Stroke-Like Symptoms Status-Post Tenecteplase (TNK) Administration: A Rare Case of Hemiplegic Migraine

Hemiplegic migraine (HM) is an uncommon type of migraine, often misdiagnosed as an ischemic stroke due to its similar clinical presentation. We present a case of a 39-year-old female, with a past medical history of migraine headaches, who presented to the emergency department with sudden onset left-sided facial droop and left lower extremity deficits for two hours. A CT scan of the head was negative for any acute intracranial hemorrhage. The National Institutes of Health Stroke Scale (NIHSS) score was 5, and tenecteplase (TNK) was subsequently administered. Further work-up revealed unremarkable MRI of the brain with and without contrast, sinus rhythm serial EKGs without evidence of any arrhythmias, and unremarkable troponins. The transthoracic echocardiogram (TTE) was unremarkable for any intracardiac shunts. The patient's symptoms were ultimately attributed to HM, given that the work-up for all other etiologies was ruled out. It is crucial for clinicians to perform thorough histories and physical exams for prompt detection and management of HMs and to minimize exposure to the potential adverse effects of thrombolytic agents.