Objective: To identify the myriad ways migraine can present, including with muscle spasm(s) that can appear to be dystonia and thus serve to make this differentiation challenging at times. Features of dystonia include muscle spasms and abnormal postures, occasionally segmental or focal, lateralized or generalized but rarely associated with head pain which may be the most obvious differentiation between migraine and dystonia, however, head pain may not be the primary presentation of migraine.

Background: Migraine is very common in the world population.  The most common presentation is common or classic migraine with acephalgic, ophthalmic or retinal migraine being other common subtypes.  Hemiplegic migraine remains uncommon and is often treated as a medical emergency upon its initial presentation, with acute stroke treatments provided and associated work-up ensuing.  We review a patient with years of neck pain and history of Radiofrequency Ablation (RFA), chronic pain and carpal tunnel syndrome in the dominant right upper extremity, dystonic tremor and migraine with classic associated features of affective and sleep disorders.

Method: Evaluation in the movement disorders clinic revealed a patient carrying a diagnosis of dystonia for >20 years, reporting tremor in the hand, arm and neck increased over the past year consistent with dystonic tremor.  Examination revealed no tremor but subtle dystonic posturing of the right hand,  right torticollis and R>L spooning.  No dyskinesias or other hyperkinetic movements observed.

Results: Genetic testing for Familial Hemiplegic Migraine and Generalized Dystonia was pursued and returned negative for both hereditary conditions.  This resulted in reassessment of her migraine management which revealed sub-optimally controlled pain episodes.  Adjustment of the treatment regimen resulted in better control of pain and episodes of abnormal movement.

Conclusion: Migraine is common in the world population and its pathologic mechanisms remain obscure despite it being so commonly seen and treated in our clinics.  The myriad ways in which migraine presents should be a routine part of movement disorders education.

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MDS Abstracts - https://www.mdsabstracts.org/abstract/hemiplegic-migraine-masquerading-as-dystonia/