Metamorphopsia associated with topiramate for migraine prevention

Metamorfopsia associada ao uso de topiramato para prevenção de enxaqueca

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Metamorphopsia associated with topiramate for migraine prevention

Metamorfopsia associada ao uso de topiramato para prevenção de enxaqueca

Ana Claudia Rodrigues de Cerqueira^I; Antônio Egídio Nardi^II

^IDoctoral student in Panic and Respiration Laboratory, Institute of Psychiatry, Federal University of Rio de Janeiro (UFRJ), INCT Translational Medicine (CNPq), Rio de Janeiro RJ, Brazil

^IIFull Professor in the Panic and Respiration Laboratory, Institute of Psychiatry, UFRJ, INCT Translational Medicine (CNPq), Rio de Janeiro RJ, Brazil

^{Correspondece}

A 33-year-old woman (registration 70-247/ IPUB-UFRJ) has had recurring headaches since the age of 18. She described more right-sided than left-sided throbbing, which could be severe and associated with nausea, light and noise sensitivity, and vomiting. She has had a visual aura, seeing "zig-zags", lasting for 20 to 30 minutes before the headaches. The only preventive measure she had taken in the past was divalproex sodium, with good efficacy. Because of the weight gain as a side effect, she refused to take it again. Her body mass index (BMI) was 35.3. She was started on preventive therapy with topiramate at 25 mg daily for two weeks that was to be increased weekly to 100 mg daily. After 13 days of treatment, she developed continuous visual illusions upon waking in the morning; when looking at human faces, they were distorted and swollen. On many occasions, objects in front of her appeared to be either nearer or farther away. These visual phenomena persisted for approximately 12 hours and gradually disappeared with the discontinuation of topiramate. Thereafter, she never had similar experiences. None of these events was accompanied by the loss of consciousness or headache. The patient's impressions of reality and self-recognition were preserved. The neurological and psychiatric examination was normal, and a complete examination by a neuro-ophthalmologist was normal. An EEG, with activation procedures (hyperventilation and photic stimulation), and the MRI of the brain were normal.

Metamorphopsia is a visual illusion affecting the perception of the size, shape or inclination of objects¹. Although this condition occurs in migraine aura, topiramate has been reported to induce other visual illusions, such as palinopsia (the illusion of a persistent or recurrent visual images following the removal of the exciting stimulus)² and alterations in body perception ("Alice in Wonderland syndrome") in patients with migraines³.

The mechanism by which topiramate may cause these visual illusions in migraineurs is unknown. However, because it may occur in the aura of migraines, these visual illusions are likely to be a result of the migraine.

Received 07 September 2011;

Received in final form 02 October 2011;

Accepted 10 October 2011

Conflict of interest:

There is no conflict of interest to declare.

• 1. River Y, Ben Hur T, Steiner I. Reversal of vision metamorphopsia: clinical and anatomical characteristics. Arch Neurol 1998;55:1362-1368.
• 2. Evans RW. Reversible palinopsia and the Alice in Wonderland syndrome associated with topiramate use in migraineurs. Headache 2006;46:815-818.
• 3. Jürgens TP, Ihle K, Stork JH, May A. "Alice in Wonderland syndrome" associated with topiramate for migraine prevention. J Neurol Neurosurg Psychiatry 2011;82:228-229. doi:10.1136/jnnp.2009.187245

Publication Dates

• Publication in this collection
  01 Mar 2012
• Date of issue
  Mar 2012