Investigators from Children's Hospital of Philadelphia, PA, conducted a retrospective chart review of 48 children (average age at presentation 8.1 yrs, range 5-14 yrs; 73% male) diagnosed with “Alice in Wonderland” syndrome (AWS) or “Alice in Wonderland”-like syndrome between 1993 and 2013. Micropsia occurred in 69%, teleopsia in 50%, macropsia 25%, metamorphopsia 15%, and pelopsia (objects appear nearer) in 10%. MRI and EEG were normal. Etiology was infection (viral or streptococcal sore-throat) in 33% of patients, migraine in 6%, and head trauma in 6%. A family history of migraine was elicited in 46%; 5 parents (33%) of affected patients had experienced AWS symptoms. Of 15 patients with follow-up by telephone interview, 20% had occasional recurrences, 40% had no further attacks, 40% were still having symptoms, 4 (27%) developed migraine, and 1 patient (7%) had seizures. The interval between initial diagnosis and telephone contact was an average of 6.5 yrs (range, 2.1-13.53 yrs). [1]

COMMENTARY. AWS is a disorder of childhood that affects boys more often than girls, and may subsequently ‘metamorphose’ and develop into migraine in one quarter of patients.

Headache metamorphosing into AWS. Patients with a diagnosis of childhood headache in 1983 were interviewed by telephone in 1993, 2003, and 2013. Of 28 patients monitored, headaches were ongoing in 71%, and distortions of time and space were experienced by >25% and ∼20%, respectively. There was no clear correlation with migraine, and patients with tension-type headaches also reported the AWS symptoms. Distortions of space and time persist into the fifth decade for many patients initially observed with headaches in childhood [2].