u/LazyMe4732

Alice in Wonderland syndrome is one of those neurologic phenomena that often gets framed as psychiatric before anyone considers migraine aura or focal cortical dysfunction.

A patient described recurrent episodes where the room seemed to stretch away, the ceiling rise upward, and her hands appear small and distant, accompanied by depersonalization. No headache. Multiple ER visits ended with a diagnosis of panic attacks.

But the episodes were highly stereotyped, gradual over minutes, similar in duration, and without a postictal phase. Interictal EEG was normal. Family history of migraine.

The phenomenology raised the possibility of migraine aura without headache (acephalgic migraine) presenting primarily as Alice in Wonderland–type perceptual distortion rather than typical visual aura.

The overlap with focal seizures and psychiatric presentations makes attribution difficult, but it is striking how often unusual neurologic syndromes are initially interpreted through a psychiatric lens before anyone recognizes the neurologic pattern.

How often have you seen atypical aura syndromes mistaken for psychiatric disease?

A 58-year-old woman had 3 months of persistent vomiting. No clear diagnosis despite multiple visits. She eventually presented with a stroke. The cause? Fibromuscular dysplasia. Made me rethink how often we miss vascular causes in “benign” presentations. How often do you consider FMD in stroke patients without an obvious cause?