Migraine with acute confusional state (ACS):
- Rare, often seen in children or elderly patients.
- Presents with altered consciousness, disorientation, and cognitive impairment.
- May mimic encephalopathy or delirium; EEG may show diffuse slowing.
- Rationale: Likely due to cortical spreading depression affecting the temporal lobe.
- Hemiplegic migraine:
- Recurrent attacks of headache with motor weakness (hemiparesis) and sometimes sensory or visual symptoms.
- Familial form (FHM) linked to mutations in CACNA1A, ATP1A2, or SCN1A genes (channelopathies).
- Sporadic form lacks genetic mutations but shares clinical features.
- Rationale: Cortical spreading depression triggers focal neurological deficits.
- Migraine with brainstem aura (BAS):
- Symptoms include vertigo, ataxia, dysarthria, and bilateral sensory disturbances.
- Often misdiagnosed as stroke or multiple sclerosis.
- Rationale: Brainstem involvement due to cortical spreading depression.
- Ophthalmoplegic migraine:
- Rare, presents with headache and transient oculomotor nerve palsies (III, IV, or VI).
- May be associated with orbital pain and ptosis.
- Rationale: Possibly due to nerve ischemia or inflammation.
- Retinal migraine:
- Transient monocular visual disturbances (scotomas, blindness) with or without headache.
- Rationale: Focal retinal ischemia or cortical spreading depression.
Key diagnostic considerations:
- Exclude structural lesions (e.g., tumors, stroke) with neuroimaging.
- EEG may help rule out seizures or encephalopathy.
- Genetic testing for familial hemiplegic migraine if indicated.