By Jennifer Bickel, M.D.
Director of the University of Kansas Medical Center Headache Clinic, Children’s Mercy Hospital, Kansas City, Kansas

THE CASE

Curtis is a 12-year-old boy who started having migraines at the age of 8. His headaches generally occur every few months and are well treated with over-the-counter medications. However, one year ago, while he was in the middle of watching television, he became confused. His mother said he was agitated and holding his head. She also said that he was speaking nonsense, as if talking in another language. She called 911 and Curtis was taken to the ER where tests were done.

A comprehensive toxicology screen was normal as was an MRI of the brain. An EEG was performed to look for seizure activity. While no seizure activity was noted, Curtis’s brain waves did have some non-specific slowing. There were no recent stressors in his life and no history of psychological problems. No clear cause was detected.

Curtis’s agitation and confusion continued until he fell asleep that evening. He awoke in the morning feeling fatigued, but otherwise back to normal. Curtis had no recollection of the event. He did, however, remember feeling a mild headache with nausea earlier in the day.

The episode has not reoccurred.

DISCUSSION

Acute confusional migraine is a condition first described in the medical literature over 30 years ago. It is considered by many to be a “migraine variant” and occurs in children of school age.

In the typical scenario, a child will have a sudden onset of agitation, language problems, amnesia and confusion. Most routine studies, such as those performed in Curtis’s case, will be negative. The symptoms almost always resolve with sleep or within 24 hours. The child will not remember the event. Acute confusional migraine may reoccur but often does not. About a third of children will report a mild head injury, such as bumping their head, prior to the event. The vast majority of children will have a personal or family history of migraine, or will later develop typical migraine headaches.

Acute confusional migraine is a “diagnosis of exclusion.” This means other conditions must be ruled out in order to diagnose it. It is important to ensure that no drug or medication has been ingested, that there is no infection, and that it is not a seizure. It should never just be assumed that a child is having a confusional migraine. At times, psychological disturbances can present in a similar fashion. However, if all the testing is normal and there is a complete resolution of symptoms and a history of migraine, acute confusional migraine is a likely cause.

There is not much known about acute confusional migraine in regard to its cause. It is not a common presentation of migraine, but I believe it is safe to say most pediatric headache specialists encounter it several times a year.

No serious complications are thought to result from acute confusional migraine. Approximately a third of children will have a reoccurrence of symptoms. Once other conditions have been ruled out, it can be treated in a similar fashion to migraine. Oftentimes a dark, quiet room, pain control and, perhaps, a sleep aid are all that is needed. In certain situations, the best treatment is to start preventive headache medications to decrease the chance of reoccurrence.

Correction

In the article “EKGs Recommended for Cluster Headache Sufferers Taking Verapamil” in the November/ December 2007 issue of NHF Head Lines, bradycardia was defined as a rapid heartbeat. Bradycardia is a slow heartbeat.