Migraine verses Bell’s Palsy: A Case Study
Submitted by Heather Rhodes, APRN-BC
Case Study: Sarah is a 38-year-old African American woman who presented to the clinic with sudden onset left sided facial paralysis after having a migraine headache for two days unrelieved by Imitrex. She has a history of migraine headaches, COVID-19 infection in 2021, hypertension, and asthma. She recently located to the area to help care for her ailing mother. She took a new position working full time as an accountant. She has been experiencing significant stress from the move, the new job and from caring for her mother. She currently is taking Lisinopril for her hypertension and ProAir HFA for her asthma. Vital signs are stable. She is afebrile.
Migraine. Migraine headaches are considered a central-nervous-system (CNS) disorder with cortical spreading depression (CSD) explaining pain pathology (Bhaskar, Saeidi, Borhani & Amiri, 2013). Migraine headaches are episodic resulting from “CNS dysfunction that leads to activation of the trigeminal vascular system” and is characterized by either acute or gradual onset of severe pain that last between 4-72 hours (Bhaskar, Saeidi, Borhani & Amiri, 2013; May, 2018). Other prodromal symptoms may include visual disturbances, fatigue, fluid retention, nausea/vomiting, photophobia and aura with retina migraine (transient blindness) being a rare variant (Bhaskar, Saeidi, Borhani & Amiri, 2013; May, 2018; Mayhew & Carhart, 2015).
Treatment for migraine headache includes Triptans, beta-blockers and nonsteroidal anti-inflammatory drugs (NSAIDs) for acute attacks (Bhaskar, Saeidi, Borhani & Amiri, 2013; May, 2018). Sumatriptan (Imitrex) nasal spray is categorized as a triptan. This classification of drug is considered a selective serotonin receptor agonist. They work by stimulating serotonin, reducing inflammation, and constricting blood vessels (Lexicomp, 2018). Sumatriptan nasal spray has a rapid onset of 15 minutes with a half-life of one to four hours. It is metabolized by the liver and excreted in the urine. Adverse reactions (nasal spray) includes rhinitis, dizziness, nausea, unusual taste and local irritation. Sumatriptan is contraindicated in patients with ischemic heart disease or history of cerebrovascular syndromes, use within 2 weeks of discontinuing an MAO type A inhibitor or in patients with severe hepatic impairment (Lexicomp, 2018). Patients should administer this medication at onset of symptoms and if the migraine has not resolved, the patient should repeat the dose in 2 hours. The patient should not take more than 40mg in 24 hours. The patient should call or come back in if the patient is having more than 4 migraines in a month (Lexicomp, 2018).
Although it is not fully understood how beta-blockers prevent migraine headaches, the thought is that improving blood flow to the brain positively impacts prevention. Propranolol (Inderal) is a non-selective beta-adrenergic blocker. It is metabolized by the liver and excreted in the urine. Onset of action is 1-2 hours with rapid and complete absorption (Lexicomp, 2018). The half-life of propranolol is 3-6 hours, and it is excreted primarily in the urine. (Lexicomp, 2018). Patients should take this medication every 6-8 hours. Patients with low blood pressure may not be able to tolerate this medication, and should be cautioned that it can cause drowsiness, fatigue, vertigo and lethargy. It should not be prescribed in patients who have a history of hypersensitivity to beta-blockers, sick-sinus syndrome or heart block greater than first degree. Propranolol should not be abruptly stopped (Lexicomp, 2018).
Bell’s Palsy. The most common cause of acute unilateral facial paralysis is Bell’s palsy (Moonery, 2013). This is a self-limiting neurologic condition resulting from inflammation of cranial nerve VII (Mayhew & Carhart, 2015; Mooney, 2013). Cranial nerve VII innervates the stapedial (stapes) muscles of the middle ear (hearing), tongue (taste), eyelids (blinking), mouth, cheeks (smiling and frowning) and tear glands (lacrimation and salivation) (Moonery, 2013; Woo & Robinson, 2016). It is important to note that patients who are presenting with Bell’s palsy do not have arm drift, altered level of consciousness, paralysis of any limbs or unequal pupils whereas patients who are presenting with stroke will more likely have these presenting symptoms (Mayhew & Carhart, 2015).
Although an exact cause for Bell’s palsy has not been identified, herpes simplex type 1 and varicella zoster virus are highly suspected (Mayhew & Carhart, 2015). Other possible causes include bacterial infection of the ear, stress, vascular ischemia and autoimmune disorders (Mayhew & Carhart, 2015; Mooney, 2013). Cranial nerve VI travels through the temporal bone via the z-shaped Fallopian canal in the skull (Moonery, 2013; NIH, n.d.). This canal is approximately three centimeters long. This pathway is unforgiving and if inflammation of the nerve occurs along this pathway, impingement (much like compartment syndrome) occurs and if left untreated can cause permanent damage with loss of nerve function (Mayhew & Carhart, 2015).
Treatment for Bell’s palsy is primarily supportive with a 90% full recovery rate (Mayhew & Carhart, 2015). According to Mooney (2013), the National Institute for Health and Care Excellence (NICE) (2012) guidelines recommend corticosteroid therapy as a first line treatment option with Prednisolone being the first option. It “decreases inflammation by suppression of migration of polymorphonuclear leukocytes and reversal of increased capillary permeability” (Lexicomp, 2018, p. 1721). It is rapidly absorbed, metabolized by the liver and excreted in the urine. Its half-life is 2 to four hours (Lexicomp, 2018). Adverse reactions with this medication include edema, hypertension, increased bruising, glaucoma, epistaxis, headache, nervousness and vertigo (Lexicomp, 2018). Patient should monitor weight. If the patient is diabetic, he/she should also watch blood sugars closely as prednisolone will affect them.
The other recommended treatment option is antiviral agents such as acyclovir (Zovirax) to help shorten the course of Bell’s palsy (NIH, n.d.). This medication “inhibits DNA synthesis and viral replication by competing with deoxyguanosine triphosphate for viral DNA polymerase and being incorporated into viral DNA” (Lexicomp, 2018, p. 45). It is poorly absorbed, metabolized by cellular enzymes, has a half-life of less than 3 hours and is excreted in the urine (Lexicomp, 2018). It is contraindicated in patients who have hypersensitivity to acyclovir. Patients should be monitored for neurotoxicity (i.e., tremors, confusion, agitation, etc) and it should be cautiously used in patients with renal impairment.
Case Study: Sarah was found to have Bell’s Palsy and was prescribed an oral steroid and acyclovir (Zovirax). After four weeks, she fully recovered from her symptoms and was able to return to work without restrictions.
Understanding the difference between migraine headaches and Bell’s Palsy will help drive appropriate care and treatment options for improved outcomes and a more rapid recovery.
- Bhaskar, S., Saeidi, K., Borhani, P., & Amiri, H. (2013). Recent progress in migraine pathophysiology: Role of cortical spreading depression and magnetic resonance imaging. European Journal of Neuroscience, 38(11), 3540-3551.
- Lexicomp. (2018). Drug information handbook for Advanced Practice Nursing (27th ed.). United States: Wolters Kluwer.
- May, A. (2018). Hints on diagnosing and treating headache. Deutsches Aerzteblatt Internatinal, 115(17), 299-308. doi: 10.3238/arztebl.2018.0299
- Mayhew, G., & Carhart, E. (2015). Differential diagnosis: Bell’s palsy vs. stroke. EMS World,44(9), 47-53.
- Moonery, T. (2013). Diagnosis and management of patients with Bell’s palsy. Nursing Standard, 28(14), 44-49.
- National Institute of Neurological Disorders and Stroke (NIH). (n.d.) Bell’s Palsy Fact Sheet. Retrieved from https://www.ninds.nih.gov/Disorders/Patient-Caregiver-Education/Fact-Sheets/Bells-Palsy-Fact-Sheet
- Woo, T. M, & Robinson, M. V. (2016). Pharmacotherapeutics for Advanced Practice Nurse prescribers (4th ed). Philadelphia, PA: FA Davis Company