 3rd treatment, a week after the 2nd, she had experienced only a minor episode affecting her arm only, i.e., she had significantly improved, and she was excited!  Immediately after our appointment, she was due (pre-arranged) to see a neurologist for the first time but was nervous about going on her own, so with her consent (and I was seeing her outside of my usual clinical schedule so I could), I accompanied her to this appointment with the neurologist whom I knew but hadn’t seen for 30 years. I sat back, not wanting to influence, but on two occasions, I had to politely suggest that improvement had occurred, but it appeared to fall on deaf ears. A triptan and a prophylactic medication were prescribed, and an appointment was made for three months. My patient chose not to go down the prophylactic pathway, but I encouraged her to fill the script for the triptan for any episodes – which have not been required.”

“You weren’t employing evidence-based practice then.”

“Rather empirical clinical evidence (fundamental to ‘Evidence Informed Practice’) accrued over 35 years.  To sanction my intervention requires a departure from a common practice in headache medicine, i.e. hitting the default key, also known as a diagnosis with uncertain pathophysiology,” comes Watson’s assertive reply.

Uncles are Great, Aren’t They?

“How did she come to you – I gathered it would not have been via a medical professional.”

“Correct, ironically, it was her uncle...”

The waiter has returned...  

Until next time... 

Dr Dean Watson PhD, Musculoskeletal Physiotherapist

Watson Headache® Institute

Email dean@watsonheadache.com

Reference: 

1.         Alfayyadh MM, Maksemous N, Sutherland HG, Lea RA, Griffiths LR. Unravelling the Genetic Landscape of Hemiplegic Migraine: Exploring Innovative Strategies and Emerging Approaches. Genes (Basel). Mar 31 2024;15(4).

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