Confusional Migraine: What Is It And How Is It Treated?

It is estimated that about 12%¹ people have experienced migraines or severe headaches, and anyone who has can attest to how disruptive to daily life they can be. One rare type of migraine is called a confusional migraine, or acute confusional migraine (ACM), and it impacts children and teenagers more commonly than adults. 

Research is still in its early stages regarding this particular condition, but there are some helpful treatment options for those suffering from ACM. Learn more about how to spot the signs of ACM, its causes, and how doctors can treat it for you or your loved one. 

What is a confusional migraine?

Migraines commonly produce severe headaches, and sometimes they can cause a person to have sensitivity to light and sound or experience nausea and vomiting. A confusional migraine can cause those same effects, but they can also cause confusion.

Confusional migraines are considered a migraine variant,² meaning that it is a migraine that creates symptoms in addition to a headache.

Not much is known about ACM due to a limited number of reviews and case studies. However, some research³ has uncovered preliminary information about the causes of ACM and how to treat it safely and effectively. 

Who is usually affected by ACM?

General migraines tend to impact people in their 30s the most, and women are three times more likely than men to suffer from them. When it comes to ACM, however, children and teenagers are most commonly affected.

It is currently estimated that somewhere between 0.45% and 7%⁴ of children that have migraines show symptoms consistent with ACM, but some believe that ACM is underdiagnosed. Children between the ages of 5 to 17 make up about three-fourths of ACM cases, but approximately 17% of those who experience confusion migraines are over 18 years old. 

There also appears to be a slightly higher prevalence of ACM in males than females. 

Symptoms of acute confusional migraines

Confusional migraines present some of the same symptoms as regular migraines, and they often start as a headache. In addition, confusional migraines can also produce the following symptoms:

• Disorientation

• Agitation

• Confusion

• Speech issues

• Blurred vision

• Auras

• Memory problems

While regular migraines can sometimes last between 4 to 72 hours when untreated, confusional migraines usually last for less than 24 hours. Some people may only display confusion for as little as a few minutes, but others may experience symptoms for even longer. 

Some people experience headaches before or during confusion symptoms, while others may not experience headaches at all. After a confusional migraine resolves, people often feel brain fog, mood changes, and extreme fatigue. 

It is typical for people to fall asleep after a confusional migraine episodes also common for people to forget the confusional migraine attack, which may make it difficult to identify triggers that bring about migraines for these sufferers. 

Are confusional migraines different from photo epilepsy?

ACM is diagnosed by exclusion, meaning that several other conditions with similar symptoms must be ruled out first. These conditions may include infection, metabolic abnormalities, and seizures.

Photosensitive epilepsy is a condition that can present as confusional migraines and vice versa. This is because people with photosensitive epilepsy sometimes experience headaches before a seizure and show confusion and other symptoms similar to confusional migraines during a seizure.

This may include cognitive impairments and lethargy, as well as feeling confused or experiencing memory loss after the seizure.

Migraine and epilepsy share some mechanisms, but it's important to get a diagnosis to determine whether you have ACM or photosensitive epilepsy to improve your chances of getting proper treatment. 

To properly diagnose ACM, your doctor may order several tests and images to look for other causes of migraines and confusion, which can include blood tests, MRI and CT scans, and an evaluation of your past medical history and family history. This may help to rule out other causes of your symptoms. 

There are currently some efforts by researchers to develop classification criteria to better screen for and diagnose confusional migraines and ACM. However, that may still be several years away because ACM impacts such a small portion of the population. 

Causes of ACM

Not much is known about the potential causes of confusional migraines, but there does appear to be a link between a history of mild head trauma and ACM. Some researchers also believe there may be an association between emotional stress and confusional migraines. 

Regular migraines seem to run in families, and ACM appears to be more common in those that have a family history of migraines. More research is needed to better establish potential causes of confusional migraines in both adults and children. 

Triggers

Although it appears that ACM may be associated with mild head trauma, they don't appear to be triggers that specifically bring on confusional migraines instead of regular migraines. For this reason, it may be helpful to avoid triggers that commonly bring on regular migraines to avoid confusional migraines as well. 

Some of the most common triggers people with migraines experience are:

• Certain foods, like salty and processed foods

• Food additives, like artificial sweeteners and MSG

• Changes in weather

• Changes in sleeping patterns

• Stress

• Vigorous physical activity

• Alcoholic drinks

• Caffeine

• Dehydration

• Strong smells

• Light

Triggers can be highly variable, so it may be helpful to take note of what possibly brought on a confusional migraine episode, provided you can remember what you were doing or where you were before it happened.

Once you have a better understanding of what may trigger migraines, you can take steps to avoid them and decrease your odds of suffering from a confusional migraine attack. 

If your family members suffer from migraines, it might be helpful to compare your triggers with theirs to further narrow down what might bring about your migraines. Your doctor may be able to make recommendations for avoiding triggers, but it might also take some experimentation on your part to figure out what works best to prevent migraines from getting worse once they start. 

Treatment options for those with ACM

There are no current official treatment options for confusional migraines. However, there are a few ways to treat a regular migraine that can at least help with some of the discomforts of confusional migraines.

This includes getting enough sleep or taking over-the-counter pain relievers. There are also three prescription medication treatments that show some promise for treating and preventing confusional migraines: sodium valproate, topiramate, and prochlorperazine.

Sleep

Changes in sleep may trigger confusional migraines in some, whether that is getting more or less sleep than usual. Interestingly, one small study found that 16% of people who entered a deep sleep after confusional migraine symptoms presented themselves and woke up without confusion and other migraine symptoms spontaneously. 

Getting enough sleep on a regular basis is important for overall health, and sleep disorders may be associated with increased headaches and migraines. Getting adequate sleep can also help keep stress to a minimum, which may, in turn, prevent migraine attacks in the first place. 

Many people find it helpful to go into a cool, dark, and quiet room and rest or sleep at the onset of symptoms of a regular migraine. This may be worth trying to prevent confusional migraine symptoms from getting worse. 

Over-the-counter pain relievers

Over-the-counter (OTC) pain relievers may not help much with symptoms of confusion or agitation, but they may at least reduce the amount of pain one experiences from the headaches caused by migraine. 

The most popular OTC pain relievers for migraines include aspirin and ibuprofen because they also work to reduce inflammation, which is one mechanism of migraines. Acetaminophen is another option, but since it doesn't address inflammation, it may not provide as much relief for those with migraines. 

If you or your loved one are suffering from frequent migraines or those that last a long time, it can be easy to overuse OTC pain relievers to try to get some relief. Unfortunately, using these medications too much or for too long can result in medication overuse headaches. 

Medication overuse headaches can produce symptoms similar to confusional headaches, like memory problems, irritability, and difficulty concentrating, and that won't go away until you stop using OTC pain relievers for a while. This can be particularly stressful if you are experiencing intense pain, but your doctor may be able to recommend other treatments in the meantime.

The appropriate dose of OTC pain relievers can vary, especially for children. Talk with your child's doctor about proper dosing for OTC pain relievers or choose the children's version of the medication and follow directions accordingly. 

Sodium valproate

One of the treatment options for confusional migraines is sodium valproate. This is mostly used to prevent migraines in adults and treat epilepsy and bipolar disorder in children. This medication isn't typically used to treat migraines in children, but it has shown an ability to control ACM attacks in some children. 

If your doctor believes that sodium valproate is a good option for you or your child, they will give you a recommended administration method (pill, liquid, granules, etc.) and dosage. Some types of sodium valproate are taken once or twice per day for adult migraines and child epilepsy or bipolar disorder. There isn’t currently a regimen recommended for children with confusional migraines. 

Sodium valproate can produce some unpleasant side effects, including nausea, diarrhea, dry mouth, and weight gain. Be sure to talk to your doctor if you experience these conditions. 

Topiramate

Topiramate is an anticonvulsant that is primarily used to treat seizures. It can also be used for migraine headache prevention but doesn't provide any relief from the pain of a migraine once it has set in. 

In one case study,⁵ topiramate was given to a 12-year-old girl that showed severe agitation, confusion, headache, and nausea. When she was taken to the hospital, she was experiencing her third bout of ACM symptoms within the last four weeks. After taking topiramate, she did not experience any more confusional migraines in the following 14 months. 

Unfortunately, there are only a few case studies to demonstrate the possibility of topiramate in the role of preventing ACM. More research is needed to establish an agreed-upon treatment plan. 

Although options are currently limited for the treatment of ACM in adults and children, the above treatment options may help you feel better, shorten your migraines, or prevent them from occurring in the future. If you are experiencing the symptoms associated with ACM, it's important to seek immediate medical attention.

Prochlorperazine

Prochlorperazine is a medication that is typically used to help with nausea, as well as schizophrenia. This medication may also be a helpful treatment option for those suffering from confusional migraines. One study found that it was effective for acutely managing recurrent ACM episodes. 

When administered intravenously, it appeared to be highly effective at treating most episodes. This study was very small, only consisting of two patients for a total of six episodes, but it may help to point researchers in the right direction to create better treatments or figure out regimens that can help ACM more specifically. 

Are confusional migraines genetic?

There may be a genetic component to confusional migraines. One study found that 62% of people with ACM had a family history of migraines and headaches, but not specifically confusional migraines. More research is needed to determine whether confusional migraines are genetic.

The lowdown

Acute confusional migraines are a rare and complicated condition, and much is unknown about how to create standardized treatment plans and protocols. This is due to such limited research on the subject, but researchers are working on more treatments for general migraines that may also help treat confusional migraines in the future. 

If you or a loved one experiences symptoms consistent with a confusional migraine, it's best to seek emergency treatment to ensure your symptoms are not caused by a potentially more severe condition that may lead to permanent damage, such as epilepsy or a stroke.