‘Possessed’: Acute Confusional Migraine in an Adolescent, Prevented by Topiramate

Abstract

Acute confusional migraine (ACM) is recognized as a rare, but highly disabling migraine equivalent, mostly reported in children and adolescents. Herein we describe the case of a 12-year-old girl admitted to hospital for an acute confusional state and severe psychomotor agitation, associated with a pulsating headache and nausea, which turned out to be a manifestation of ACM. The girl was discharged on topiramate prophylaxis, titrated up to 75 mg/die; no recurrence of confusional and/or headache episodes has been reported over the last 14 months to date. Due to the rarity of this clinical entity, only anecdotal reports about acute and prophylactic treatment of ACM are available in the literature. The case reported herein suggests that topiramate seems to be effective in ACM prophylaxis, although a longer observation period in our patient and more cases are needed to confirm any long-term clinical benefit.

Acute Confusional Migraine: Distinct Clinical Entity or Spectrum of Migraine Biology?

“…Treatment : No specific therapy was mentioned in most case reports; however, some reports suggested efficacy of sodium valproate and prochloroperazine as treatment modalities for acute confusional state [ 12 , 19 , 21 , 22 ]. Prophylactic treatment with topiramate seems to be effective in the treatment of recurrent ACM [ 24 ]. Recently, propofol was given to a patient who developed confusion and agitation following headache, to achieve sedation.…”

“…Arousal, however, is usually not decreased in ACM; and other brainstem signs and symptoms such as tinnitus, vertigo, diplopia and ataxia typically seen in migraine with brainstem aura are usually absent in ACM. Some of the EEG findings reported in basilar artery migraine [ 41 , 42 , 43 , 44 , 45 , 46 , 47 , 48 , 49 ] and ACM [ 1 , 2 , 3 , 4 , 6 , 19 , 24 ] include FIRDA pattern and slow wave abnormalities in the delta theta range, however unilateral slowing in the delta-theta range has also been described in migraine with aura [ 45 ]. The presence of frontal intermittent rhythmic delta activity or FIRDA on EEG is a non-specific finding that can be found in patients with different conditions including toxic or metabolic encephalopathies and brain structural abnormalities [ 50 , 51 , 52 ].…”

“…Migraine specific treatments such as triptans and ergotamine or nonspecific treatments such as dopaminergic antagonist [ 21 ] and over-the-counter pain medications were often used. Common preventive medications such as anti-hypertensive (propranolol) [ 10 , 28 ], and anti-seizure (topiramate, valproic acid) [ 11 , 19 , 22 , 24 , 27 ] were used. These medications might be effective in the prophylaxis of ACM due to inherent ability to affect CSD [ 59 ] as well as modulate altered neurotransmission of the trigeminovascular pathway [ 60 , 61 ].…”