Hemiplegic migraine induced by exertion

Background: It is known that exertion can aggravate migraine headache. However, the relationship between exertion and migraine aura is unknown. Objective: To study the relationship between exertion and migraine aura. Design: Case report. Setting: Tertiary care hospital. Patient: A 67-year-old man presented with recurrent attacks of exertion-induced hemiplegic migraine. Since the hemiparetic attacks were exertion induced, they were initially ascribed to recurrent transient ischemic attacks. However, the clinical picture, normal findings on cerebral angiography and neuroimaging (during the period of hemiparesis), lack of response to treatment with antiplatelets and anticoagulants, and successful treatment with verapamil suggested that the hemiparesis was not due to ischemia, but was indeed a migraine aura. We suggest that exertion induced the aura of hemiparesis by lowering the threshold for the development of cortical spreading depression. Even though our patient had no family history of hemiplegic migraine, a mutation in an ion channel gene (eg, the CACNAIA gene on chromosome 19) might account for his episodic attacks. Conclusion: Migraine aura should be included in the differential diagnosis of exertion-induced focal neurologic deficit.