Clinical characteristics of Alice in Wonderland syndrome in a cohort with vestibular migraine

Background Alice 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. Methods Retrospective chart review of patients diagnosed with VM seen between August 2014 and January 2018. Results Seventeen 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. Conclusions This 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.