Dazed and Confused: A Complex Migraine Variant

David Parkes, DO, Christopher Schwartz DO, Alan Lucerna DO, James Espinosa MD, Bhumi Shah DO

Emergency Medicine Residency and Department of Emergency Medicine, Rowan University, SOM

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Conclusions:

We describe the case of a complex migraine presenting as sudden onset

obtundation, confusion, expressive aphasia, global weakness, and nausea

in an otherwise healthy 26-year-old male presenting to the emergency

department. The patient had no known past history of headache and

achieved full return to neurological baseline within 24 hours of symptom

onset after migraine treatment. Headache and more specifically Migraine

is a common presentation seen in the emergency department. Clinical

gestalt given subtle differentiations in mimicking conditions in

combination with reassuring imaging and lab work can help rule out

more concerning disease processes and help make the diagnosis.

Consideration for early neurology involvement and headache treatment

can shorten symptom length and therefore, overall hospital course.

Abstract:

While most migraine headaches are benign, easily treatable, and

able to be discharged home, there is a small percentage that blur

the lines and raise concern for neurological compromise. We

describe one such rare case of a 26-year-old male with no

known history of migraine that presented to the emergency

department with acute onset obtundation, confusion, aphasia,

and weakness. Labs and imaging of the patient were grossly

unremarkable. Treatment with a migraine cocktail and valproate

led to full recovery within 24 hours of initial presentation.

Infrequently, complex migraines can present with significant

and concerning mental status changes. Early imaging,

neurologic evaluation, and pharmacological intervention are

helpful to symptom management, improved condition, and

shorter hospital stays.

Introduction:

Acute primary headache, best defined as a headache not caused

by or attributed to another disorder, constitute approximately 2-

4% of all emergency department visits annually [1]. 90% of

these headaches are considered migraine, tension, or cluster [2].

Migraine headaches in particular are responsible for, on average,

1.2 million emergency department visits in the United States

annually [3]. Complex migraine, also known as “migraine with

aura” typically refers to severe headache accompanied by

reversible neurological symptoms [4]. This type of migraine

variant encompasses close to 30% of migraine headache

emergency department visits. Symptoms may include visual

disturbances, nausea, photophobia, sonophobia, numbness,

speech changes, and weakness among others and can last

anywhere from minutes to days.

Case Presentation:

A 26-year-old male with a past medical history of cervical spine

injury in 8th grade presents to the emergency department via

EMS with somnolence, disorientation, delirium, headache,

aphasia, generalized weakness, whole body numbness,

insomnia, nausea, vomiting, and diarrhea. Per EMS, the

patient’s girlfriend called 911 due to the patient experiencing a

sudden change in mental status upon waking up that morning.

The patient’s girlfriend further noted that as far as she knew

nothing like this had ever occurred before. On presentation, the

patient was lying in bed unable to stay awake and requiring

constant sternal rubbing to elicit any verbal response. When a

response was given, it was only non-sensical words and/or

phrases.

Case Presentation continued:

He was noted to be moving all his extremities equally when

sufficiently stimulated. Vital signs: blood pressure 124/65 mmHg,

heart rate 103 bpm, respiratory rate 18 bpm, pulse oximetry 98%

on room air, temperature 98.4 F. Review of systems was limited

due to mental status change; however, the patient was oriented to

person and was persistently able to inform staff of a severe

headache. Physical exam revealed an otherwise healthy appearing

Hispanic male with a body mass index of 21.5. The patient’s

girlfriend said that he did not smoke or use drugs, however, he did

drink alcohol socially. Lab work was remarkable for a hemoglobin

of 17 g/dL, WBC 12.4 B/L, total bilirubin of 1.6 with direct of 0.2

mg/dL, elevated serum protein at 8.6 mg/dL, elevated urine pH

(>9.0), elevated creatinine 1.30 mg/dL (baseline unknown),

elevated urine protein (1+), elevated urine ketones (3+), and

elevated urobilinogen (1+). A CT head without contrast, 1 view AP

chest x-ray, EKG, and urine drug screen were unremarkable. Due

to the patient’s initial presentation, he was first treated with 2 mg

IV narcan and ammonia 15% inhalant smelling salt, which only

slightly improved his level of alertness. On full re-evaluation

around 2 hours after arrival, the patient was notably more

conversational and less obtunded but remained somnolent and very

confused. Hence, in conversation with neurology, the decision was

made to perform a lumbar puncture in the face of persistent

somnolence and confusion. LP results were unremarkable. The

patient was then admitted to the hospital for MRI brain/cervical

spine and further neurological evaluation. The following day, after

evaluating the patient and his imaging, it was proposed by

neurology that the patient had likely been suffering from a

complex migraine. MRI brain and cervical spine were

unremarkable for any acute pathology. He was treated with Reglan

5 mg IV, Decadron 10 mg IV, Benadryl 50 mg IV, Depakote 1 g

IV, Tylenol 650 mg PO, Thiamine 100 mg PO, Ativan 1 mg IV,

Zofran 4 mg IV, and 1L NSS. His symptoms fully resolved and he

was discharged home with plans for close neurological follow up

Discussion continued:

Easily the most concerning and broadened differentials belong to those

who are unable to describe or characterize their symptoms due to

profound neurological deficits or a change in mental status. In the case

of stroke versus migraine, overlapping symptoms may include but are

not limited to disorientation, visual changes, vertigo, and generalized

malaise. However, for the busy emergency department provider there

are subtle distinctions that may help provide some early differentiation

for stroke rule out and perhaps even reassurance in an unclear

presentation.

The unequivocally most useful initial test in any such patient is the CT

brain without contrast study to evaluate for acute hemorrhage or

completed stroke. If negative and lab work including a urine drug

screen are unremarkable then consideration towards lumbar puncture

should be given. If results still remain inconclusive or vague, then

admission for MRI and neurology evaluation should be considered in

addition to symptomatic migraine treatment.

Discussion:

Primary migraine headache presentations in the emergency

department patient can vary greatly depending on the patient and

his or her history. Most reassuring are patients with a strong

migraine history that can easily describe the quality of their

typical headaches and sometimes even the medications that best

help alleviate their symptoms. More concerning patients are those

with no previous history that describe headache red flags in their

present illness.