Jayaprakash A Gosalakkal
Consultant Paediatric neurologist
UHL Leicester UK LE15 WW
E-mail: jayprakash.gosalakkal@uhl-tr.nhs.uk
 

Abstract:
Confusional migraine, a disorder that is mainly encountered in childhood, has not been categorized by the International headache society. It is a rare form of migraine, which should be recognized in order to avoid diagnostic errors and unnecessary investigations. Many have pointed out the similarities between Transient global amnesia in adults and acute confusional migraine in children. Diagnosis is clinical and EEG changes are non specific .

Keywords: Confusional migraine, paediatric.

Introduction

Acute confusional state (ACS) as a manifestation of migraine in the paediatric age group was initially described by Gascon and Barlow in 1970(1) Confusional migraine, a disorder that is mainly encountered in childhood, has not been categorized by the IHS (International headache society) (2). It is a rare form of migraine, which should be recognized in order to avoid diagnostic errors and unnecessary investigations.

Incidence:
In a study of 76 patients Shabbat et al (3) found 13 cases of confusional migraine. The age ranged between 6 and 15 years (mean age 10.8 years). All patients reported headache and confusion. In a larger study Al-Twaijiri et al found of a total 1,106 patients with migraine, 108 patients with migraine equivalents of which five had acute confusional migraine (4.6%). In acute confusional migraine, there was no clear female predominance (4).

Pathogenesis:
Nesu et al in a study of 3 cases of confusional migraine found that although MRI and MR angiography showed no abnormal findings, IMP-SPECT performed within 48 h of migraine attacks revealed a regional change in cerebral blood flow, which in one case demonstrated hypo perfusion in the left posterior cerebral artery (PCA) territory. They felt SPECT was helpful for the diagnosis of Acute confusional migraine and speculated that transient hypoperfusion affecting the dominant-sided PCA territory involving the medial temporal structures was responsible for the confusion with amnesia in ACM (5). Many have pointed out the similarities between Transient global amnesia in adults and acute confusional migraine in children (6). Interestingly similar periods of confusion have been described in adults with left-sided posterior cerebral artery infarction. (7)
Clinical features: Typically periods of confusion occur with headaches. The duration of confusion can last from several hours to weeks (8). In some instances periods of confusion are precipitated by minor head injury. Confusional attacks are often replaced after a while by typical migraine attacks (9). In a study of twelve patients with episodes of acute confusional migraine (ACM) Pietrini et al reported (10) prolonged agitation and mental confusion with the headache attacks, occurring mostly among adolescents.

 
EEG changes:
The EEG during the episodes have been said to show diffuse, slow abnormalities and a peculiar pattern known as FIRDA (frontal intermittent rhythmic delta activity). After the acute stage, EEG gradually tended to show normalization. Soriani et al (11) described an uncommon electroencephalographic pattern recorded during the episodes, characterized by diffuse continuous beta activity in a patient. Tinuper et al (12) reported in a case of confusional migraine that the ictal EEG showed slow waves over the left hemisphere, the abnormality gradually clearing up during the four days following the attack. The EEG is currently not considered as sensitive and specific to make diagnostic determination.

Treatment :
Sleep: Parrino et al (13) drew attention to the positive effect of sleep in terminating attacks of acute confusional migraine (ACM) in two adolescents. They observed that in both cases the episodes ended when the patients fell asleep spontaneously. The post- event polysomnograms displayed a regular quality and duration of the physiologic components of sleep. Random posterior slow waves occurred only during the nocturnal awakenings and REM periods.



References

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