Central scotoma and 'muddled thinking' as migraine aura.

Dear Editor, We are very grateful to Professor Daroff, as well to our patients, for their goodwill in sharing with us their experience of aura. The letter by Professor Daroff (1) is a nice example of the fact that, in spite of contemporary technology, description of symptoms is the first and necessary step to answer the questions ‘why’ and ‘how’. We are in line with Professor Daroff when it comes to using term ‘‘Confused thinking’’ rather than ‘‘Muddled thinking’’ as a better description of such a cognitive state. We could also propose ‘‘Delusional thinking’’ as more appropriate terminology, which more precisely points out the higher cortical dysfunctions associated with visual aura. The appropriate descripter for his described symptoms (2) could be ‘‘Delusional scotoma state’’, for the inability to recognize the nature and duration of his own symptoms that is manifested during reading. We agree that ‘‘. . . failure to recognize negative scotoma at once’’ (3) could be explained by higher cortical dysfunctions due to the cortical spreading depression. While ‘‘delusional’’ thinking may be a scientifically accurate term, introducing such a term could create the erroneous interpretation of a psychiatric cause for the denial during migraine. Migraine was considered to be a psychiatric or, at least a personality disorder, for a long time, before the neurobiology of the disorder became evident. We would like to have more opportunities to study these phenomena (4) in order to determine the timing and sequence of events during aura, as well as the possible localization and mechanism of the particular disorder, before labeling them with a scientific term.