Case 7 A woman with hemiplegic migraine

A 40-year-old woman, Jane, presented to a general practitioner, Dr Allen, on a Monday morning. On the previous Saturday she had been shopping with her sister when she began to feel unwell. She had had pain in her neck and the back of her head, nausea and felt clammy. Her sister had found her a seat in the shopping mall. Her sister wondered if Jane was having a panic attack, as this had happened before. Her lips and tongue became tingly and her left arm became numb. A passer-by had been called and helped Jane back to the car. Her sister drove her home and Jane spent the day in bed with a severe headache. The following day (Sunday) Jane was much better, though she still had severe headache and neck ache. By Monday she was feeling considerably better. Dr Allen noted that Jane had a history of anxiety and depression, had been taking citalopram but had recently stopped and had been prescribed sumatriptan in the past.

What would you do now?

Dr Allen checked Jane’s pulse, blood pressure, fundoscopy, walking and the power in her arms, all of which were normal. Dr Allen wondered about a diagnosis of hemiplegic migraine, possibly related to stopping the citalopram, arranged some blood tests, prescribed a tryptan in wafer form plus some tramadol and arranged review in a week. In a week Jane was better.

What would be your differential diagnosis and how would you discriminate between them?

Two months later Jane returned to see Dr Bendick, who was an ST3 general practitioner registrar in the practice. Dr Allen was his trainer. Jane had had two episodes in the interim where she had had headache and numbness affecting her right arm and leg. These had been less severe than the first episode but had scarred her as she had wondered if she was having a stroke. The numbness had lasted a day or so and headache had lasted several days, though it was only severe for a day or so. Examination was normal.

Dr Bendick decided to ask Dr Allen. Dr Allen felt that the diagnosis was hemiplegic migraine. They were initially going to prescribe propanolol but Jane pointed out that she had been told not to take propanolol (which she had been prescribed for panic attacks in the past), because she had asthma. Dr Bendrick found asthma medication in the past drugs. Dr Allen suggested pizotifen instead. Two weeks later Dr Bendick reviewed Jane. She had had no further episodes since taking the pizotifen. Dr Bendick advised continuing the pizotifen for 3 months.

Three weeks later Jane collapsed while watching her daughter’s school play. She was admitted to hospital by emergency ambulance and a head CT scan showed a large right intracerebral haemorrhage thought to be due to an arteriovenous malformation. Jane died two days later on ITU.

Jane’s husband brought a claim against Dr Bendick and Dr Allen. It was alleged that the diagnosis of hemiplegic migraine was unsafe, that the history recorded was insufficiently detailed and did not accord with Jane’s sister’s account, that Jane was taking the combined oral contraceptive pill and that this should have been stopped, and that Jane should have been referred into hospital with the first and subsequent episodes.

Do you think his claim will succeed?

Expert opinion

The diagnosis of hemiplegic migraine was not implausible but unfortunately it was clearly unsafe (Black, ; NICE, 2008). There were also other oversights in Jane’s management which, while they did not directly cause her harm, would be likely to be considered by the Court to be indicative of substandard practice.

Dr Allen recorded a history of transient neurological dysfunction associated with headache. However, there was little recorded detail about duration of symptoms and no detail about the onset of the headache. With any transient neurological symptom the detailed history is all important in making the diagnosis and needs to be recorded in significant detail.

It would have been good practice to attempt to get a telephone history from Jane’s sister. This would have revealed that the onset of the headache was sudden, that Jane had had difficulty holding a water bottle in her left hand and had had difficulty walking to the car. There had been a suspicion of left-sided facial weakness and the weakness lasted several hours.

There was evidence in Dr Allen’s witness statement that she was reassured by the fact that examination was normal and by the fact that Jane had a past history of classical migraine. However, it is clear that transient neurological symptoms can still be due to serious underlying disease and that Jane’s history of classical migraine still only marginally increased the likelihood that the diagnosis was hemiplegic migraine but that, critically, it did not make the presumptive diagnosis a safe one. Hemiplegic migraine is one of those diagnoses that, although it figures prominently in medical teaching and textbooks, is rare.

Dr Allen was inappropriately reassured and she did not consider the necessary differential diagnoses.

If Dr Allen had looked up migraine using medical web resources she would have read that it may sometimes be safe to ascribe fully reversible hemisensory symptoms that resolve in 5–60 minutes to migraine, if the time course of the aura and headache is typical and there is a suggestive past history, but it is never safe to ascribe motor symptoms to migraine without specialist investigation to exclude other causes such as TIAs, subarachnoid haemorrhages or vasoactive tumours.

Dr Allen appears to have ‘prematurely anchored’ on the hypothesis of hemiplegic migraine and failed to consider the other possibilities.

As is often the case when a diagnosis has been made in an unsafe manner, the problem was compounded because subsequent clinicians assume it is correct. In this case Dr Bendick assumed that the diagnosis was correct. Dr Bendick, as a trainee, would be assessed by the standard of a reasonably competent fully qualified colleague.

It is relatively common that, even in training practices, careful scrutiny reveals that there are significant failings in the summarized past medical history. In this case it should have been recorded that Jane had a past history of asthma. This had already nearly resulted in significant error when Jane had been prescribed beta blockers for anxiety but had still not been recorded on the summary. Neither Dr Allen nor Dr Bendick had established that Jane was taking the combined pill, which is contraindicated with focal migraine. The Claimant experts were critical of these failings even though they led to no harm.

Legal comment

It seems that Jane’s family will be able to establish that Dr Allen was negligent in not referring her for specialist investigation after the first consultation. She also should have stopped the oral contraceptive pill. Dr Allen’s initial negligence was continued by Dr Bendrick at subsequent consultations. He had two opportunities to refer Jane, but did not take them. The fact that he is only a trainee does not mean he is judged by a lower standard. He is judged by the standard of the ordinary competent GP (see Expert comment above).

The two doctors’ MDOs will wish to investigate what the outcome would probably have been if Jane had been referred at the first consultation. In investigating causation, their expert will be asked to consider the following questions: when would she have been investigated, and what would the investigations have shown?; what treatment would have been given?; would death have probably been avoided?

If the answer to this last question is yes, then Jane’s husband and children will have a good claim. They will be entitled to bereavement damages of £11 800 and a sum representing the unnecessary pain and suffering she experienced before she died. Her children will have a claim for the loss of their mother’s love, care and support during their childhood. Her husband will have a claim to cover the loss of the care Jane provided to him. The family will also be entitled to compensation representing her financial contribution to the household.

The value of this claim will depend on Jane’s earning power and other features of her family life, but it will most likely be worth in excess of £100 000 and could be significantly more.

Stay updated, free articles. Join our Telegram channel

Join