Abstract
Since her early 30s a 72-year-old female migraine sufferer has experienced recurrent episodes of Lilliputian hallucinations occurring at the peak of her severe migraine attacks and lasting between 2 min and 5 min, suggesting that her miniature hallucinations represent a visual migraine aura symptom. The existence of Lilliputian hallucinations of a migrainous nature is confirmed by four similar case reports reviewed from the migraine literature. The occurrence of similar Lilliputian hallucinations in the syndrome of peduncular hallucinosis, due to mesencephalic and/or thalamic lesions, supports the notion that the patient's recurrent Lilliputian hallucinations might have been aura symptoms of basilar migraine.
Introduction
In 1909 Leroy (1) defined Lilliputian hallucinations as a peculiar type of miniature hallucination, occurring during intoxication and in a variety of internal, neurological and psychiatric diseases. A patient may see brightly coloured, clearly defined little people, in lines or taking part in very complicated life-like antics, or he may see tiny animals or fantastic creatures. The reality judgement may be well preserved, with the accompanying affective state characterized by charm and joy and only rarely by fear or terror (2). In this single case report, we present a migraine patient who experienced recurrent Lilliputian hallucinations as visual aura symptoms of her migraine attacks.
Case report
The now 72-year-old female, whose mother and grandmother had suffered from migraine, reported a history of recurrent headache attacks since she was 10. Her attacks, which were usually ‘timed for a day’ and only sometimes lasted up to 5 days, were characterized by a side-changing unilateral headache of a pulsating nature, moderate or severe intensity of the headache, with aggravation by physical exercise and nausea that only sometimes culminated in vomiting, and photo- as well as phonophobia. According to the patient, ‘In my younger days I had attacks weekly, but monthly as the years went on. After my 60s, attacks have receded, but in stressful times I still have a daily migraine’. As a prodrome, she frequently noted an altered mental state of extreme alertness. ‘Strangely enough, before an attack my mind was so alert’, she explained, ‘but afterwards I was drained for days'. She repeatedly experienced aura symptoms of both migraine with typical aura (unilateral visual disturbances, unilateral numbness, speech difficulties) and basilar migraine, respectively (visual symptoms in both the temporal and the nasal fields of both eyes, vertigo, diplopia, bilateral sensory and motor disturbances). Physical, ophthalmological, neurological and psychiatric examinations were unremarkable. The patient thus fulfilled the IHS criteria of the said two types of migraine, viz. migraine with typical aura and basilar migraine (3).
In 1982 the patient had participated in the second national Migraine Art competition, jointly sponsored by the Migraine Action Association (formerly the British Migraine Association) and Boehringer Ingelheim UK Limited, whereby entrants were challenged to illustrate the pain, how they feel and what they see during a migraine attack and the social implications resulting from an attack (4, 5). On the left hand side of her drawing (Fig. 1) she depicted a recurrent visual aura featuring complex Lilliputian hallucinations. Since her early 30s she has repeatedly experienced this type of visual aura, usually every 2–3 months. According to the patient, ‘These are/were black beetles with faces that run across the carpet and ceiling at the peak of an attack. The experience lasts 2–5 min. It starts with two or three beetles, then they become more, moving away in line. When I close my eyes, I can’t see them any longer. I am perfectly aware of the fact that these beetles with faces represent a tricking of my eyes which is obviously related to my having a severe migraine. It's a funny experience which doesn't frighten me at all!'.
Drawing depicting the patient's visual aura, featuring Lilliputian hallucinations.
Discussion
The 72-year-old patient has suffered from attacks of migraine with aura since her childhood, fulfilling the diagnostic criteria for both migraine with typical aura and basilar migraine (3). Since her early 30s she has repeatedly experienced Lilliputian hallucinations that are suggested to represent visual aura symptoms of migraine. Their duration, ranging from 2 to 5 min, and the characteristics of the associated headache are in agreement with the criteria of migraine with aura (3). The migraine aura usually heralds the headache, whereas the patient's Lilliputian hallucinations always occurred at the peak of the headache phase of her attacks, but it is well known that the aura may, in some cases, accompany rather than precede the headache of the migraine attack (3). The migraine aura usually lasts 5–20 min (3) rather than the 2–5 min duration of the Lilliputian hallucinations, but even shorter visual auras of no more than 1 min duration have previously been recorded in the literature (6). The phenomenological characteristics of the patient's miniature hallucinations, featuring a type of animal/human hybrid fantastic creature (‘beetles with faces’), her correct reality judgement and her affective response to the ‘funny experience’ confirm previous descriptions of Lilliputian hallucinations.
Only a few similar observations have been recorded in migraine sufferers, most of them published in the older neuropsychiatric literature and thus lacking strictly operationalized diagnostic criteria of migraine. One of Mitchell's (7) patients described the apparition of a tiny dwarf who became gradually transformed into a giant gladiator finally striking him on the head. A patient of Mingazzini's (8, p. 139) had ‘visions of small, indefinite, equal sized objects’. A patient of Schob's (9, p. 165) once ‘saw around the lamp, for a quarter of an hour, a real dance of small, approximately 15 cm high figures, like children’s toys; they were in very rapid movement and disappeared immediately when the lamp was switched off'. During a migraine attack, a patient of Klee's (10, p. 51) ‘had on one occasion seen 20 cm high, greyish coloured Red Indians crowding round in the room in which he lay (Lilliputian hallucination). He was not afraid of them, as they did not seem to have anything to do with him’. Thus, in the diagnostic work-up of patients presenting with Lilliputian hallucinations, especially if they are recurrent and/or associated with headaches, migraine has to be considered as a possible differential diagnosis.
According to Cummings & Miller (11, p. 49), Lilliputian hallucinations ‘appear to have no specific localizing’ significance. A possible exception, however, is the syndrome of peduncular hallucinosis, which frequently involves vivid Lilliputian hallucinations in the presence of a lucid mental state (12). This syndrome is usually associated with mesencephalic and/or thalamic lesions (13). Peduncular hallucinosis has been reported as a complication following vertebral angiography (14), as manifestation of vertebrobasilar insufficiency based on severe hypoplasia of a vertebral artery (15) and as a result of the disruption of blood flow in the basal artery occurring in the ‘top of the basilar’ syndrome (16). Considering that the migraine sufferer reported in this study fulfills the IHS diagnostic criteria of basilar migraine, it is suggested that her recurrent Lilliputian hallucinations might represent aura symptoms of basilar migraine, viz. symptoms localizable to the brain stem (3).
