Clinical characteristics of Alice in Wonderland syndrome in a cohort with vestibular migraine

Abstract

BackgroundAlice in Wonderland syndrome (AIWS) is a rare sensory perception disorder, most often caused by migraine in adults. We aimed to characterize the clinical characteristics of AIWS in a cohort of vestibular migraine (VM) patients.MethodsRetrospective chart review of patients diagnosed with VM seen between August 2014 and January 2018.ResultsSeventeen patients were identified (10 women) with a median age at onset of 45 years (range 15–61 years), and median age at presentation of 49 years (range 17–63 years). Eighty-two percent reported 1 AIWS symptom, 12% reported 3 symptoms, and 6% described 2 symptoms. The most common symptom was visual distortions (47%), followed by extrapersonal misperceptions (41%) and somesthetic distortions (29%). Most AIWS occurred during VM episodes (77%). Eleven patients were seen in follow-up; 10 described complete or partial resolution of both AIWS and VM with migraine preventive therapy, while 1 experienced complete resolution of VM but continued to have AIWS. Neuro-otologic abnormalities improved in 2 patients.ConclusionsThis study characterizes the clinical features of AIWS in patients with VM. We observed several rare and highly unusual AIWS misperceptions (frosted-glass vision, underwater vision, dolly zoom effect, sensation of the brain coming out of the head, closed-eye visual hallucinations, and headlight glare–induced marco/microsomatognosia), and resolution or improvement in AIWS and VM with migraine preventive treatment.

The Spectrum of Vestibular Migraine: Clinical Features, Triggers, and Examination Findings

“…Fascinatingly, VM episodes were associated with Alice in Wonderland syndrome (AIWS) dysperceptions as well (Table ); 6.9% described extrapersonal misperceptions (out‐of‐body experience, derealization), 6.9% reported visual distortions, and 3.1% experienced somesthetic distortions. These dysperceptions are described in detail elsewhere …”

“…These dysperceptions are described in detail elsewhere. 69 Interictal Symptoms.-During the interictal period, vestibular symptoms were also extremely common ( Table 7). The vast majority described some degree of VID (88.6%), and experienced dizziness with a variety of visual stimuli, most commonly supermarket aisles, busy patterns, movies (3D, IMAX, and action), first-person shooter videogames (where the player sees the action through the eyes of the avatar), scrolling on electronic screens (eg, smart phones, tablets, and computers), optic flow (eg, driving past a row or trees or concrete barriers), and rapidly moving or spinning objects (eg, windshield wipers, and ceiling fans).…”

“…AIWS misperceptions were also described, and consisted of visual distortions, extrapersonal misperceptions, altered time perception, and somesthetic distortions. 69 Persistent sensitivity to light (10.7%), odors (6.1%), and sound (2.3%), as well as cognitive slowing, fatigue, and visual snow were experienced in the interictal period as well.…”

Vestibular migraine — an underdiagnosed cause of vertigo. Diagnosis and treatment

“…Some patients report tinnitus, fullness of the ear, palpitations, and even mild and transient hearing loss, during their episodes [18]. Several authors have described an accompanying Alice in Wonderland Syndrome -a rare and fascinating sensory perception disorder, with the symptoms of visual distortions, extrapersonal misperceptions, or somesthetic distortions [16,45]. Some studies show that VM patients are significantly more anxious and agoraphobic, have depression symptoms and insomnia, have higher sensitivity to separation, and are prone to seek medical reassurance [16,46].…”

Alice in Wonderland syndrome (AIWS): A research overview

“…For example, a case of abdominal colic was found to have occurred with AIWS [18]. Another study reported that nearly 77% of AIWS occurred during the vestibular migraine [19]. .…”