1
|
Molina Gutiérrez MÁ, Ventas Maestre R, Rodríguez Sánchez C, Díaz de Terán J. Clinical characterization of pediatric acute confusional migraine: a single-center case series. Acta Neurol Belg 2024:10.1007/s13760-024-02582-1. [PMID: 38755330 DOI: 10.1007/s13760-024-02582-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Accepted: 05/10/2024] [Indexed: 05/18/2024]
Abstract
INTRODUCTION Acute confusional migraine (ACM) is a rare disorder characteristic of pediatric patients. Our objective was to describe the clinical characteristics of patients diagnosed with ACM who visited our pediatric emergency department (PED). METHODS This study was a retrospective review of children who presented to our PED between January 2012 and December 2022 with a discharge diagnosis of ACM. RESULTS During the study period, 23 patients were enrolled: 11 males (47.8%) and 12 females (52.2%); median age was 10.8 years (IQR: 8.3-13.6). Eight patients reported a history of headache. The median length of stay of PED was 4.7 h. Onset was abrupt (less than 12 h) in 100% of cases. Changes in the level and content of consciousness occurred in 47.8% and 91.3% of patients, respectively; confusion (73.9%) was the most common neurological manifestation. Eighteen patients had urgent brain CT scans, none showing pathological findings. Four patients required benzodiazepines to control their psychomotor agitation. Nine patients were hospitalized, including one in the intensive care unit. Two patients underwent MRI and one patient underwent EEG during hospitalization, with normal results. DISCUSSION ACM is a rare condition in pediatric neurology characterized by acute onset of confusion or altered mental status before, during, or after migraine headache. Clinical features overlap with other neurological disorders, making diagnosis challenging. To improve the diagnosis, treatment, and research of AMC, it is essential to include it in the International Classification of Headache Disorders and establish standardized diagnostic criteria.
Collapse
Affiliation(s)
| | - Raquel Ventas Maestre
- Pediatric Emergency Department, Hospital Universitario la Paz, Paseo de la Castellana, 261, 28046, Madrid, Spain
| | - César Rodríguez Sánchez
- Pediatric Department, Hospital Universitario del Vinalopó, Carrer Tonico Sansano Mora, 14, 03293, Elx, Alicante, Spain
| | - Javier Díaz de Terán
- Headache Unit, Department of Neurology, Hospital Universitario de la Paz, Madrid, Spain
| |
Collapse
|
2
|
Womble MN, McAllister-Deitrick J, Marchetti GF, PsyD ER, Collins MW, Elbin RJ, Kontos AP. Risk Factors for Vestibular and Oculomotor Outcomes After Sport-Related Concussion. Clin J Sport Med 2021; 31:e193-e199. [PMID: 31219931 PMCID: PMC6904531 DOI: 10.1097/jsm.0000000000000761] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Accepted: 02/22/2019] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To investigate the association between risk factors and vestibular-oculomotor outcomes after sport-related concussion (SRC). STUDY DESIGN Cross-sectional study of patients seen 5.7 ± 5.4 days (range 0-30 days) after injury. SETTING Specialty clinic. PARTICIPANTS Eighty-five athletes (50 male athletes and 35 female athletes) aged 14.1 ± 2.8 years (range 9-24 years) seeking clinical care for SRC. INTERVENTIONS Participants completed a clinical interview, history questionnaire, symptom inventory, and vestibular/ocularmotor screening (VOMS). Chi-square tests with odds ratios and diagnostic accuracy were used to examine the association between risk factors and VOMS outcomes. MAIN OUTCOME MEASURES The VOMS. RESULTS Female sex (χ2 = 4.9, P = 0.03), on-field dizziness (χ2 = 7.1, P = 0.008), fogginess (χ2 = 10.3, P = 0.001), and post-traumatic migraine (PTM) symptoms including headache (χ2 = 16.7, P = 0.001), nausea (χ2 = 10.9, P = 0.001), light sensitivity (χ2 = 14.9, P = 0.001), and noise sensitivity (χ2 = 8.7, P = 0.003) were associated with presence of one or more postconcussion VOMS score above clinical cutoff. On-field dizziness (χ2 = 3.8, P = 0.05), fogginess (χ2 = 7.9, P = 0.005), and PTM-like symptoms including nausea (χ2 = 9.0, P = 0.003) and noise sensitivity (χ2 = 7.2, P = 0.007) were associated with obtaining a postconcussion near-point convergence (NPC) distance cutoff >5 cm. The likelihood ratios were 5.93 and 5.14 for VOMS symptoms and NPC distance, respectively. CONCLUSIONS Female sex, on-field dizziness, fogginess, and PTM symptoms were predictive of experiencing vestibular-oculomotor symptoms/impairment after SRC.
Collapse
Affiliation(s)
- Melissa N. Womble
- Inova Medical Group, Department of Sports Medicine, Inova Sports Medicine Concussion Program, Fairfax, VA
| | | | - Gregory F. Marchetti
- Duquesne University, Department of Physical Therapy, Rangos School of Health Sciences, Pittsburgh, PA
| | - Erin Reynolds PsyD
- Baylor Scott & White Sports Therapy & Research, Sports Concussion Center, Frisco, TX
| | - Michael W. Collins
- University of Pittsburgh, Department of Orthopaedic Surgery, UPMC Sports Medicine Concussion Program, Pittsburgh, PA
| | - RJ Elbin
- University of Arkansas, Department of Health, Human Performance and Recreation, Office for Sport Concussion Research, Fayetteville, AR
| | - Anthony P. Kontos
- University of Pittsburgh, Department of Orthopaedic Surgery, UPMC Sports Medicine Concussion Program, Pittsburgh, PA
| |
Collapse
|
3
|
Acute Confusional Migraine: Distinct Clinical Entity or Spectrum of Migraine Biology? Brain Sci 2018; 8:brainsci8020029. [PMID: 29414874 PMCID: PMC5836048 DOI: 10.3390/brainsci8020029] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2017] [Revised: 01/22/2018] [Accepted: 02/01/2018] [Indexed: 01/03/2023] Open
Abstract
The goal of this review is to explore the literature reports of acute confusional migraine (ACM) including patient characteristics, migraine symptomatology, and proposed diagnostic criteria. A literature review was conducted using PubMed, Scopus and Web of Science using the terms “confusional migraine” and “confusional state in migraine”. All the relevant articles from 1970 to 2016 were included. A total of 120 patients were found in the literature. Most of the cases were seen in the pediatric population with a slight male predominance. Personal or family history of migraine was common. Most patients had a headache prior to the confusional state. In addition to confusion and agitation, some developed visual (32.5%) and/or sensory symptoms (19%) and/or speech problems (39%) either prior to or during the confusional state. Data on treatment outcomes is lacking. Patients with most common forms of migraine report attention and cognitive disturbances but awareness remains intact as opposed to patients with ACM. ACM is a distinct entity and should be included as part of the appendix of International Classification of Headache Disoders-3 beta version (ICHD-3β) criteria. Prospective studies are needed to further study this disorder and its association with other migraine forms.
Collapse
|
4
|
Abstract
Context: An era of increased awareness of sports concussions may decrease a provider’s ability to diagnose the athlete’s actual condition and may ultimately prolong the restriction of the injured athlete from sports. Trauma-triggered migraine is a source of headaches, especially in athletes with a family history of migraines. Evidence Acquisition: Research articles were primarily obtained through the electronic database PubMed from 1993 to August 2012. Primary research parameters included trauma-induced headaches, trauma-induced migraines, and posttraumatic migraine. The secondary search parameters included concussions, migraine treatments, and traumatic migraine treatments. Study Design: Clinical review with case report. Level of Evidence: Level 5. Results: There are no symptoms that distinguish trauma-triggered migraines from concussions, as headache is the most common complaint for both conditions. There is a paucity of studies that offer treatment guidelines for athletes with recurring headaches after trauma sustained during sporting events. Preventive treatment of migraines has been validated and proven effective. Conclusion: Trauma-triggered migraine should be considered in the differential for recurrent trauma-induced headaches. There is a lack of research evaluating efficacy and side effects of treatment of trauma-triggered migraine, and no information was found directing when an athlete can safely return to play.
Collapse
|
5
|
Kontos AP, Elbin RJ, Lau B, Simensky S, Freund B, French J, Collins MW. Posttraumatic migraine as a predictor of recovery and cognitive impairment after sport-related concussion. Am J Sports Med 2013; 41:1497-504. [PMID: 23698389 DOI: 10.1177/0363546513488751] [Citation(s) in RCA: 141] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Although previous research has demonstrated that patients with posttraumatic migraine (PTM) after concussion report more symptoms and cognitive deficits after injury than do those without PTM, it is not known whether these effects persist beyond the first week of injury or whether PTM predicts recovery time. PURPOSE To determine whether PTM during the first week after injury predicts (1) cognitive impairment and symptoms in the second week after injury and (2) overall recovery time. STUDY DESIGN Cohort study; Level of evidence, 2. METHODS Participants were 138 male high school football players with a mean age of 15.96 years (SD, 1.18 years; range, 13-19 years). They were classified into 3 groups: PTM (headache, nausea, and photosensitivity or phonosensitivity), headache (headache without the other PTM symptoms), or no headache (no headache or PTM symptoms). The Immediate Post-concussion Assessment and Cognitive Test (ImPACT) was used to assess cognitive performance and symptoms at baseline, postinjury days 1-7, and postinjury days 8-14. Recovery time data were collected from medical records. RESULTS The PTM group performed worse on verbal memory than did the headache group at 8-14 days after injury. The PTM group performed worse on visual memory, reaction time, and symptoms than did the other groups at 1-7 days and 8-14 days after injury. The PTM group was 7.3 times (95% confidence interval, 1.80-29.91) more likely to have protracted recovery (>20 days) than the no headache group and 2.6 times (95% confidence interval, 1.10-6.54) more likely than the headache group. CONCLUSION Results suggest that PTM is associated with cognitive impairments and protracted recovery and that headache alone is not a good predictor of recovery.
Collapse
Affiliation(s)
- Anthony P Kontos
- Department of Orthopaedic Surgery/UPMC Sports Medicine Concussion Program, University of Pittsburgh, Pittsburgh, Pennsylvania 15203, USA.
| | | | | | | | | | | | | |
Collapse
|
6
|
Pacheva I, Ivanov I. Acute confusional migraine: is it a distinct form of migraine? Int J Clin Pract 2013; 67:250-6. [PMID: 23409692 DOI: 10.1111/ijcp.12094] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2012] [Accepted: 11/16/2012] [Indexed: 12/16/2022] Open
Abstract
UNLABELLED The International Classification of Headache Disorders (ICHD-II) - 2004 recognises many migraine variants (different from migraine without aura and migraine with typical aura), but acute confusional migraine (ACM) remains unclassified and most clinicians are not well acquainted with it. AIM The aim of this study was to illustrate ACM in the neuropaediatric practice, to discuss its place in the ICHD-II and to propose diagnostic criteria. PATIENTS AND METHODS A total of 2509 files of newly diagnosed patients, aged 0-18 years, treated as in- and outpatients in the Neuropaediatric Ward at the Plovdiv Medical University Hospital between 2002 and 2006 were screened retrospectively. Their diagnosis was based on detailed medical history, physical and neurological examination, additional functional, imaging and laboratory investigations. Migraine and migraine variants were diagnosed according to ICHD-II, but specific forms (e.g. ACM and Alice in wonderland syndrome) were also included. RESULTS One hundred and eleven patients met the diagnostic criteria for migraine. Migraine variants comprised 24.3% of all migraine cases. In particular, ACM represented 11.1% of migraine variants or 2.7% of migraine and 0.12% of all paediatric neurological diseases. Here, we report three cases of ACM with analysis of the typical clinical and EEG features, review the literature and propose diagnostic criteria. CONCLUSION ACM may present as either the only manifestation of a migraine attack or in the context of other migraine forms. ACM should have its own distinct place in the ICHD-II, may be as a subtype of migraine with complex aura.
Collapse
Affiliation(s)
- I Pacheva
- Department of Pediatrics and Medical Genetics, Medical University-Plovdiv, Plovdiv, Bulgaria.
| | | |
Collapse
|
7
|
Schipper S, Riederer F, Sándor PS, Gantenbein AR. Acute confusional migraine: our knowledge to date. Expert Rev Neurother 2012; 12:307-14. [PMID: 22364329 DOI: 10.1586/ern.12.4] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Acute confusional migraine (ACM) is a rare migraine variant, affecting children and adolescents, as well as adults. Between 0.45 and 7.8% of children with migraine present with ACM, but the disorder may well be underdiagnosed. ACM is an exclusion diagnosis and some dangerous causes of confusion (e.g., epilepsy, ischemia, hemorrhagia, neoplasm, intoxication and encephalitis) should be ruled out. The confusional state often manifests with a wide diversity of cortical dysfunctions, such as speech difficulties, increased alertness, agitation and amnesia. Exact history taking, clinical examination, and laboratory, radiological and electroencephalographical findings lead the practitioner towards the diagnosis. Approximately half of the cases may be triggered by mild head trauma. Transient global amnesia is an important differential diagnosis, possibly caused by similar pathophysiological mechanisms. The exact pathomechanism remains unclear, with the common hypothesis comprising of the confusional state as a complex aura phenomenon, in which the cortical spreading depression wave reaches not only the occipital, but also the temporal, parietal and frontal cortex, as well as the brainstem and the hippocampi, leading to transient hypoperfusion and dysfunction of these brain areas.
Collapse
Affiliation(s)
- Sivan Schipper
- Headache & Pain Unit, Department of Neurology, University Hospital Zurich, Frauenklinikstrasse 26, CH-8091, Zurich, Switzerland
| | | | | | | |
Collapse
|
8
|
Gaul C, Kraya T, Holle D, Benkel-Herrenbrück I, Schara U, Ebinger F. Migränevarianten und ungewöhnliche Manifestationen der Migräne im Kindesalter. Schmerz 2011; 25:148-56. [DOI: 10.1007/s00482-011-1021-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
|
9
|
Gantenbein AR, Riederer F, Mathys J, Biethahn S, Gossrau G, Waldvogel D, Sándor PS. Confusional migraine is an adult as well as a childhood disease. Cephalalgia 2010; 31:206-12. [DOI: 10.1177/0333102410377361] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background: Acute confusional migraine (ACM) is considered a rare migraine variant primarily seen in children and adolescents. Patients and Methods: We present a series of eight adults and two adolescents suffering from migraine attacks associated with transient confusional states. Results: Eight patients reported two or more such attacks. One of them reported mild head trauma in the past. One patient reported mild head trauma as a possible trigger. Further investigations were unremarkable in all patients and did not suggest underlying structural abnormalities, epilepsy or cerebrovascular disease. In none of these patients did we find another cause to explain the observed phenomenon. Conclusions: Based on this series of patients, we suggest expanding the concept of confusional migraine from the paediatric population to adults. The temporal course of the confusion as well as the association with visual and other aura symptoms suggest cortical spreading depression as the underlying pathophysiology.
Collapse
|
10
|
|
11
|
Bru M, Nouyrigat V, Landrieu P. Manifestations neurologiques spectaculaires après traumatisme crânien bénin : étude rétrospective de 51 enfants. Arch Pediatr 2006; 13:17-22. [PMID: 16239099 DOI: 10.1016/j.arcped.2005.09.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2005] [Accepted: 09/14/2005] [Indexed: 10/25/2022]
Abstract
UNLABELLED Mild head traumas, as a rule, remain a- or paucisymptomatic. In a few cases however, spectacular manifestations develop despite absence of intracerebral lesion. POPULATION, METHODS: We have studied retrospectively 51 such children and contacted their family in order to clarify the follow-up. RESULTS The dominant symptoms allowed to categorize the following situations: syncope-like loss of consciousness (11 cases), seizures (6), severe headaches with neurologic signs (15), confusion (8), visual disorders (6), amnesic ictus (5). Recurrences were possible but benign: in 8/11 children in the group "syncopes", in 1/6 in the group "seizures", in 5/21 in the 4 other groups. In the latter 4 groups, 11/21 children developed common migraine. Except for the only case who developed epilepsy later on, scholarship was normal in the 25 cases with sufficient follow-up. DISCUSSION Beside syncopes and seizures, the long-lasting episodes suggested a migrainous pathogeny, perhaps at a maturative stage where the trigger of migrainous mechanism is at a low level in the brain. CONCLUSION The mildness of the knock, the normality of CT scan including when the symptoms are present and the normality of both consciousness and examination once the symptoms have disappeared allow to avoid further investigations.
Collapse
Affiliation(s)
- M Bru
- Service de neurologie pédiatrique, service des urgences pédiatriques, hôpital Bicêtre, Assistance-publique-Hôpitaux-de-Paris, 94270, France
| | | | | |
Collapse
|
12
|
Solheim O, Skeidsvoll T. Transient global amnesia may be caused by cerebral vein thrombosis. Med Hypotheses 2005; 65:1142-9. [PMID: 16061328 DOI: 10.1016/j.mehy.2005.05.042] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2005] [Revised: 05/18/2005] [Accepted: 05/19/2005] [Indexed: 11/21/2022]
Abstract
Transient global amnesia (TGA) is a disorder of unknown aetiology, characterized by sudden loss of anterograde memory, in the absence other neurological signs or symptoms, followed by complete recovery in less than 24h. Precipitating actions such as strenuous physical activity or valsalva-like manoeuvres are frequently reported. Since first described in 1958, by Fisher and Adams, the possible pathophysiology has undergone much speculation. Nonconvulsive epileptic seizures, migraine, paradoxical embolism thorough a patent foramen ovale, and transient ischemic attacks have been proposed as potential mechanisms. One of the latest hypotheses is that venous congestion causes either ischemia or induces spreading depression in the medial temporal lobes. It has been demonstrated that retrograde flow in the internal jugular veins occurs more frequently during valsalva manoeuvres in TGA patients than in controls, supporting a dysfunctional venous circulation as part of the pathogenesis. However, earlier hypotheses typically fail to explain the relatively low recurrence rate of TGA, lack of comorbidity and the relation to precipitating events. If cerebral venous hypertension was the solely cause of TGA it would presumably be much more common with very high recurrence rates among those predisposed of the condition. Structural changes observed in MRI and SPECT studies along with reports of mild cognitive impairment lasting much longer than the amnestic episodes, indicate that TGA is less transient and perhaps somewhat less benign than earlier believed. Many cases of TGA seem to be associated with factors of increased risk of cerebral venous thrombosis, such as polycythemia, antiphospholipid antibodies, venous hypertension, female sex and more. We suggest that most cases of TGA may be due to small thrombi in the deep cerebral venous system. Small venous thrombi may difficult to visualize even when using modern imaging technology. Further studies of TGA patients with for example blood analysis of D-dimer together with MR venography or CT venography could be done to evaluate this new hypothesis.
Collapse
Affiliation(s)
- Ole Solheim
- Department of Neurosurgery, University Hospital of Trondheim, St. Olavs Hospital, Olav Kyrres gt 17, N-7005 Trondheim, Norway.
| | | |
Collapse
|
13
|
Answer. CAN J EMERG MED 2004. [DOI: 10.1017/s1481803500009532] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
|
14
|
Affiliation(s)
- Kirsten Bechtel
- Section of Pediatric Emergency Medicine, Yale-New Haven Children's Hospital, New Haven, CT 06504, USA.
| |
Collapse
|
15
|
|
16
|
Abstract
This article reviews the less frequently encountered varieties of migraine. It is suggested that these disorders be approached by evaluating possible underlying etiologies before positively diagnosing migraine. This decreases the likelihood of "missing" structural or metabolic disorders. The classification, diagnostic evaluation, differential diagnosis, and treatment options of these disorders is reviewed and a selection of references appended for additional information.
Collapse
Affiliation(s)
- A David Rothner
- Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH 44195-0001, USA.
| |
Collapse
|