The patient is an 18-year-old female high school student previously diagnosed with migraine and schizophrenia. She was brought to the Emergency Department by her family due to acute agitation, confusion and episodes of crying and laughing.
Upon initial assessment, the patient was observed to have catatonic features, such as psychomotor retardation, stupor, selective mutism and ambivalence. No psychotic or mood features were observed at that time. The patient’s mother reported that the patient was doing fine until three days prior to her presentation. The patient fainted on the bus on the day of her final exam. Her mother described psychomotor retardation, regressive behaviour, hyperphagia and perseveration of speech when attempting to communicate with the patient. She was concerned when the patient was unable to identify her family members and would shift from sobbing to inappropriate laughter spontaneously. The patient was started on lorazepam in the Emergency Department and subsequently improved.
Upon admission to the psychiatric ward, the patient reported no recollection of the events that took place after her collapse and did not comprehend the reason behind her admission.
She reported that prior to fainting on the bus, she was experiencing a severe migraine attack with motor weakness. She stated that she had fainted around five times in her lifetime, usually after experiencing a severe migraine.
The patient started having migraine attacks three years ago. She had headaches almost daily and had multiple visits to the Emergency Department requiring intravenous paracetamol to relieve her headaches. The patient’s migraines were mainly right-sided and were usually accompanied by right-sided eye pain, tinnitus, upper and lower limb weakness, and dizziness. She disclosed that sometimes she heard voices while experiencing severe headache episodes. She elaborated that she heard the voice of one male speaking in "their own language" that only she can understand. Once the headache resolved, the voice stopped after nearly 24–48 hours.
She complained of the following symptoms that typically appear before the headache starts: tearing of the right eye, shortness of breath, circles of light, bilateral tremors in the hands and feet, blurry vision, and occasionally slurred speech and stuttering.
Upon examination, no papilledema was observed. The neurological examination results were normal. Computed tomography was performed and was significant for mildly prominent bilateral lateral ventricles with no periventricular ooze, suggesting increased intraventricular pressure. Magnetic resonance venography and magnetic resonance imaging were performed, and no abnormalities were noted.
The patient was initially managed for her migraine with the nonsteroidal anti-inflammatory drugs, amitriptyline and topiramate. Neither of the agents were effective, and the patient was recently started on prophylactic botulinum toxin injections, which had mild effects that wear off after a month.
The patient’s first encounter with mental health services was a year ago, when she was diagnosed with schizophrenia. She reported complex visual hallucinations and second-person auditory hallucinations. The patient was insightful about these hallucinations; however, there were few incidents where she lacked insight and could not tell if these hallucinations were un-real. She also reported feelings of paranoia, specifically of being watched and followed, but never to a delusional level. The patient denied experiencing delusions of passivity or delusions of though control.
The patient was started on olanzapine 5 mg a year ago. She stated that olanzapine improved her sleep, increased her appetite, and reduced the auditory hallucinations accompanying her migraines. At a later visit, the patient disclosed that she stopped taking olanzapine and started taking fluoxetine as advised by her friend. She reported that this change caused improvements, such as less anxiety and irritability.
The patient stated that she was physically abused by her father when she was 15 years old. She specifically highlighted an incident where the father slapped her face forcefully, which initially affected her facial sensations in the side where she was slapped. She started physiotherapy, but it was unsuccessful, and ultimately culminated in the onset of her chronic migraines. Her parents separated during this period.
She denied any family history of mental illness and denied substance misuse.
The patient had no significant medical problems other than chronic sinusitis.
There was no history of head trauma or meningitis or a known family history of migraine or psychiatric illness.
The patient had achieved normal milestones as a child.
The patient was discharged from the psychiatric unit with a diagnosis of sporadic hemiplegic migraine-induced psychosis and was prescribed lamotrigine 25 mg twice daily. During outpatient follow-up, the dose of lamotrigine was gradually increased until the patient reached a dose of 250 mg. She reported more than 50% improvement in headache severity and frequency, which eventually resolved her psychosis. The patient developed an itchy rash at this dose, and the dose was reduced to 200 mg, which provided a similar response as per the patient’s report. She also reported gastrointestinal side effects that were successfully managed by dividing the dose to thrice daily administration and taking it after meals.