Acute Confusional Migraine: Case Reports and Discussion as a Distinct Entity

Background: Acute confusional migraine (ACM) is a migraine variant manifesting with confusion, agitation, disorientation, altered mental status, and/or memory deficits. ACM has notably been excluded from the International Classification of Headache Disorders (ICHD-3 β), despite previous literature describing 120 cases and proposing a standardized classification. Considering these findings, clinicians must be aware of this condition as it can be confounded with other serious health conditions (e.g., stroke, encephalitis, and epilepsy). Objective: Herein, we describe three cases with altered consciousness during a migraine attack, discussing diagnostic criteria, treatment, prognostic implications, and future perspectives. Results: The first case, an 18-year-old male, presented to the emergency room with migraine with visual aura, followed by confusion and torpor. After 24 h, he was completely recovered without deficits. In the second case, a 30-year-old woman in puerperium presented with a visual aura followed by headache, confusion, and disorientation. She recovered her conscience without deficits. The third patient, a 36-year-old woman, showed up in the emergency room presenting migraine, hemiplegia, and confusion. She recovered without deficits after 8 days. Finally, the genetic panel confirmed familial hemiplegic migraine (for the third patient). All the tests, including brain computed tomography (CT) scan, angioscan, brain magnetic resonance imaging (MRI), lumbar puncture (LP), and toxicological workup, had normal results for all three patients. They were treated for migraine with long-term control. Conclusion: ACM is a significant condition that can be mistaken for other serious health issues. Health professionals need to be better informed about their diagnosis and management strategies. Therefore, we proposed criteria to include ACM in the ICHD-3 β classification, and we emphasize the need for future studies to improve understanding and treatment of this condition.