A 14-year-old girl who presented with yearly attacks of bilateral internal ophthalmoplegia, nausea and headache since the age of 9 is the subject of a case report from the Department of Child Neurology, University Hospital Nijmegen, The Netherlands. She complained of blurred near vision when reading, associated with photophobia, phonophobia, nausea and aspirin-resistant bitemporal headaches. Attacks lasted 1 to 7 days. The pupils were symmetrically dilated during the attack and there was no response to direct or consensual light with complete loss of accommodation. The father and paternal aunt had migraine. [1]

COMMENT. The authors note that ophthalmoplegic migraine with bilateral mydriasis has not previously been described in children. A single ischemic lesion localized in the central parasympathetic nucleus of Perlia and the Edinger-Westphal nuclei is proposed as the likely mechanism for the bilaterality of the mydriasis. Other causes including drugs, deodorant-antiperspirants, perfumes were excluded.

Unusual clinical manifestations of migraine are reviewed by Ehrenberg BL [2]. Some patients have headaches without aura, some have confusional spells, memory lapses and episodes of speech arrest resembling complex partial seizures. Basilar migraine is manifested by auras of vertigo, dysarthria, tinnitus, decreased hearing, diplopia, disturbances in both visual fields, bilateral sensory loss or weakness, or alterations in consciousness. The syndrome of benign epilepsy of childhood with occipital paroxysms is preceded by hallucinations or visual loss and associated with occipital spike-wave activity on interictal EEG. Episodes with auras or hallucinations lasting 5 to 60 minutes resemble migraine attacks. Numerous studies show a high incidence of EEG abnormalities in large populations of migraine patients [3]. A beneficial response to phenytoin in this and other studies does not contraindicate a diagnosis of migraine. Migraine-epilepsy syndromes are reviewed by Andermann F [4]. These include epileptic seizures induced by a classic migraine aura and seen more often in children than in adults.