Unmasking Hemiplegic Migraine: A Diagnostic Dilemma in the Shadow of Stroke

A rare presentation of a migraine headache is hemiplegic migraine (HM), which can clinically imitate other conditions, including transient ischemic attack (TIA) and cerebrovascular accident (CVA), with unilateral muscle weakness or hemiplegia, making accurate diagnosis challenging. We present a 41-year-old male patient who was admitted with symptoms of a unilateral occipital headache, expressive aphasia, and right-sided motor weakness on two occasions over six days to two different hospitals. CT with and without contrast, echocardiogram, troponin I, EKG, and MRI results were normal. The patient was seen and discharged by neurology to be treated for headaches as an outpatient with butalbital-acetaminophen-caffeine. A diagnosis of sporadic HM was made after a thorough history by the primary care provider and managed conservatively with verapamil. This case highlights the critical role of primary care in synthesizing clinical information and history to establish an accurate diagnosis, underscoring the need for detailed patient evaluation. Raising awareness of HM as part of the differential diagnosis is vital after ruling out life-threatening conditions through imaging and clinical evaluation.