Treatment & ER Protocols: Managing the Attack Safely

Managing hemiplegic migraine (HM) requires a different approach than typical migraines. Because HM symptoms mimic a stroke, having a clear medical plan—including what to take and, more importantly, what to avoid—is essential for your safety ^[1][2].

The Home Action Plan

When an attack begins, fast action is necessary. Because symptoms like aphasia (inability to speak) can come on quickly, you should:

1. Notify Someone Immediately: Tell a family member or coworker the moment you feel the aura start, before you lose the ability to communicate.
2. Get to a Safe Place: Lie down in a dark, quiet room to minimize sensory input.
3. Take Your Medication: Take your prescribed acute medication (like an NSAID) immediately, exactly as directed by your neurologist.

The Safety Warning: What to Avoid

• Triptans and Ergotamines: For many years, these vasoconstrictors (which narrow blood vessels) have been the “gold standard” for typical migraines ^[3]. However, in HM, doctors are concerned these drugs could restrict blood flow further during the “brain tsunami” phase. They are traditionally contraindicated and generally avoided by ER doctors, though you should follow your specific headache specialist’s guidance ^[3][4].
• Estrogen-Based Birth Control: If you are a female patient, it is critical to know that migraine with aura (especially HM) carries a significantly higher stroke risk when combined with estrogen-based contraceptives (like combination birth control pills). Discuss progesterone-only or non-hormonal options with your doctor immediately ^[1].

Acute Treatment: Safe Alternatives

Your doctor may suggest these alternatives for treating an attack as it happens:

• Symptomatic Control: High-dose NSAIDs (like ibuprofen or ketorolac) and anti-emetics are often used ^[5][6].
• Intravenous (IV) Magnesium: Some clinical reports suggest IV magnesium can be effective for severe attacks ^[7].
• Non-Vasoconstrictive Options: Newer drugs like ditans (e.g., lasmiditan) do not cause blood vessel narrowing and may be a safer choice ^[8][9].

Preventive Care: Reducing the Frequency

If attacks are frequent or severe, your doctor may recommend a daily medication.

• Flunarizine: Often considered a standard preventive for HM, this calcium channel blocker can help reduce how often attacks occur ^[10][11].
• Acetazolamide: A classic, frequently utilized preventive medication specifically for familial hemiplegic migraine (especially the FHM1 subtype) ^[12].
• Anti-Epileptic Drugs (AEDs): Medications like Topiramate, Lamotrigine, or Valproate are used to stabilize brain activity ^[6][11].
• CGRP Monoclonal Antibodies: New preventive drugs (like fremanezumab) are showing promise in early case reports ^[13][14].

The ER Protocol: Your “Migraine Passport”

One of the biggest challenges with HM is being misdiagnosed in the ER. To advocate for yourself and ensure safety, carry an ER Protocol Letter (also called a “migraine passport”) from your neurologist ^[1][15].

Your letter should include:

1. Your confirmed diagnosis (FHM or SHM) and known genetic mutations ^[1][6].
2. Your typical symptoms: Describe your specific pattern of one-sided weakness and duration ^[1].
3. A strict warning against tPA (clot-busters): The letter must explicitly state that you have HM to help ER staff avoid administering unnecessary and dangerous stroke medications like tPA, which carry an unwarranted risk of severe hemorrhage in HM patients ^[1].
4. A list of “No-Go” drugs: Note that triptans and ergotamines are generally avoided ^[1].
5. Recommended treatments: Provide the ER doctor with your neurologist’s preferred plan ^[1].

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