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Objective To assess the ictal symptoms, interictal symptoms, psychiatric comorbidities, and interictal neuro‐otologic examination findings in vestibular migraine (VM). Methods Retrospective chart review of 491 patients seen from August 2014 until March 2018 at a tertiary neurology referral center for vestibular disorders to identify patients fulfilling the 2012 VM criteria. Results One hundred and thirty‐one patients (105 women) were identified. Mean age of VM onset was 44.3 (±13.7) years. Preceding the onset of vestibular symptoms, most had migraine (57.3%) and motion sickness (61.1%). It was common to have a family history of migraine (50.8%) and episodic vestibular symptoms (28.1%). Common ictal symptoms were triggered (visually induced and head‐motion) and spontaneous vertigo, accompanied by photophobia and phonophobia (118/131 [90.1%] patients), nausea (105/131 [80.2%] patients), aural symptoms (79/131 [60.3%] patients), and headache (65/131 [49.6%] patients). Interictally, many experienced visually induced (116/131 [88.6%] patients), head‐motion (86/131 [65.6%] patients), and persistent (67/131 [51.1%] patients) dizziness. Psychiatric comorbidities include anxiety (92/131 [70.2%] patients), depression (53/131 [40.5%] patients), insomnia (38/131 [29.0%] patients), phobic disorders (15/131 [11.5%] patients), and psychogenic disorders (11/131 [8.4%] patients). Common triggers were stress (52/131 [39.7%] patients), bright lights (35/131 [26.7%] patients), weather changes (34/131 [26.0%] patients), and sleep deprivation (34/131 [26.0%] patients). Interictal neuro‐otologic examination was abnormal in 56/131 (42.7%), usually hyperventilation‐induced, head‐shaking‐induced, vibration‐induced, and positional nystagmus. The most common balance‐test finding was impaired sharpened Romberg’s test (22/130 [16.9%] patients). Conclusions In this single center study, we found that VM typically affects women in their 40s, with a personal and family history of migraine. Typical ictal symptoms were triggered and spontaneous vertigo, associated with photophobia and phonophobia, nausea, aural symptoms, and headache. Interictal vestibular symptoms, comorbid psychiatric disorders, and non‐specific interictal neuro‐otologic findings were common.

BackgroundAlice in Wonderland syndrome (AIWS) is a rare sensory perception disorder, most often caused by migraine in adults. We aimed to characterize the clinical characteristics of AIWS in a cohort of vestibular migraine (VM) patients.MethodsRetrospective chart review of patients diagnosed with VM seen between August 2014 and January 2018.ResultsSeventeen patients were identified (10 women) with a median age at onset of 45 years (range 15–61 years), and median age at presentation of 49 years (range 17–63 years). Eighty-two percent reported 1 AIWS symptom, 12% reported 3 symptoms, and 6% described 2 symptoms. The most common symptom was visual distortions (47%), followed by extrapersonal misperceptions (41%) and somesthetic distortions (29%). Most AIWS occurred during VM episodes (77%). Eleven patients were seen in follow-up; 10 described complete or partial resolution of both AIWS and VM with migraine preventive therapy, while 1 experienced complete resolution of VM but continued to have AIWS. Neuro-otologic abnormalities improved in 2 patients.ConclusionsThis study characterizes the clinical features of AIWS in patients with VM. We observed several rare and highly unusual AIWS misperceptions (frosted-glass vision, underwater vision, dolly zoom effect, sensation of the brain coming out of the head, closed-eye visual hallucinations, and headlight glare–induced marco/microsomatognosia), and resolution or improvement in AIWS and VM with migraine preventive treatment.

Trigeminal neuralgia (TN) is a facial pain syndrome characterized by severe recurrent paroxysms of unilateral facial pain in regions innervated by the trigeminal nerve. 1 Based on the International Headache Society classification, pain lasts from a fraction of a second to 2 min, is severe in intensity, and characterized as electric shock-like, shooting, stabbing, or sharp in quality. The pain must be precipitated by innocuous stimuli within the affected trigeminal distribution. 1 It can be idiopathic or arise from secondary causes, such as an underlying brain tumor, classified as secondary TN. 1 The severe repetitive nature of the pain can significantly impact the patient's quality of life.Persistent idiopathic facial pain (PIFP), formerly called atypical facial pain, is a chronic disorder with unexplained pain in the distribution of the trigeminal nerve. It is characterized as deep, dull, aching, burning, and pulling. In some cases, the pain is bilateral. 2 The pain recurs daily for >2 h/day over >3 months. Neurological examination should be normal, and a dental cause should be excluded. 1 Although some patients show neuropathic pain characteristics, its pathophysiology is not well understood. 3 First-and second-generation antiseizure drugs are currently recommended for treatment of facial pain of multiple etiologies, including TN. However, these treatments can be ineffective or cause various side-effects, particularly in the elderly population.Carbamazepine is the only approved drug for treatment of TN and is often used in other facial pain conditions. It is often poorly tolerated and tachyphylaxis frequently develops with prolonged use.Lacosamide is a third-generation antiseizure drug with a good safety

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In most cases, women with headache disorders have normal pregnancy and delivery outcomes and should not be discouraged from becoming pregnant. Pre-pregnancy planning includes weaning of contraindicated medications. Most women with migraine without aura improve during pregnancy. Although there are limitations, various acute and preventive treatments may be employed, including non-pharmacologic options. Anti-epileptic medications should be avoided. For pseudotumor cerebri, the mainstay of treatment includes diuretics and therapeutic lumbar punctures, avoiding topiramate. Surgical treatment may be necessary if vision is threatened. Close monitoring and collaboration between an ophthalmologist, neurologist and obstetrician are critical. New-onset pseudotumor cerebri requires an investigation for secondary causes such as cerebral venous thrombosis. In the absence of a pre-existing primary headache disorder, new headaches in the postnatal period warrant evaluation for secondary headache disorders, including post-dural puncture headache, stroke, cerebral venous thrombosis, pre-eclampsia, eclampsia, reversible cerebral vasoconstriction syndrome (RCVS), and pituitary apoplexy.