To report a rare case of a patient with a diagnosis of acute confusional migraine (ACM).

ACM is a diagnosis of exclusion and was historically seen in children and adolescents. This diagnosis is more easily identified when isolated from co-morbidities. It can however present in a patient with coexisting disease processes, making ACN difficult to diagnose which can delay the appropriate treatment and decrease quality of patient care.

Case report

A 27 years-old female patient with history of polycystic ovarian syndrome (PCOS) presented to the emergency department (ED) with multiple stereotypical spells with headache, altered mental status (AMS) and an aggressive behavior. Her baseline blood work and urine toxicology were normal. MRI brain and cerebrospinal fluid (CSF) analysis was unremarkable. The next morning, her symptoms resolved with no re-collection of last 36 hours and was discharged to home. A week later, the patient presented in ED with same symptoms, however this time she was treated with antibiotics for urinary tract infection. The third episode brought the patient to ED with symptoms of altered mental status, slurred speech and aggression, and again the neurological and laboratory exam were normal. However, the EEG exam showed diffuse intermittent slowing in theta and delta waves with no epileptiform activity. Patient’s psychiatric evaluation was also unremarkable and the patient was discharged on topiramate with the diagnosis of ACM. Post discharge, patient did not have any clinical follow-up.

Although ACM is uncommon in adult population but it can be considered a diagnosis of exclusion in patient presenting with headaches associated with AMS and no organic brain pathologies.