Headache Medicine, v.10, n.2, p.41-42, 2019
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CASE REPORT
Alice in Wonderland Syndrome
Síndrome de Alice no País das Maravilhas
Wilson Luiz Sanvito
1
1
Associate Professor and Emeritus Professor
of Neurology at the Medical Sciences School
of Santa Casa in São Paulo. Assistant Étranger
of the Paris Medical School.
*Correspondence
Wilson Luiz Sanvito
E-mail: wsanvito@uol.com.br
Received: June 12, 2019.
Accepted: June 20, 2019.
At the end of my ofce
hours, I saw to a distressed
mother. Her 9-year-old daughter
presented that day during recess a
condition characterized by strange
perceptions. She reported seeing
huge and deformed people (big
noses, crooked mouths, exceedingly
long arms...). The manifestation
lasted approximately 15 minutes and
was followed by facial paleness and
an episode of mental confusion, with
verbalization of disconnected words
and incoherent phrases. Some
minutes later, the child became
drowsy and fell asleep. When her
mother arrived at the school, she
was still sleeping. When she woke
up, two hours later, she was lucid and
reported only feeling a heaviness in
her head.
During questioning, the mother
informed that since the age of
8 years, her daughter presented
headache episodes preceded
sometimes by blurry vision. The
mother is a migraineur and her
own mother, already deceased, was
also one. Nothing abnormal was
found when examining the minor
and I stated to the mother that the
episode was probably a migraine,
which during childhood can present
this kind of manifestation. In face
of the unbelief of the mother, I
requested a computed tomography
of the head and an EEG – both of
which did not show abnormalities.
I had the opportunity to follow-
up on this patient over the course
of three years. During this time,
she presented headache episodes,
not all of which were preceded
by visual manifestations. In this
case, the diagnosis was settled as
migraine with aura, consisting of a
variant called Alice in Wonderland
Syndrome.
Visual auras are the most
common and originate from the
posterior portion of the brain
(occipital lobe). The description
of a visual aura is not always easy
for the patient. The most detailed
and precise descriptions are
done through own experience, by
either doctors or other healthcare
professionals that suffer from this
sort of migraine. Data are frequently
collected from patients through the
anamnesis, in complaints during the
crises at emergency services, using
questionnaires during interviews,
and by analyzing drawings made
during the postcritical period.
All methods present limitations.
Loss of vision in half the visual
eld (hemianopsia) or in certain
points of the visual eld (negative
scotoma) are common complaints.
Scotoma can also be positive and
manifest in several ways: focused
ashes, colorful circles, the illusion
of blinking lights, eye oaters,
zigzagging lines, mosaic vision (like
a kaleidoscope)... Scotoma can have
various colors (gray, red, golden,
blue or purple), though the color
may not be specic and be more
like a very bright white. There is
also a form of negative scotoma in
which the migraineur sees objects
split in half. This condition can either
increase in size as the crises evolve
or become fragmented into smaller
parts.
Auras can be more elaborate
and present themselves as
distortions of visual gures. These
phenomena are more frequent in
children and are externalized as
perception disorders, which can
include various types of body image
distortions (macropsias, micropsias,
metamorphopsias), feelings of
derealization and depersonalization,
and changes to their perception of
time. This is the Alice in Wonderland
syndrome. In this curious syndrome,
the patient has the feeling that
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Alice in Wonderland Syndrome
Sanvito WL, et al.
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Headache Medicine, v.10, n.2, p.41-42, 2019
people are either exceedingly large (macropsias) or
disproportionally small (micropsias). This inadequacy in
size can also be perceived regarding one’s own body,
such that an individual may feel for example that one
of their limbs is gigantic. Other manifestations may
occur: distortion of their own body segments (as if
looking into a distorting mirror) or of others, feeling
of levitation or of a double personality, loss of spatial
recognition, etc. Transitory alterations in certain areas
of the brain (particularly in parietal lobe areas) seem
to be responsible for these described psychosensory
abnormalities. Auras are believed to be determined
through spreading depression, though it is not clear why
extremely elaborate auras – with important perception
disorders – are more frequent during childhood. Perhaps
the immature brain (not entirely myelinated) can be
more vulnerable to a spreading depression event.
This type of migraine is more common in children and
usually begins around the age of 8 years. The associated
manifestations, translated into elaborate auras, usually
give way during adolescence.
The Alice in Wonderland syndrome was reported
for the rst time in 1955 by the English psychiatrist
John Todd, who believed the syndrome was related to
defects in parts that form the eyes. However, it is known
now that the condition occurs due to a neural change
in perception that affects vision, feelings, touch and
even body image. The condition was initially described
as Todd’s syndrome, but as a reader and admirer of
Lewis Carroll, the psychiatrist proposed the name that
established Carroll as an author.
Though this is a polemic discussion, it seems like
migraines inuenced Lewis Carroll’s description of
some characters in the book Alice in Wonderland. The
Englishman Charles Lutwitge Dodgson (1832-1898)
adopted the name Lewis Carroll as a pseudonym to sign
his works of ction (4). This is the explanation. Lewis
Carroll was a professor, mathematician, poet, painter,
amateur photographer and deacon of the Anglican
Church. He would sign his academic publications (math
and logic) with his real name. Carroll was a curious
person that did not get along with adults and adored
young girls. He dedicated his most successful books to
a girl named Alice, daughter of dean Liddell. It seems
that Carroll loved Alice deeply, a 10-year-old girl, while
he was 32 years old. The author was also an excellent
photographer (photography was considered at the time
avant-garde art) and enjoyed photographing girls in
either revealing clothes or naked (2,3).
Regardless of Carroll’s “bilious headaches”, detailed
records from his diary (collected 20 years after they were
reported) demonstrated that he suffered from migraines
with aura. However, the book Alice in Wonderland
appeared in 1865, which according to scholars
researching his biography was before the beginning
of his migraines. Nevertheless, the subject is still under
discussion, with some believing the author had already
experienced previous migraine events.
In conclusion, I must emphasize that the Alice in
Wonderland syndrome is not a prerogative to migraine
and should be considered as a differential diagnosis
for epilepsy, use of hallucinogenic drugs (such as
LSD), consumption of hallucinogenic mushrooms,
schizophrenia, and brain tumors. The syndrome can
also occur during the initial phases of infection by the
Epstein-Barr virus in children (1).
REFERENCES
1. Bolis, V., Karadedos, Ch. et al. – Atypical manifestations
of Epstein-Barr virus in children: a diagnostic challenge. J
Pediatr (Rio J). 2016; 113-21.
2. Sanvito, W. L. - Alice no país das maravilhas. In O Mau Gênio
do Cérebro: O impacto da doença neurológica. A Girafa,
São Paulo, 2006, p. 65.
3. Sanvito, W. L. - Síndrome de Alice no país das maravilhas.
In Síndromes Neurológicas, Atheneu (4ª edição), Rio de
Janeiro, 2019, p. 15.
4. Stoffel, S. L. Lewis Carroll and Alice - New Horizons.
Thames and Hudson, London, 1997.
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