Hemiplegic Migraine: An Imitator of Cerebrovascular Disease

Hemiplegic migraine is a rare subtype of migraine with aura characterized by reversible unilateral motor weakness, often accompanied by transient visual, sensory, or speech disturbances. Because the motor deficits frequently mimic acute cerebrovascular events, patients often undergo urgent stroke evaluations, creating significant diagnostic uncertainty. We present the case of a 72-year-old woman with a clinical stroke with negative MRI imaging 10 months prior, who presented to the emergency department with stroke-like symptoms for the past three days and a National Institutes of Health Stroke Scale (NIHSS) score of 5. Head CT and CT angiography confirmed no hemorrhage. Subsequent work-up revealed no acute or remote ischemia or infarction. This case highlights the diagnostic challenge posed by the clinical overlap between hemiplegic migraine and ischemic stroke. Although structural imaging is often normal in hemiplegic migraine, early presentation before symptom resolution can prompt unnecessary therapy. The case highlights the importance of thorough history-taking for early recognition and appropriate management of hemiplegic migraine.