A 23-year-old male presents to the emergency department (ED), thinking he is having a stroke. He has hemiparesis on the right side — tingling, numbness, weakness and ataxia in his right hand and arm as well as paralysis on the right side of his face, which is causing his speech to be slurred. He reports an excruciating headache and nausea and is photosensitive. He has a temperature of 101.5 °F. He can communicate that his symptoms "came out of nowhere" and hit him "like a ton of bricks."

A friend has accompanied him to the ED and says the patient has had two other attacks similar in nature over the past 9 months, both of which are comparable in presentation to this one, but onset of symptoms was more gradual, over at least 30 minutes. He reports extreme lethargy in the day or two prior to these attacks. After the first attack, his motor symptoms lasted about 3 hours. But after the second attack, it took several weeks for his symptoms to resolve fully — well after the headache had resolved. Both times, they have occurred during very stressful periods, usually related to mid-term/final exam week at school and working extra hours.

The patient is a first-year law student. In addition to going to school full-time, he works as a clerk in a legal office to support himself. He is often under acute stress and reports habitual lack of sleep. He has a negative family history of headache or any neurologic conditions. He has no additional comorbidities. Routine laboratory bloodwork is unremarkable.