Michael nicholas 129101 82 year old man admitted under the stroke team august 2025 with 2 episodes of expressive dysphagia and right sided weakness severe headache at the time and some visual disturbance in his left eye all symptoms had resolved by the. Of discharge he underwent a ct and mri head which didn't demonstrate any features of acute ischemia but did show mild small vessel disease and was discharged subsequently presented on the 2026 2 days ago it was a stroke call from suast seen by the medical registrar on arrival so seen by the medical registrar on arrival with a right sided facial droop and expressive dysphagia identical to admission in september then hss 3 on arrival and 0 within 1 hour resolution of symptoms followed by headache same as last presentation discussed with doctor france at that time likely atypical migraine rather than tia third occurrence with identical symptoms tia very unlikely and headache fits more with migraine you can see the discharge summary from september 2025 presented with 2 episodes of expressive dysphasia and left eye weakness severe headaches some visual disturbance in his left eye also no liver resolved no known weakness he had a ct and mri of the head which showed small vessel disease only blood tests from today are weighted asd are weighted full blood count are weighted blood tests from the eighteenth were all normal ct head from the eighteenth showed moderate background small vessel ischemic changes but no acute infarct no intra or extra axial hemorrhage no acute abnormality we've tried a few times and we're just we're we're gonna yeah oh okay okay I'm gonna feel a little agitated thought you were take a little bit but I'm not really sure if that's not enough okay so I think that's why I'm trying probably that code for 1 is kidney yeah if you go down to the corridor through the end doors patient should try days of yeah she's basically waking up and then she's going to get to other the the the the the the the the the the the the the hi nicholas hi in hi I'm rob nice to meet you to meet you I'm 1 of the medical registrars how are you alright good I'm glad I see you've been back and forth to us a few times with this malarkey yeah what's happened this time well I just get this terrible terrible headache headache and that's the primary thing is a headache yeah and I'm talking a lot of rubbish but I've got a rubbish load of rubbish and I know you're slurring your words oh yeah yeah he drops things and his his eyes look funny and and what way do your eyes look funny I've I've never known it no no you know he just it doesn't what I say is like a day he looks dazed then dazed yeah yeah but he did have a stroke is it was either georgia or any well you know that yeah I don't think you had a stroke there did you no I was just thinking of his neck you had a scan of your head and you had an mri scan which didn't show you had a stroke which is good wasn't it yeah we so we scanned your neck as part of it and 1 of the vessels in your neck was ever so slightly narrowed yeah but didn't look like it needed any treatment and it doesn't sound like you've had any treatment no then you've had a few more episodes similar to yeah each yeah these 2 episodes something similar to that and once they're gone but he's gonna tell me I'm okay but I never know when it's gonna come when it's gonna come again and isn't that quite good can I take something to stop it yeah and he it gets for a lot of time I know what what I wanna say but it it's not coming out won't come out funny isn't it yeah so I thought you were just gonna come up today with a really horrible attitude and when you came in 2 days what did they was not understanding from reading obviously we've got that off migraine yeah migraine sometimes you can get these funny things so migraine we don't really understand it but we know that it's and a bit of the brain is starved of blood for a brief? Of time yeah and then it causes terrible headaches and it can cause weird neurological symptoms yeah yeah which can be weakness on 1 side of the body it can be speech disturbance all kinds of things I'm but he gets very agitated with me mhmm but because he's 82 you know I don't know if that sounds silly mhmm is that a part of getting older or we don't part of having a very bad headache and not being able to get your words out yeah I think it must be very frustrating exactly yeah we're having a coffee in the in the kitchen today but is there something I could take yeah just to because paracetamol is not exactly yeah would you like me to get you something you could take because when you came in last time there was talk of getting you on some medicine which you can do to prevent this from happening a permanent sort of medicine yeah alright well sorry go on take it from me if I saw you because some you know if he's really not feeling well I'd say well I've only got paracetamol in that sorry how often will you have these symptoms well I don't know that's a trouble trouble I mean I've had them 2 days and on the eighteenth and then today yeah mhmm I might not get anything else for a week or 2 or whatever balance but I might get it tomorrow or so I don't know so that you're balancing that and I have to say be careful oh when I've got it my headache and do you still have any symptoms no no a bit of a headache headache but you're not having symptoms are you kidding me I I usually got a lot of pain in my head yeah but it's not so bad no it's gone had some you had some walking the girls going yeah some of that it's good stuff no but but we could send you over with a bottle of that yeah go on no she did have water but if I could get something that look would I can live in 60 years really she's lucky really you're pretty good I love it that lucky no cradle snatcher or something sorry no no what you're a cradle snatcher is that what it is no don't be starved oh you're nice well she was when I first met her she was 14 and I was yeah you're perfect and I was 60 but I was I good looking she was I mean be saying saying was well you did feel right I mean all together we've been together 63 years lovely yeah but apart from that we're fine and these symptoms are scary aren't they they're horrible the headache I don't know what to do with it but people with strokes don't tell me they're having headaches they don't they they get symptoms that come on suddenly you don't get a stroke I'm not 1 of the stroke doctors I don't specialise in stroke but we manage a lot of strokes as medical registrars so I actually specialise in the other end of the body but we do a bit of everything these days if you could come up with the other end if you want to help me know if you could come come up I'm on my area just gonna I can't tell you I'm just gonna tell me off and then if I do get an headache you're not gonna yeah so yeah what we usually use for these is a spray a nasal spray right and it because the brain is connected just to the nose it's called a sumatriptan nasal spray and you have it when you're getting symptoms lots of people will get a feeling do like they're gonna have you have that like you feel weird like you're gonna have the headache start for maybe half an hour before is that fair to say that's true yeah so during that. Of time you take the nasal spray and then it tries to stop the attack from happening can I get that for a minute I can get it prescribed for you then you can have it with you yeah great and that's from what from my doctor and all that yeah I can I've written something now that you can take to any pharmacy maybe you can get some tonight okay maybe not yeah and if not then you can get some in the morning oh fine to spray up your nozzle thank you so it's not gonna end get skinny and all this there's nothing I worry about so this is what so we saw we scanned your head you your ct scan was normal which is great back on the eighteenth you obviously not had that again today you've loads had of blood tests on the eighteenth they were normal as well yeah was no doubt and the blood tests today aren't nothing to worry about no excellent we had a look at everything and the stroke consultant doctor france had a look at everything and looked at your scans and we all felt that this was migraine and it fits with that because people with strokes don't have head migraines can cause really weird neurological symptoms I'm that's a main thing that you told us that shouldn't you I'm sorry wrong you're yeah everything's fine you're alright people with strokes their symptoms don't get better so quickly and they don't go on and off get a terrible attack and they're disabled and you have another terrible attack and they get more disabled so this is not what you have so I might get it in 6 months back in 20 20 something when you came into hospital you didn't have a stroke then either so that's really good news no oh stop it jeremy that's great yeah so let me get you the nasal spray yeah and you get me out of here right you can get me out of here oh yes yeah yeah that sound alright she did get some of the toilet paper chris we can get that let me go get you the nasal spray thank you very much you're always it's a pleasure it's a pleasure alright I'll come back in a minute yeah so impression migraine with or out as previous diagnosed previously diagnosed neurological symptoms completely resolved on examination no residual neurological symptoms heart sounds normal chest clear abdomen soft and nontender no peripheral edema investigations reviewed from previous admission and reassuring spent some time with the patient and his wife discussing the diagnosis and best management step plan home with sumatriptan as an abortive for migraine safety netting advice did gp yeah letter to gp dear gp I have the pleasure of meeting mister and missus nicholas in the emergency department today full stop <\n\n> They presented following a recent presentation on the eighteenth of this month where he was seen as a stroke call on admission because of speech symptoms and weakness full stop his investigations were reassuring and he was subsequently discussed with the stroke team and diagnosed with migraine with aura and discharge full stop <\n\n> He's presented today with a flare of the same symptoms again full stop <\n\n> He describes a severe left sided posterior headache which starts after a? Of aura full stop subsequently he'll develop transient neurological symptoms including speech disturbance both dysarthria and dysphagia as well as some limb weakness full stop these symptoms were completely resolved at the time of assessment full stop <\n\n> I've reassured him that we believe these symptoms to be migraine related and I've given him prescription for sumatriptan 50 mg orally to be used as an abortive for migraine and I hope this improves his symptoms full stop paragraph I'd be grateful if you could add this to his repeat prescriptions full stop yours sincerely