After a period of severe exertion (moving furniture for 30 minutes), he had a typical attack and was admitted to the hospital. During the examination, he complained of excruciating right-sided throbbing headache and photophonophobia. His blood pressure was 129/81 mm Hg; his heart rate was 72 beats/min; and he was afebrile. The results of his general medical examination were normal. On neurologic examination, his mental status was normal. He had mild nonfluent aphasia, right-sided central facial paresis, hemiparesis (3/5), hemihypesthesia (50%), hyperreflexia, and extensor plantar response. Headache and neurologic deficits lasted for 1 day and resolved spontaneously within 1 hour. The results of the following laboratory tests and determinations were normal: complete blood cell count, general chemistry profile, coagulation studies, protein C, protein S, antithrombin III, anticardiolipin antibody, erythrocyte sedimentation rate, C-reactive protein, antinuclear antibody, serum pyruvate, serum lactate, thyroid function test, urinalysis, urinary drug screen, radiography of the chest, electrocardiography, transesophageal echocardiography, electroencephalography, computed tomography of the brain, magnetic resonance imaging with contrast (during the period of hemiparesis), and cerebral angiography. A typical attack was provoked by 20 minutes on a cardiac treadmill, but the results of the patient's cardiac and blood pressure monitoring were unremarkable. He had a mild headache, mild nonfluent aphasia, right-sided central facial paresis, hemiparesis (4/5), hemihypesthesia (75%), hyperreflexia, and extensor plantar response. His headache and neurologic deficits lasted for a few hours and resolved spontaneously within half an hour. He was treated with a combination of warfarin, aspirin, pentoxyfylline, phenytoin sodium, and amitriptyline hydrochloride for 2 years, but continued to have recurrent attacks (about 10). Subsequently, all his medications were discontinued, and he was treated with sustained-release verapamil (240 mg/d). He had complete relief of headache and hemiplegic attacks and remained asymptomatic for the following year.