Our objective is to describe a very atypical presentation of acute migraine. Acute quadriplegia in migraine has never been described before.

We present case of a 47-year-old Caucasian female with past medical history of complex migraines who presented to the Emergency Room with complains of sudden onset of quadriplegia. This was initially thought to be secondary to an acute spinal cord infarction. Her mental status and cranial nerves exam were normal. Her motor exam revealed quadriplegia, she was hyper reflexive in all four limbs and had bilateral up going Babinski’s sign. Her sensory exam revealed abnormal sensations in C5 distribution. Her basic blood work up including electrolytes, complete blood count and liver function tests were normal. She underwent magnetic resonance imaging of brain, cervical spinal cord, thoracic spinal cord, lumbar spinal cord and spinal angiography which showed no abnormalities. Lumbar puncture was performed, and cerebrospinal fluid examination was also within normal limits. Blood work up for auto immune diseases including vasculitis, vasculopathies and paraneoplastic etiology was insignificant. She also had a normal cardiac work up and aortogram. Over the next 24 to 48 hours, the patient showed gradual improvement and on discharge she went home ambulatory with a normal neurological examination. She was started on Topiramate for migraine prophylaxis on discharge. She followed up in clinic three months later and had remained asymptomatic.

Migraine headaches can have variable clinical presentations. We concluded that this was an unusual case of complex migraine with clinical presentation similar to an acute spinal cord infarction. Emergency Room physicians and Vascular Neurologists should take into consideration atypical presentations similar to our case when evaluating patients in the Emergency Room. Correct diagnosis is of utmost importance for accurate and timely treatment.