Paroxysmal hemicrania masquerading as a stroke in an elderly gentleman: case report
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CASE REPORT
Open Access
Paroxysmal hemicrania masquerading as a stroke in an elderly gentleman: case report Boon Hian Tan1* , Astrid Melani Suantio1† and Yeow Hoay Koh2†
Abstract Background: Paroxysmal hemicrania has not been associated with ipsilateral weakness, loss of sensation and Horner’s syndrome. This report is the first of its kind documented in literature. Case presentation: This was an elderly, sixty-five-year-old Chinese male who presented with a headache fulfilling criteria of paroxysmal hemicrania and was found to have signs of ipsilateral conjunctival injection, Horner’s syndrome, weakness and loss of sensation; with resolution of the patient’s physical signs after relief of the headache. Brain magnetic resonance imaging did not show any strokes or other headache mimics. The patient had a marked response to indomethacin and a decrease of headache intensity and frequency with indomethacin prophylaxis. Conclusions: Paroxysmal hemicrania has joined the list of stroke chameleons and that it would be one of the differentials in a patient with hemiplegia, hemisensory loss, autonomic signs and severe headache. It suggests that paroxysmal hemicrania in the elderly present atypically. Keywords: Paroxysmal hemicrania, Stroke mimics, Horner’s syndrome, Trigeminal autonomic cephalalgia, TAC, Case report
Background Trigeminal autonomic cephalalgia (TAC) is a diverse group of unilateral headaches with ipsilateral autonomic features [1]. The paroxysmal hemicrania (PH) subtype occurs more commonly in females and typically affects patients aged between 40 and 50 years of age [2–4]. It is a disease involving multiple episodes of strictly unilateral, severe, short-lasting headaches occurring with cranial autonomic features with good response to indomethacin [1, 3, 4]. It is uncommon, but not unheard of, for elderly patients of age of 65 years and above, to also be affected [3, 4]. There have been reports of patients as old as 81 years of age with PH [4].
* Correspondence: [email protected] † Astrid Melani Suantio and Koh Yeow Hoay contributed equally to this work. 1 Department of General Medicine, Geriatric Medicine, Sengkang General Hospital, 110 Sengkang East Way, Singapore 544886, Singapore Full list of author information is available at the end of the article
The physical examination of patients known to have PH has had reports of loss of sensation to the ipsilateral face, loss of visual acuity and the acquisition of a relative afferent papillary defect [3, 4]. The loss of motor power in the limbs and the development of Horner’s syndrome during a PH episode have not yet been described in the current literature [3, 4]. There are many diseases that are initially diagnosed as PH and subsequently revised, based on subsequent neuroimaging evidence, as other diagnoses. These includes strokes involving the brainstem, arterio-venous malformations, meningiomas, bulking pituitary lesions, vascular loops encompassing the trigeminal nerve and Moya-Moya disease [4–13]. Strokes are known to be more common in the geri
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