CWH B0216575

 A

Key features from the vignette:

• Transient R-sided weakness + slurred speech for ~2.5–3 h

• Right-sided headache behind eye afterwards

• History of migraines on Pizotifen

• Normal neuro exam now

• MRI brain normal

• Presented later with lightheadedness and tachycardia

Top 3 Differential Diagnoses

1. Hemiplegic migraine

   • Migraine with transient unilateral weakness and speech disturbance.

   • Fits migraine history and headache after neurological symptoms.

2. Transient ischemic attack (TIA)

   • Transient focal neurological deficit lasting <24 h.

   • Must always be excluded even if imaging normal.

3. Carotid artery dissection

   • Can cause unilateral headache (often behind eye) + transient neurological deficit.

   • Important cause of stroke in younger patients.

Top 3 Tests

1. CT angiography of head and neck

   • To assess carotid/vertebral arteries for dissection or stenosis.

2. Electrocardiogram + cardiac monitoring

   • Look for arrhythmias (e.g., atrial fibrillation) causing embolic TIA.

3. Carotid Doppler ultrasound

   • Evaluate carotid stenosis or dissection.

✅ Most likely overall: hemiplegic migraine given migraine history + normal MRI, but TIA must be ruled out first.

If you'd like, I can also show how examiners expect you to structure answers for neurology OSCE/SAQ questions like this (there’s a common scoring pattern).