Psychiatric disorders during migraine attacks are not uncommon. In fact, as long ago as 1890, Babinski described De la migraine ophtalmique hystérique based on four migraine cases with visual aura and hysteria. However, this nosological entity is often overlooked due to the arduous historical task of defining conversion disorder (CD). Nonetheless, migraine associated with CD, or Babinski's migraine (BM), is a well-documented subset of migraine with aura (MWA), which requires an interdisciplinary approach involving the neurology, psychiatry, and psychology fields.12 Here we report a noteworthy BM case formed by migraine with brainstem aura (MBA) and CD.

A 45-year-old woman presented in another hospital with a past medical history of pharmacoresistant seizures in her adolescence, after trying two tolerated schedules with carbamazepine and phenytoin. Notwithstanding, she reached a seizure-free status in adulthood despite being off antiepileptic medication. Besides, she also had a family history of MWA (in her mother and sister). The findings of magnetic resonance imaging (MRI) of the brain and neck, blood and cerebrospinal fluid (CSF) studies, and video-electroencephalography (video-EEG) were normal, as were those of cardiac investigations.

She consulted our department for a second medical opinion, complaining of a 1-year clinical presentation of daily, self-limited episodes that were elicited by emotional stress, which had developed gradually and were characterized by recurrent stereotyped, generalized paresthesia, binocular diplopia, and slurred speech. These spells occurred sequentially, leading to altered consciousness about 1 hour before an intense throbbing occipital headache began, with aggravation of the pain by head movement. They occurred in conjunction with changing symptoms such as obtundation, mutism, eyes closed with opening resistance, flexo-extension movements, asynchronous pelvic contortion and kicking, axial and appendicular pseudodystonias, and opisthotonus. Each attack typically lasted 90 minutes, between which she was completely well.

A neurological examination after suggestion (Supplementary Video 1 in the online-only Data Supplement) confirmed the previous observations. The findings of CSF studies, prothrombotic screening, electrocardiography (ECG), Holter ECG, brain MRI and MR angiography, EEG, and video-EEG were normal. A psychiatric evaluation resulted in a diagnosis of MBA (Table 1)3 added to persistent CD (Table 1) with nonepileptic psychogenic seizures (PNES);4 that is, BM. She was started on dexketoprofen at 25 mg thrice daily, flunarizine at 5 mg daily (increased to 10 mg per day after 6 months), lorazepam at 1 mg during an acute crisis, fluoxetine at 20 mg daily as maintenance therapy, and psychotherapy. During one of the psychotherapy sessions, the patient reported that she had been sexually abused as a child. After 5 years of follow-up appointments she achieved a significant reduction of headaches and the frequency, length, and intensity of PNES. Finally, she remained free of attacks. Currently, this situation persists stable.

MBA is a rare and underdiagnosed subtype of MWA. These patients suffer from a constellation of negative and/or positive signs and symptoms (excluding motor weakness) that are referable to the brainstem or posterior circulation territory. This clinical scenario can be challenging, and raise differential diagnosis with a host of conditions including complex partial seizures, multiple sclerosis, vertebrobasilar transient ischemic attacks, posterior fossa tumors, and encephalitis.356 Furthermore, CD constitutes a scarcely known pathology that is shared between psychiatry and neurology. PNES can be found as one of the symptoms accompanying CD. First described by Charcot in 1892 under the diagnosis of hysteroepilepsy, still nowadays PNES are a diagnostic, psychopathological, and psychotherapeutic problem.7 Moreover, a PNES diagnosis is eventually obtained in 25–30% of patients diagnosed with intractable epilepsy.8 These cases warrant a thorough evaluation including MRI and video-EEG. Some common PNES findings are long episodes, predominance among women, young age at onset (usually between 10 and 35 years), and preservation of ictal consciousness. The motor activity is not consistent with a recognizable epileptic pattern, and consciousness is recovered immediately once the episode has finished.489 A key aspect of the paradigm underlying BM is that the conversive response is structured in a dramatic constellation of corporeality symptoms and produced by frustration, with BM appearing when the consciousness is impaired. This phenomenon may be caused by involvement of the brainstem reticular formation and/or deficient brain integration of emotion processing, executive control, and motor networks. In addition, pain in the form of headache as well as hypnosis would act as elicitation factors that decrease consciousness to reach the hysterical threshold.123456789

In conclusion, we suggest including BM as a diagnostic subcategory within MBA. Rescuing this Babinski's legacy that has been omitted for decades will help in designing better diagnostic approaches and applying optimal therapies that can improve the quality of life of these patients.