What Is Confusional Migraine?

Confusional migraine, also known as acute confusional migraine (ACM), is a type of migraine that causes recurrent attacks of severe headache, as well as confusion, agitation, and language difficulties, among other symptoms. Most often seen in infants, children, and adolescents, this primary headache disorder is very rare.

The symptoms of confusional migraine, similar to those of stroke, last anywhere from two hours to two days. They’re thought to arise due to wave activity in certain brain regions, spurred by the release of certain hormones and neurotransmitters. Notably, this type of headache attack can be triggered by factors like sleep, stress, and diet, among others.   

Types of Migraine

Overall, migraines affect about 9% of the total population. While adult and senior cisgender women represent the majority of overall cases, three-quarters of confusional migraine cases are seen in children under 17.

Primarily, there are two types of migraine:

• Migraine without aura: Headache attacks come in stages and are accompanied by other symptoms, including nausea, irritability, fatigue, and sensitivity to light and sound, among many others. The head pain is often localized on one side of the head.
• Migraine with aura: With this type of migraine, the headache, nausea, and other symptoms are preceded by an aura phase. Usually lasting for 30 minutes, it causes visual disturbances, such as blurriness, colored lights, blind spots, flashing lights, or moving lines. This can also affect other senses, like taste and smell, and affect speech ability.

Alongside confusional migraine, there are a number of other migraine variants, sometimes called complicated migraines. In these cases, the headache attacks are accompanied by neurological symptoms. They include:

• Migraine with brainstem aura: Causes pain at the back of the head, visual disturbances, numbness, tingling, and vertigo (problems balancing)
• Hemiplegic migraine: Causes paralysis on one side of the body alongside the other symptoms
• Ophthalmoplegic migraine: Paralyzes or severely weakens muscles around the eyes
• Paroxysmal vertigo: Severe dizziness and inability to remain balanced; it may or may not be accompanied by headache.
• Paroxysmal torticollis: This can also arise without headache. It is when muscles on one side of the neck suddenly contract, making the head tilt.   
• Cyclic vomiting: A 24-hour period of intense nausea that accompanies migraines that recurs once every two to three months
• Abdominal migraine: Pain in the stomach and abdominal region for one to two hours

Confusional Migraine Symptoms

Confusional migraine is typically a recurrent condition, occurring one or more times a month. Primarily, this condition is characterized by:

• Periods of confusion
• Memory problems
• Disorientation
• Irritability or agitation

This is accompanied by the traditional symptoms of migraine, which include:

• Splitting, severe headache, typically on one side of the head
• Nausea, vomiting
• Severe light, sound, or smell sensitivity
• Pale skin
• Moodiness and irritability
• Loss of appetite

Attacks also cause a range of other temporary effects:

• Sudden blindness
• Partial blindness or blind spots
• Changes in senses of taste and smell
• Numbness
• Burning and prickling sensations on the skin
• Speech and comprehension problems

The confusion state usually follows, but may also precede, the onset of headache itself. It can last anywhere from 15 minutes to three days. Typically, this stage resolves within 24 hours, with most feeling drowsy afterward.

Risk Factors

Several factors can predispose you to developing confusional migraine:

• Genetics: Evidence suggests both a strong genetic component to developing migraines generally, as well as confusional migraines specifically. You have a higher chance of developing the condition if parents or close relatives experience attacks.
• Age: Three-quarters of cases are seen in children between the ages of 6 and 17. That said, cases in those younger and older can occur.
• Obesity: Excessive weight, especially obesity (a body mass index [BMI] above 30), increases the chances of developing attacks.  

Triggers

As a subtype of migraine, confusional migraines can be kicked off by certain stimuli, foods, or other factors. Common triggers include:

• Stress, anxieties, or disruptions to your routine
• Physical fatigue, overexertion
• Dehydration
• Fluorescent, flashing, or very powerful lights
• The light from TVs, monitors, or devices
• Alcohol
• Menstruation, menopause, or hormone replacement therapy
• Food triggers, such as alcohol, dark chocolate, cured meats, aged cheeses, and processed foods
• Changes in weather
• Overuse of pain medications

Diagnosis

With neurological symptoms like those caused by confusional migraine, ruling out other potential causes of these issues, such as epilepsy, is a big part of diagnosis. This may involve:

• Assessment of medical history: In addition to assessing the basics of your current health status, doctors look at any medical conditions you have, medications you're taking, and other factors, such as family history. A presence of former head trauma can contribute to confusional migraines, specifically.
• Imaging: To confirm that the case is migraine—and not another neurological disorder or structural issue—imaging may be performed. Magnetic resonance imaging (MRI), computed tomography (CT) scans, and electroencephalogram (EEG) are used to assess the blood vessels and other structures.
• Lab work: Routine lab work such as blood tests and urinalyses can help rule out conditions such as diabetes, thyroid issues, infections, and more.

Treatment for Confusional Migraine

In the absence of a singular “cure” for migraines, treating the condition often means combining strategies to both prevent attacks and manage them after onset. There are pharmaceutical options for both, as well as other medical approaches to confusional migraine. Some lifestyle changes can help.

Preventive Medications

Especially in cases where attacks occur more frequently, medications may be prescribed for confusional migraines to prevent attacks. Several classes of drugs are prescribed:

• Anticonvulsants, especially Topamax (topiramate) and Depakote (sodium valproate)
• Tricyclic antidepressants, such as Elavil (amitriptyline) or Pamelor (nortriptyline)
• Antihistamine drugs like Benadryl (diphenhydramine) and Periactin (cyproheptadine)
• Beta-blockers, including Inderal and Inderal LA (propranolol) and Blocadren (timolol).
• Calcium-channel blockers, such as Calan and Isoptin (both are verapamil)
• Calcitonin gene-related peptide antagonists (CGRPs), such as Aimovig (erenumab)

Abortive Medications

There are also a number of medications that can help take on symptoms after migraine. Some are available over-the-counter, while for others you’ll need a prescription. These abortive or “rescue” drugs include:

• Nonsteroidal anti-inflammatory drugs (NSAIDs), such as Advil, Aleve, and Motrin (ibuprofen)
• Acetaminophen, sold as Tylenol, Sudafed, and others
• Triptans, such as Zomig (zolmitriptan), Imitrex (succinate), and Maxalt (rizatriptan)
• Antiemetics (alongside others for nausea management), such as Emend (aprepitant) and DexPak (dexamethasone)
• CGRPs, such as Ubrelvy (ubrogepant) and Zavzpret (zavegepant)

Biofeedback

For migraine in children and adolescents, which represent the majority of confusional migraine cases, biofeedback is an alternative medicine method that may help. Since stress and tension are common triggers, the goal of this therapy is to sense these levels rising so that you can work to manage them.

In biofeedback therapy, the patient wears sensors to track physiological signs of stress, such as heart rate, breathing, sweating, and muscle activity. Eventually, they learn to detect when distress or physical overexertion may be bringing on attacks.

With that knowledge, they can be proactive about managing migraines and help prevent them. This may involve mindfulness techniques, meditation, breathing exercises, and learning other strategies to release tension.

Other Strategies

Several other methods may also be recommended for a migraine management plan, including:

• Herbs and supplements: Some herbs and supplements may help, including magnesium, riboflavin, and coenzyme Q10.
• Trigger avoidance: Keeping track of attacks and potential triggers and working to avoid those is another good way to stay ahead of migraine.
• Regular sleep: Since sleep problems and disruptions are common factors in migraine, try to make sure you get enough sleep (adults require seven to eight hours, children need nine to 12, and infants and newborns require more). Wake up and go to bed at regular times, and make your bed a "no-device zone."
• Regular exercise: By helping with obesity and improving sleep quality, exercise can be helpful. However, since overexertion is a trigger, be mindful of how hard you are working and don’t push it.
• Healthy habits: Steering clear of tobacco and alcohol is associated with a reduced frequency of attacks.
• Healthy diet: Aim to avoid dietary triggers, and eat a healthy, well-balanced diet.

Prognosis and Coping

While confusional migraines can be challenging to take on, the good news is that they are treatable and can be managed. In most children and adolescents who experience them, medications and other strategies are able to ease their frequency and intensity within six months. They also aren’t associated with actual damage to brain structures.

That said, researchers have found links between confusional migraine in adolescence and migraine with aura in adulthood. More than half of those who experience migraines during their teen years will experience recurrence as adults.

Since migraines are unpredictable, and since they’re often linked with depression and anxiety, it can be challenging to live with them. Additional strategies may be needed to ease the burden, including:

• School support: Since migraines can be so disruptive, special accommodations may need to be made for children in school. Parents should talk to the school nurse, administration, and teachers about confusional migraine and what can help.
• Rehabilitation programs: Some hospitals have headache centers that specialize in helping patients develop different strategies to take on chronic migraine cases. Some off-label approaches, such as neurostimulation—using electricity to gently shock pain centers in the brain—may also be considered.
• Counseling: Those with chronic health conditions like migraines may also find benefit in working with a therapist or counselor. These experts may employ techniques to work on pain perception, like cognitive behavioral therapy, or help cope with the emotional fallout of living with a medical condition.
• Community: Social media groups and online forums of patients living with migraine can be good sources of practical support. Advocacy organizations, such as the American Migraine Foundation, also provide helpful information, while promoting research into the treatment of the condition.

A Word From Verywell

There’s no doubt that confusional migraine attacks can be very debilitating and even frightening. However, this condition can be effectively managed. Additionally, as our understanding of this neurological disorder continues to grow, so will treatments become even more effective. Essential in all of this is to take a proactive approach. If you or your child suffers from migraine, talk to your doctor about what you can do to take on this condition.