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Complex MIgraines or Not??
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Complex MIgraines or Not??

About 4 months ago the right side of my mouth started drooping. I was having a great deal of jaw and ear pain. Went to the dr they said it was a mild case of bells palsy. It never got any worse but there were days that seemed better then others. I started having pressure on the top of my head so my neurologist did and MRI which came back normal, I also had a head ct and a mri of my spine all normal, blood work normal as well. After approx 6 weeks the drooping was gone but returned after about two weeks...it comes and goes one day it seems fine the next my lip is drooping again. Went back to the neuro who agreed it was not bells palsy because it seems to vanish then reappear. I have started having head aches so now he thinks I am having complex migraines that are affecting my facial nerves however I don't know that I feel comfortable with that. I didn't have a head ache the entire time my lip drooped for 6 weeks so I don't undertand how it could be migraines...is this possible or should I still be worried?
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Thanks for using the forum. I am happy to address your questions, and my answer will be based on the information you provided here. Please make sure you recognize that this forum is for educational purposes only, and it does not substitute for a formal office visit with your doctor.

Without the ability to examine you and obtain a history, I can not tell you what the exact cause of your symptoms is. However I will try to provide you with some useful information.

While facial drooping can occur in the setting of complicated migraine, a complicated migraine would be unlikely to cause facial drooping of several days to weeks duration in the absence of headache.

One test that may be helpful in determining whether or not there is an identifiable lesion of the facial nerve is a specific type of EMG/NCS study of the facial nerve.

In general in the setting of headache with facial weakness (and please understand I do not mean to imply that I am specifically concerned about the following in you, but just in general), one would be concerned about the presence of a mass lesion (such as a tumor or otherwise), but if the MRI is entirely normal (and if the MRI was done with contrast, the IV dye gadolinium, and adequate cuts of the posterior fossa were obtained, a specific area of the brain where the facial nerve exits the brainstem), then concern for something like a tumor is much less likely. Certain demyelinating disorders can affect the facial nerve and not be evident on MRI if the lesion is small; EMG/NCS would potentially pick up the presence of this lesion.

Other considerations would be a lesion not evident on MRI that is leading to your headaches with your facial droop, including a vascular malformation (such as one type called an AVM, or a smaller lesions such as a vascular loop around the facial nerve) or a problem at the base of the skull/in the bony part where the facial nerve traverses near the ear. Testing to investigate these disorders could include a CT angiogram, MRA, or if a venous disorder is suspected (if the headaches are occuring in the setting of oral contraceptive exposure and/or smoking), an MRV.

If structural lesions (lesions evident on imaging) are excluded, other possibilities that can lead to headache with facial nerve palsy include infectious such as VZV (varicella zoster) and HSV (herpes simplex), certain types of vasculitis that affect the cranial nerves (such as Wegner's granulomatosis), sarcoidosis, Lyme disease (if you are from an area that has Lyme), HIV, and if the pain is in the temple area and jaw, temporal arteritis. If these are suspected, testing may include blood work and lumbar puncture for CSF fluid analysis.  

If the facial drooping is intermittent (lasting minutes to hours) then resolving off and on, and there is any type of facial twitching, then concern for seizures would be present to. Another disorder that causes intermittent facial pulling (that may be confused with drooping) is called hemifacial spasm.

As you can see there are many possible causes to your symptoms; continued evaluation by a neurologist is recommended.

Thank you for this opportunity to answer your questions, I hope you find the information I have provided useful, good luck.
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