Management of Alice in Wonderland Syndrome in a Child with Migraine
Reassure the family that Alice in Wonderland syndrome (AIWS) is a benign, self-limited migraine aura variant that typically resolves spontaneously, and initiate standard migraine management with NSAIDs for acute episodes while considering prophylactic therapy if attacks are frequent.
Initial Assessment and Reassurance
Alice in Wonderland syndrome represents a migraine aura characterized by visual metamorphopsia (distortions in perceived size, shape, or spatial relations of objects), including micropsia (objects appearing small), macropsia (objects appearing large), and teliopsia (objects appearing distant) 1, 2. This syndrome can occur as:
- Aura preceding migraine headache - the typical presentation where perceptual distortions occur before headache onset 1
- Aura without headache - where visual distortions occur without subsequent headache, which is rare but well-documented in children 3, 4
- Persistent aura - lasting days to weeks, which is exceptional but reported 2, 3
The most critical initial step is excluding secondary causes while providing reassurance about the benign nature of this condition 4, 5.
Rule Out Red Flags and Secondary Causes
Before attributing AIWS to migraine, evaluate for warning signs that would require urgent neuroimaging or alternative diagnosis 6:
- Fever or signs of infection - AIWS can occur with Epstein-Barr virus infection and resolves spontaneously within 48 hours 5
- Focal neurologic deficits beyond typical aura symptoms 6
- Altered level of consciousness 5
- Headache awakening child from sleep 6
- Rapidly increasing frequency or marked change in pattern 6
- Abrupt onset of severe headache 6
If red flags are present, obtain MRI (preferred over CT) per American College of Radiology recommendations, though the yield in primary headache disorders is <1% 6.
Acute Episode Management
For Active AIWS Episodes:
Provide immediate reassurance - the perceptual distortions are temporary and not dangerous, which helps reduce the child's fear during episodes 5.
For Accompanying Migraine Headache:
Start with NSAIDs as first-line treatment 7, 6:
- Ibuprofen 400-800 mg every 6 hours (dose adjusted for pediatric weight) 6
- Alternatively, naproxen sodium 275-550 mg every 2-6 hours 6
Avoid triptans in children with complex aura presentations - it is reasonable to minimize triptan use in children with basilar-type migraine symptoms or complex aura variants like AIWS, given unknown stroke risk 7. The American Heart Association specifically recommends avoiding triptans in children with hemiplegic migraine, basilar migraine, or known vascular risk factors 7.
Never use opioids or butalbital-containing compounds - these carry dependency risk and cause medication-overuse headache 6.
Prophylactic Therapy Considerations
Consider prophylaxis if AIWS episodes or migraines occur more than twice weekly 6. Evidence-based options include:
- Amitriptyline - recommended for pediatric migraine prophylaxis 7
- Sodium valproate - effective option, though contraindicated in females of childbearing potential 7
- Cyproheptadine - particularly useful in younger children 7
- Topiramate - evidence-based preventive option 7, 6
- Verapamil or other calcium channel antagonists - can be combined with aspirin if no contraindications 7
One case report demonstrated marked improvement with valproate in a patient with prolonged AIWS attacks lasting ≥7 days, with resolution of both clinical symptoms and enhanced cortical excitability on neurophysiological testing 2.
Special Considerations for AIWS
Beta-blockers should be used cautiously or avoided - these agents might worsen intracranial vasoconstriction in children with complex migraine variants 7.
Episodes may precede the development of typical migraine - AIWS can occur as isolated aura before the child develops the full migraine syndrome with headache 3, 4. This pattern does not change management but helps with prognostic counseling.
Duration varies significantly - while most aura symptoms last 5-60 minutes per diagnostic criteria 7, AIWS can persist for days to weeks in exceptional cases 2, 3. Prolonged episodes still typically resolve spontaneously or with prophylactic therapy 2, 3.
Monitoring and Follow-Up
Track headache frequency with calendars to assess treatment response and identify medication overuse 7.
Watch for medication overuse - using acute medications more than 10-15 days per month for >3 months can cause rebound headaches 7, 6.
Reassess if symptoms change - new neurological symptoms, altered consciousness, or deviation from typical AIWS pattern warrants re-evaluation for secondary causes 6, 4.
Common Pitfalls to Avoid
- Over-investigating benign AIWS - extensive neuroimaging is unnecessary when presentation is typical for migraine aura without red flags 6, 4
- Prescribing triptans for complex aura - avoid in basilar-type symptoms or hemiplegic features given theoretical stroke risk 7
- Failing to provide adequate reassurance - the bizarre perceptual distortions cause significant fear in children and families; emphasizing the benign, temporary nature is therapeutic 4, 5
- Missing infectious triggers - always check for Epstein-Barr virus if AIWS occurs with pharyngitis or fever, as this resolves spontaneously 5