Three children, ages 13 to 17 years, with occipital seizures resembling the visual aura of migraine are reported from St Thomas’ Hospital, London, England. Case 1, a 14-year-old boy with weekly episodes of visual hallucinations beginning at age 8, first complained of concentric spherical rings of red and yellow moving from left to right visual field, without impaired consciousness, convulsion, or headache. After age 10 years, the visual hallucinations were followed by left-sided tonic deviation of the head and clonic movements of left face and arm, accompanied by loss of consciousness, post-ictal sleep and headache. Interictal EEGs and MRI were normal. Carbamazepine started at age 11 years prevented further attacks. Cases 2 and 3 also had visual hallucinations accompanied by headache and either loss of posture or convulsive movements; MRIs were normal, EEGs showed no epileptiform activity, and carbamazepine controlled attacks in one. The other patient refused treatment and attacks continued. [1]

COMMENT. The interpretation of the visual hallucinations in these three children as epileptic events, and differing from migraine, is based on clinical manifestations, including the brevity of the symptom, multicolored patterns rather than black and white, onset on the same side, lack of photophobia, mild post-ictal headache, and response to antiepileptic medication. The lack of epileptiform activity on interictal EEGs is troublesome, and a positive video-EEG recording during an attack would have been more convincing. The authors stress the need to evaluate visual hallucinations both quantitatively and qualitatively to distinguish epilepsy, and especially benign childhood occipital seizures, from migraine phenomena.