Atypical Presentation of a Migraine in a Chiropractic Clinic: A Case Report
Shawn M. Neff, DC, MAS, FACO1, 2, Brittany C Garcia3
1 Staff Chiropractor, Martinsburg Veterans Affairs Medical Center, Martinsburg, WV
2Adjunct Faculty, Palmer College of Chiropractic
3 Student, Palmer College of Chiropractic
Published: March 2017
Journal of the Academy of Chiropractic Orthopedists
March 2017, Volume 14, Issue 1
This is an Open Access article which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. The article copyright belongs to the author and the Academy of Chiropractic Orthopedists and is available at: http://www.dcorthoacademy.com. © 2017 Neff/Garcia and the Academy of Chiropractic Orthopedists.
Introduction: The purpose of this case report is to describe the management of a patient with an atypical migraine at an integrated veterans’ hospital setting. Patients often utilize chiropractic for the treatment of headaches disorders. While headaches most commonly are benign, in some cases a headache may indicate a much more serious pathology.
Clinical Features: A 41-year-old male sought care for a severe episode of acute neck pain and neck stiffness, which was accompanied by abnormalities upon neurological examination. The patient exhibited nystagmus and complained of diplopia when cardinal planes of gaze were evaluated. The patient was unable to perform heel to shin, tandem gait, finger-nose, and finger-nose-finger tests. Initially, a vertebral artery dissection was suspected, based upon the patients age, and presentation. With concerns that this patient was suffering from a stroke, he was immediately transported to the emergency department (ED) on site where further examination was performed.
Intervention and Outcome: The arteries within the cervical spine and head were evaluated via vascular ultrasound and magnetic resonance angiography (MRA) to rule out cerebrovascular accident.
Advanced imaging determined that this patient was not experiencing a vertebral artery dissection or stroke, and the patient was diagnosed with an atypical migraine. The patient’s migraine was treated in the ED with Dilaudid 1mg, Reglan IV and Compazine. He was discharged and directed to return to the chiropractic clinic the next morning. He returned to the chiropractic clinic the following morning, and he was treated utilizing diversified high-velocity, low-amplitude (HVLA) manipulation to the cervical spine. He reported relief following treatment.
This case report demonstrates the need for thorough history and neurological exam when a patient presents with a migraine in the chiropractic office and serves as a reminder that life-threatening conditions should be ruled out before proceeding with chiropractic care.
Headaches are one of the most prevalent conditions afflicting humans. According to the World Health Organization, over a one year period 47% of the global population experiences a headache disorder. This condition can be incapacitating at times, accounting for 1.3% years lost due to disability among sufferers.  Among the many conditions treated by chiropractic, headaches are one of the most common reasons for visits to chiropractors. Research and anecdotal evidence supports the use of chiropractic in treating headache.  Since many patients seek chiropractic are for headache management, it is important for doctors of chiropractic to exhibit diligence and competency when examining and diagnosing this condition. 
Headaches can be the primary diagnosis, but often times they are a symptom secondary to an underlying condition.  The most ubiquitous primary headaches include migraine, which may be accompanied by an aura, tension-type, and cluster.  Secondary causes of headache are numerous and include a variety of metabolic, neoplastic, endocrine, ischemic, psychiatric, inflammatory, and traumatic conditions.  Headaches are multifactorial in their presentation and etiology, and a thorough examination should be performed to evaluate causative factors.
In recent years, attention has been placed on the possible association of headache-like symptoms with vertebral artery dissection (VAD).  VAD involves a tear in the wall of a cervicocerebral artery, which permits blood to penetrate into the wall of the affected artery, separating the layers of the arterial wall, which may cause vascular stenosis or dilatation.  Stroke is a sequelae of VAD, because the dissected artery causes cerebral ischemia and subsequent infarction.  Patients with VAD typically present with severe unilateral head and neck pain that is reportedly unlike anything previous episodes of head or neck pain. Other symptoms associated with VAD include dizziness, vertigo, double vision, and dysarthria.  The initial presentation of a patient with a VAD commonly involves headache; therefore, many patients experiencing the initial stages of VAD are thought seek chiropractic care for the management of this head or neck pain.
While the overall incidence of VAD is low, approximately 1-1.5 per 100,000 adults , it is still important for physicians to be cognizant of the clinical features of this condition. It is common for VADs to be misdiagnosed, as the clinical presentation overlaps with other more prevalent and less life threatening conditions.  Migraines represent one condition whose clinical features mimic that of VAD. 
There are currently 324.1 million people who suffer with the disorder globally.  For most health professionals, the clinical presentation of migraine is simple to recognize. Patients typically describe the headache as unilateral head pain that is “pulsating” or “pounding” in nature.  Additionally, the migraine may or may not be preceded by an aura lasting 30 minutes to one hour.  During the attack, the patient may have sensitivity to light or sound, and nausea and vomiting have also been reported.  These represent classic signs and symptoms of a migrainous attack, but sufferers may have an atypical presentation, which complicates the diagnosis. Atypical migraines are complicated clinically, because patients may exhibit abnormal findings upon neurological examination. Exam findings such as vertigo, memory loss, dysphasia, hemiplegia, visual disturbances, and ataxia may prompt the physician to consider a more ominous condition like a stroke.  Migraines are generally a benign condition, but when presenting with a more complex symptomatology can easily cloud a physician’s differential diagnosis.
Conditions that resemble stroke are appropriately called stroke mimics. “Stroke mimic is a term for a nonvascular disease process that produces a stroke-like clinical picture. The presentation resembles or may even be indistinguishable from a stroke syndrome.”  The rate of misdiagnosis due to stroke mimics varies depending on the source, accounting for anywhere between 1.3%-30%. [15, 16] In other words, one in five people are diagnosed incorrectly as having stroke regardless of gender, age, and risk factors for the condition.  According to one study by Amort et al, the most common stroke mimics are migraines (23.6%) and epileptic seizures (43.7%). 
The history and neurological examination are critical tools for the identification and treatment of patients with suspected cerebrovascular disease. The likelihood of stroke increased with the following acute neurological deficits: facial droop, arm drift, or a speech disturbance or more commonly know as FAST.  FAST is an incredibly a useful tool in screening a patient for stroke. It is a pneumonic that stands for Face Arm Speech Test. Utilization of this technique has a positive predictive value of 64-77%.  Absence of all three factors in the test decreases the odds dramatically. 
Reliability for stroke diagnosis is lowest for historical items and subjective findings, but increases with objective findings and experience and confidence of the examining practitioner.  Despite the increased odds of stroke in patients who satisfy FAST requirements, appropriate neuroimaging and other tests are still required to exclude other potentially treatable etiologies and to better define the stroke subtype. 
In the chiropractic office, a thorough history and neurological exam are paramount when a patient presents with a headache. While the headache may be unlike others they have had in the past, in some cases the dissection-related headache may resemble their usual migraine attack. 
Patient is a 41-year-old Caucasian male who was previously seen in the chiropractic clinic at a Veterans Medical Center for low back and neck pain. He was last seen 2 months prior to this visit for neck pain. He received HVLA manipulation. On a follow-up visit, he presented with a complaint of severe right-sided neck pain and headache, which began three days prior to seeking care. The pain radiated from the right suboccipital region to the right side of his head. He also related blurred and double vision which began on the morning of his office visit. He reported his vision problems to be similar to “looking through Saran wrap.“ He denied any recent history of trauma and rated his pain as a 10 on an 11-point numeric pain rating scale (NRS). The patient’s history was significant for vein varicosity in his legs. He is on Coumadin for a history of deep vein thrombosis.
Physical exam findings included a blood pressure of 129/78 and moderate-to-severe pain upon palpation of his cervical spine and suboccipital muscles. Moderate spasm was noted in the bilateral cervical paraspinal musculature. The patient exhibited nystagmus and complained of diplopia when cardinal planes of gaze were evaluated. The patient was unable to perform heel to shin, tandem gait, finger-nose, and finger-nose-finger tests.
Due to the patient’s age, history of vein issues, and abnormal neurological exam findings the chiropractor determined that a vertebral artery dissection was among the list of likely differential diagnosis. No manipulation was performed. The patient was immediately transported by wheelchair to the emergency department.
Further examination in the emergency department revealed that the pupils were 4mm bilaterally and reactive. The patient complained of worsening headache and he developed dizziness with extraocular movements and light. No nystagmus was found. No bruits were noted. No abnormality was detected on examination of the respiratory and cardiac systems. The patient’s abdomen was unremarkable. No edema was present in the extremities. The cranial nerves were intact. The patient exhibited slow movements with mild dysmetria on the right, slow movements bilaterally with several cerebellar function tests (finger to nose, diadochokinesia, and heel to shin). Muscle strength was 4/5 proximally on the left lower extremity and 5/5 on the right lower extremity and the left distal lower extremity. Bilateral upper extremity strength was rated at 5/5.
A magnetic resonance angiography (MRA) was ordered. Ultrasound of the carotid/vertebral system and also MRA head/carotids were performed to rule out cerebrovascular accident. The MRA of head and neck was normal. Carotid Doppler ultrasound was normal and no structure damage was detected.
The patient was diagnosed with a migraine headache and was given Dilaudid 1mg , reglan IV and compazine. The patient was allergic to toradol and morphine. The patient was instructed to return for further evaluation at the chiropractic clinic the following morning.
The next morning the patient related that his headache was better after medications the emergency department provided. However, the headache was “still bad.” At the follow-up appointment, he rated his pain as a 7 on the NRS. His blood pressure was measured at 125/80. Severe pain on palpation was noted in the cervical spine and suboccipital area, with moderate pain on palpation in the lumbar paraspinal musculature. Moderate to severe muscle spasms were observed in the bilateral cervical paraspinal musculature.
Intersegmental motion was evaluated utilizing motion palpation and joint hypomobilty was noted in the left sacroiliac joint, the 10th thoracic vertebral motion unit as well as the 2nd and 5th cervical vertebral motion units. The patient’s joint dysfunction was treated utilizing diversified HVLA manipulation and he reported improvement in his headache pain immediately following treatment.
In this specific case, the patient was not having a VAD, but instead was having an atypical presentation of a common condition: migraine. The characteristics of pain associated with VAD are unspecific and can sometimes overlap and resemble a migraine.  The severity of consequences associated with VAD may be life-threatening, which emphasizes the importance of examination of patients with neurological signs and symptoms regardless of the final diagnosis. Whether the patient is truly experiencing a stroke, or the more common stroke mimic the two most important diagnostic determinants are the history and the neurological exam.  These factors direct the need for advanced imaging, which provides the final diagnosis.
While it is true that common conditions occur commonly and rare conditions occur rarely, the severity of an atypical condition makes it necessary to rule out. This case report represents an exercise in clinical decision-making for patients with complex presentations in the chiropractic office.
Written consent for this publication was obtained from the patient.
The authors declare that they have no competing interests.
The authors acknowledge Christopher B. Roecker, DC for his assistance in editing this manuscript. Supported by the Department of Veteran Affairs. The contents do not represent the views of the Department of Veterans Affairs or the United States Government.
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