Diagnostic criteria currently proposed for "ictal epileptic headache": Perspectives on strengths, weaknesses and pitfalls

Magnetoencephalography studies in migraine and headache disorders: A systematic review

BACKGROUND

Understanding the neural mechanisms underlying migraine and other primary headache disorders is critical for the development of long-term cures. Magnetoencephalography (MEG), an imaging modality that measures neuronal currents and cortical excitability with high temporal and superior spatial resolution, has been increasingly used in neurological research. Initial MEG studies showed promise in directly recording cortical spreading depression-a cortical correlate of migraine with aura. However, lately MEG technology has highly evolved with greater potential to reveal underlying pathophysiology of migraine and primary headache disorders, and aid in the identification of biomarkers.

OBJECTIVE

To systematically review the use of MEG in migraine and other primary headache disorders and summarize findings.

METHODS

We conducted a systematic search and selection of MEG studies in migraine and primary headache disorders from inception until June 8, 2023, in Medline, Embase, Cochrane, and Scopus databases. Peer-reviewed English articles reporting the use of MEG for clinical or research purposes in migraine and primary headache disorders were selected.

RESULTS

We found 560 articles and included 38 in this review after screening. Twelve studies investigated resting-state, while others investigated a sensory modality using an evoked or event-related paradigm with a total of 35 cohort and 3 case studies. Thirty-two studies focused exclusively on migraine, while the rest reported other primary headache disorders.

CONCLUSION

The findings show an evolution of MEG from a 7- to a 306-channel system and analysis evolving from sensor-level evoked responses to more advanced source-level connectivity measures. A relatively few MEG studies portrayed migraine and primary headache disorders as a sensory abnormality, especially of the visual system. We found heterogeneity in the datasets, data reporting standards (due to constantly evolving MEG technology and analysis methods), and patient characteristics. Studies were inadequately powered and there was no evidence of blinding procedures to avoid selection bias in case-control studies, which could have led to false-positive findings. More studies are needed to investigate the affective-cognitive aspects that exacerbate pain and disability in migraine and primary headache disorders.

A rare case of lupus cerebritis presenting as ictal epileptic headache: A case report

Ictal epileptic headache, characterized by headache as the sole symptom of a seizure attack, is a rare condition. In this case report, we present a 52-year-old female with a history of systemic lupus erythematosus who sought medical attention at the headache clinic due to a new type of headache. The headache was described as an intense painful wave followed by a dull headache, without autonomic symptoms or migrainous features. Magnetic resonance imaging revealed an enhancing lesion in the left hippocampus in addition to two other lesions in the corpus callosum and left parieto-occipital lobe. Electroencephalography during the headache episodes showed epileptic discharges originating from the left fronto-temporal region. The patient was initiated on levetiracetam, which resulted in the resolution of both the epileptic discharges and the headaches. This case underscores the significance of considering ictal epileptic headache as a potential secondary cause for headaches, particularly in patients with underlying conditions that may predispose them to epilepsy, such as systemic lupus erythematosus.

The assessment of the knowledge and practices of healthcare providers regarding paroxysmal non-epileptic events (PNES) in children: A cross-sectional study

OBJECTIVE

Paroxysmal non-epileptic events (PNEs) are a group of disorders that may be misdiagnosed as epilepsy. This study has aimed to assess the knowledge and practices of family physicians and pediatricians regarding the diagnosis, treatment, and follow-up of PNEs in children.

METHODS

The study was designed as a prospective cross-sectional study that was conducted between March 1, 2022, and June 1, 2022, by reaching pediatric specialists and assistants, family physicians, subspecialty assistants, and subspecialists using a Google questionnaire. The survey consists of 26 questions. The questionnaire used by the researchers was prepared in accordance with the literature search and it included detailed questions on the diagnosis, treatment, and differential diagnosis of PNEs.

RESULTS

A total of 37.3% worked as specialists. Most of the participants (41.3%) have worked in training and research hospitals, and 44.3% have been physicians for 6-10 years. The mean and standard deviation for the total score were 10.1 ± 2.6. The scores of family physicians were statistically lower than those of specialists, subspecialty assistants, and subspecialists. A total of 67.2% left the decision of whether the patient should stop taking their medication to another clinician. 45% of the doctors said that they were uncomfortable with the diagnosis.

SIGNIFICANCE

The study findings emphasized the significant knowledge gap among healthcare providers regarding PNEs in children, highlighting the need for targeted educational interventions to improve their understanding and diagnostic skills in this area.

Migraine - a borderland disease to epilepsy: near it but not of it

BACKGROUND

Migraine and epilepsy are two paroxysmal chronic neurological disorders affecting a high number of individuals and being responsible for a high individual and socioeconomic burden. The link between these disorders has been of interest for decades and innovations concerning diagnosing and treatment enable new insights into their relationship.

FINDINGS

Although appearing to be distinct at first glance, both diseases exhibit a noteworthy comorbidity, shared pathophysiological pathways, and significant overlaps in characteristics like clinical manifestation or prophylactic treatment. This review aims to explore the intricate relationship between these two conditions, shedding light on shared pathophysiological foundations, genetic interdependencies, common and distinct clinical features, clinically overlapping syndromes, and therapeutic similarities. There are several shared pathophysiological mechanisms, like CSD, the likely underlying cause of migraine aura, or neurotransmitters, mainly Glutamate and GABA, which represent important roles in triggering migraine attacks and seizures. The genetic interrelations between the two disorders can be observed by taking a closer look at the group of familial hemiplegic migraines, which are caused by mutations in genes like CACNA1A, ATP1A2, or SCN1A. The intricate relationship is further underlined by the high number of shared clinical features, which can be observed over the entire course of migraine attacks and epileptic seizures. While the variety of the clinical manifestation of an epileptic seizure is naturally higher than that of a migraine attack, a distinction can indeed be difficult in some cases, e.g. in occipital lobe epilepsy. Moreover, triggering factors like sleep deprivation or alcohol consumption play an important role in both diseases. In the period after the seizure or migraine attack, symptoms like speech difficulties, tiredness, and yawning occur. While the actual attack of the disease usually lasts for a limited time, research indicates that individuals suffering from migraine and/or epilepsy are highly affected in their daily life, especially regarding cognitive and social aspects, a burden that is even worsened using antiseizure medication. This medication allows us to reveal further connections, as certain antiepileptics are proven to have beneficial effects on the frequency and severity of migraine and have been used as a preventive drug for both diseases over many years.

CONCLUSION

Migraine and epilepsy show a high number of similarities in their mechanisms and clinical presentation. A deeper understanding of the intricate relationship will positively advance patient-oriented research and clinical work.

Visually sensitive seizures: An updated review by the Epilepsy Foundation

Light flashes, patterns, or color changes can provoke seizures in up to 1 in 4000 persons. Prevalence may be higher because of selection bias. The Epilepsy Foundation reviewed light-induced seizures in 2005. Since then, images on social media, virtual reality, three-dimensional (3D) movies, and the Internet have proliferated. Hundreds of studies have explored the mechanisms and presentations of photosensitive seizures, justifying an updated review. This literature summary derives from a nonsystematic literature review via PubMed using the terms "photosensitive" and "epilepsy." The photoparoxysmal response (PPR) is an electroencephalography (EEG) phenomenon, and photosensitive seizures (PS) are seizures provoked by visual stimulation. Photosensitivity is more common in the young and in specific forms of generalized epilepsy. PS can coexist with spontaneous seizures. PS are hereditable and linked to recently identified genes. Brain imaging usually is normal, but special studies imaging white matter tracts demonstrate abnormal connectivity. Occipital cortex and connected regions are hyperexcitable in subjects with light-provoked seizures. Mechanisms remain unclear. Video games, social media clips, occasional movies, and natural stimuli can provoke PS. Virtual reality and 3D images so far appear benign unless they contain specific provocative content, for example, flashes. Images with flashes brighter than 20 candelas/m2 at 3-60 (particularly 15-20) Hz occupying at least 10 to 25% of the visual field are a risk, as are red color flashes or oscillating stripes. Equipment to assay for these characteristics is probably underutilized. Prevention of seizures includes avoiding provocative stimuli, covering one eye, wearing dark glasses, sitting at least two meters from screens, reducing contrast, and taking certain antiseizure drugs. Measurement of PPR suppression in a photosensitivity model can screen putative antiseizure drugs. Some countries regulate media to reduce risk. Visually-induced seizures remain significant public health hazards so they warrant ongoing scientific and regulatory efforts and public education.

Headache in people with epilepsy

Epidemiological estimates indicate that individuals with epilepsy are more likely to experience headaches, including migraine, than individuals without epilepsy. Headaches can be temporally unrelated to seizures, or can occur before, during or after an episode; seizures and migraine attacks are mostly not temporally linked. The pathophysiological links between headaches (including migraine) and epilepsy are complex and have not yet been fully elucidated. Correct diagnoses and appropriate treatment of headaches in individuals with epilepsy is essential, as headaches can contribute substantially to disease burden. Here, we review the insights that have been made into the associations between headache and epilepsy over the past 5 years, including information on the pathophysiological mechanisms and genetic variants that link the two disorders. We also discuss the current best practice for the management of headaches co-occurring with epilepsy and highlight future challenges for this area of research.

Borderlands of Migraine and Epilepsy

Background

The complex relationship between migraine and epilepsy has frequently been described to represent a clinical and electrographic "borderland." These two conditions share clinical expressions such as paroxysmal and chronic nature, as well as semiology, particularly visual phenomenon.

Objective

We aimed to review the current literature on the overlapping phenomena of migraine and epilepsy.

Materials and Methods

We searched the PubMed for relevant literature and conducted a narrative review on migraine and epilepsy.

Results

Migraine and epilepsy share a complex and pathophysiologically intriguing relationship. The International Classification of Headache Disorders, 3^rd edition (ICHD-3) makes diagnostic provisions for migraine aura-triggered seizures (Subchapter 1.4.4) and headache attributed to epileptic seizure (Subchapter 7.6), the latter being further categorized as 7.6.1 Ictal epileptic headache, and 7.6.2  post-ictal headache. Neurological conditions such as certain channelopathies and epilepsy syndromes exhibit both conditions within their phenotypic spectrum, suggesting shared genetic and molecular underpinnings. Diagnostic confusion may arise, particularly between occipital epilepsy and the visual aura of migraine. Antiseizure medications may be effective for the treatment of migraines that occur in concert with epilepsy.

Conclusions

Migraine and epilepsy share several clinical features and have intertwined genetic and molecular underpinnings, which may contribute to common pathogenesis. Electroencephalography may be useful as a diagnostic tool in selected cases.

Pathophysiological Bases of Comorbidity in Migraine

Despite that it is commonly accepted that migraine is a disorder of the nervous system with a prominent genetic basis, it is comorbid with a plethora of medical conditions. Several studies have found bidirectional comorbidity between migraine and different disorders including neurological, psychiatric, cardio- and cerebrovascular, gastrointestinal, metaboloendocrine, and immunological conditions. Each of these has its own genetic load and shares some common characteristics with migraine. The bidirectional mechanisms that are likely to underlie this extensive comorbidity between migraine and other diseases are manifold. Comorbid pathologies can induce and promote thalamocortical network dysexcitability, multi-organ transient or persistent pro-inflammatory state, and disproportionate energetic needs in a variable combination, which in turn may be causative mechanisms of the activation of an ample defensive system with includes the trigeminovascular system in conjunction with the neuroendocrine hypothalamic system. This strategy is designed to maintain brain homeostasis by regulating homeostatic needs, such as normal subcortico-cortical excitability, energy balance, osmoregulation, and emotional response. In this light, the treatment of migraine should always involves a multidisciplinary approach, aimed at identifying and, if necessary, eliminating possible risk and comorbidity factors.

EEG Characteristics and Diagnostic Implications in Childhood Headache: A Multi-Center Study

Introduction: Epilepsy and migraines are frequently observed as comorbidities, with the occurrence of one disorder increasing the probability of the other. The aim of our study was to evaluate the EEG characteristics by the type of headache and the implications of EEGs in headache patients, comparing the clinical characteristics and treatments between the headache patients with normal and abnormal EEGs. Methods: We conducted a retrospective analysis reviewing the medical records of 259 patients with headaches who visited the pediatrics departments of five university hospitals and underwent EEGs over a period of 3 years. Based on the data entered, analyses of the following items were conducted: (1) comparison of the EEG abnormalities by the type of headache and the characteristics of the EEG findings and (2) comparison of the clinical characteristics between patients with normal and abnormal EEGs. Results: Of the 259 patients, 31 showed abnormal EEGs, while 228 had normal EEGs. Of the 31 patients with abnormal EEGs, 17 showed epileptiform discharges, and 11 showed rhythmic slowing. The frequency of EEG abnormalities was significantly high in patients with migraines with auras than other types of headache. The Pediatric Migraine Disability Assessment (PedMIDAS) score was significantly higher in the abnormal EEG group compared with the normal EEG group (p = 0.001). Conclusion: The results of this study suggest that the abnormal EEG group had more significant disruptions in their daily lives due to headaches than the normal EEG group and that patients with migraines with aura may need EEGs and they might also have overlapping pathophysiologic mechanisms with epilepsy.

Ictal Epileptic Headache: When Terminology Is Not a Moot Question

The relationship between headache and epilepsy is complex and despite the nature of this association is not yet clear. In the last few years, it has been progressively introduced the concept of the “ictal epileptic headache” that was included in the recently revised International Classification of Headaches Disorders 3rd edition (ICHD-3-revised). The diagnostic criteria for ictal epileptic headache (IEH) suggested in 2012 were quite restrictive thus leading to the underestimation of this phenomenon. However, these criteria have not yet been included into the ICHD-3 revision published in 2018, thus creating confusion among both, physicians and experts in this field. Here, we highlight the importance to strictly apply the original IEH criteria explaining the reasons through the analysis of the clinical, historical, epidemiological and pathophysiological characteristics of the IEH itself. In addition, we discuss the issues related to the neurophysiopathological link between headache and epilepsy as well as to the classification of these epileptic events as “autonomic seizure.”

An update on EEG in migraine

Introduction: In the past few years, brain functional analysis has provided scientific evidence supporting the neuronal basis of migraine. The role of electroencephalography (EEG) in detecting subtle dysfunctions in sensory temporal processing has been fully re-evaluated, thanks to advances in methods of quantitative analysis. However, the diagnostic value of EEG in migraine is very low, and migraine diagnosis is completely based on clinical criteria, while the utility of EEG in migraine pathophysiology has only been confirmed in more recent applications. Areas covered: The present review focuses on the few situations in which EEG may provide diagnostic utility, and on the numerous and intriguing applications of novel analysis, based on time-related changes in neuronal network oscillations and functional connectivity. Expert opinion: Although routine EEG is not particularly useful for the clinical assessment of migraine, novel methods of analysis, mostly based on functional connectivity, could improve knowledge of the migraine brain. The application is worthy of promotion and improvement in support of neuroimaging data to shed light on migraine mechanisms and support the rationale for therapeutic approaches.

Headaches and their relationships to epileptic seizures

PURPOSE

The frequent association between headache and epilepsy has been increasingly studied in recent years. Through this study, we attempted to study possible temporal associations between epileptic seizures and headaches. We also tried to describe clinical aspects of headache in our patients with epilepsy.

PATIENTS AND METHODS

We included patients with epilepsy and patients without epilepsy who presented for a first neurologic episode suggestive of epileptic seizure or unusual headache. These patients were invited to answer a standardized questionnaire screening for headache characteristics. Patients with epilepsy were asked for further data about their epilepsy. Electroencephalogram (EEG) was performed in all patients. Brain Magnetic resonance imaging MRI was reserved for patients in whom we suspected a structural lesion.

RESULTS

Overall, we included 47 patients with a mean age of about 39 ± 15 years (19 to 68 years old) and a female predominance (Sex Ratio: SR = 1.47). Most frequently, our patients documented periictal headache (Peri-IH) (85.1%) including respectively ictal headache (IH: 31.9%); postictal headache (Post-IH: 21.3%), and preictal headache (Pre-IH: 4.3%). Less frequently, our patients noted interictal headache (Inter-IH: 31.9%). Interestingly, these subgroups exhibited different headache patterns with predominantly unclassified-type headache (U-TH) in patients with IH (72.7%), tension-type headache (T-TH) in patients with Post-IH (73.3%), and migraine-type headache (M-TH) in patients with Inter-IH (60%).

CONCLUSIONS

Our results suggest that patients with epilepsy could exhibit different headache types. The clinical pattern of headache seemed to be linked to the time of seizure onset.

New-onset interictal headache in Persons with epilepsy (PWE): A case-control study

PURPOSE

In our personal experience, headache is a frequent complaint in Persons with epilepsy (PWE) receiving antiepileptic drugs (AEDs), carbamazepine (CBZ) in particular. There is hardly any systematic study on AEDs-associated headache. We assessed the association of new-onset interictal headache in PWE with CBZ compared with other AEDs and factors associated with it.

METHODS

Two thousand PWE on AEDs were screened, and 165 persons having new-onset interictal headache were identified. Eight persons were excluded because of comorbid illnesses that could potentially contribute to a headache. Finally, 157 were recruited for the study. One hundred fifty-seven age- and sex-matched PWE on AEDs, without headache, were recruited as controls. Headache questionnaire based on the International Classification of Headache Disorders (ICHD-II) criteria was used. Demographic factors, seizure characteristics, type and dose of AEDs, findings on electroencephalogram (EEG), and magnetic resonance imaging (MRI)/computerized tomography (CT) were recorded.

RESULTS

Among PWE with headache, the majority [88 (56.1%)] were on CBZ compared with other AEDs but not significantly different from controls. In 71 (45%) persons, the headache had migrainous character. In both univariate and multivariate analyses, lower seizure frequency and fewer EEG abnormalities were found to be independent predictors of headache.

CONCLUSIONS

New-onset interictal headache is a significant issue in PWE; nonmigrainous headache is more common than the migrainous type. Carbamazepine was not found to have any predilection for new-onset interictal headache compared with other AEDs. A lower frequency of seizures and EEG abnormalities in PWE with headache may suggest that seizures contribute less to the development of headache and may further support the hypothesis that AEDs may be significant contributing factors for the headache.

Comorbidity of Migraine and Epilepsy in Pediatrics: A Review

Migraine and epilepsy are classified as chronic paroxysmal neurologic disorders sharing many clinical features, as well as possible treatment options. This review highlights the similarities between migraine and epilepsy in pediatrics, focusing on epidemiologic, pathophysiological, genetic, clinical, and pharmacologic aspects. Despite the fact that several syndromes share symptoms of both migraine and epilepsy, further research is needed to clarify the pathophysiological and genetic basis of their comorbidity. Drugs used for prophylactic therapy of migraine and epilepsy have similar pharmacologic properties. The role of epileptic pharmacotherapy in the prophylaxis of migraine is assessed, including the use of conventional antiepileptic drugs, calcium channel blockers, and nonpharmacologic methods such as dietary therapy, supplements, and vagal nerve stimulation. Further randomized, controlled clinical trials assessing pharmacologic and nonpharmacologic methods for the treatment of both disorders are essential, in order to initiate new therapeutic approaches.

Pediatric Headache and Seizures

Headache and seizures are two of the most common complaints seen in the field of pediatric neurology with headache being number one. Both these conditions may coexist. Where the difficulty begins is when the symptoms are not clear cut in making a diagnosis, and conditions are possible as either an atypical seizure or migraine variant. What further complicates matters is the fact that there are many underlying neurologic conditions that carry with them a higher likelihood of developing both headaches and seizures, making each a distinct possibility when obtaining a history from a parent about unusual spells. Although differentiating between seizure and headache may not be easy, with a focused yet thorough history and appropriate use of investigative tools, it can be done. Coming to the correct diagnosis is only the start; once seizures and or headaches have been appropriately diagnosed then the real challenge begins and that is finding a way to successfully treat the headaches and seizures. Within pediatric neurology, the acute options tend to be more diagnosis specific whereas the prophylactic ones may overlap and treat both headaches and seizures. In the following review, we will discuss the epidemiology of pediatric headaches and seizures, the overlap between these 2 conditions in diagnosis, as well as how to tell them apart, and the treatment options and prognosis of both common neurologic disorders in children.

Epileptic headache: A rare form of painful seizure

PURPOSE

To describe the concept, features and mechanisms of epileptic headache (EH).

METHODS

Analysis of all published articles concerning EH and related subjects.

RESULTS

There are more than 30 published case studies of patients with headache as the only manifestation of a seizure, a condition that has been variously called "EH", "ictal epileptic headache", "hemicrania epileptica", "cephalic pain seizure". It is necessary to differentiate EH from "migralepsy" and "ictal non-epileptic headache". EH may be an isolated event or the initial phase of a seizure followed by other manifestations. An isolated EH is clinically relevant because it is often symptomatic of structural brain disease; this underlines the importance of a differential diagnosis as the head pain of EH has no specific diagnostic characteristics. The described cases indicate that the location of the foci may vary, thus suggesting the involvement of different parts of the pain network. EH is a "focal aware" seizure, but there are a few reports of cases in which it was associated with generalised epileptiform activity. A correct diagnosis of EH requires an ictal EEG recording showing epilepsy-compatible discharges that coincide with the onset and cessation of the headache. A rapid response to the acute administration of an antiepileptic drug may support the diagnosis.

CONCLUSIONS

EH is a particular type of pain seizure that has a complex pathophysiology and, when isolated, requires differential diagnostic consideration. We believe that, although it is not frequent, pain as an ictal symptom should be highlighted in the operational classification of seizure types.

Epilepsy and headaches: Further evidence of a link

OBJECTIVE

Epilepsy and primary headaches are two of the most common neurologic conditions that share some common clinical characteristics, and can affect individuals of all age groups around the world. In recent years, the underlying pathophysiologic mechanisms potentially common to both headaches and epileptic seizures have been the subject of scrutiny. The objective of this study was to determine the frequencies and types of headaches in patients with epilepsy, and evaluate any temporal relationship with epileptic seizures.

METHOD

Demographic data, epilepsy durations, seizure frequencies, seizure types and antiepileptic medications used were captured of 349 patients who were followed up at our epilepsy outpatient clinic. Patients who experienced headaches were grouped based on the type of headaches and on whether their headaches occurred in the preictal, postictal or interictal period.

RESULT

Three hundred forty-nine patients (190 females, 159 males) were enrolled in the study. The patients' average age was 30.9±13.1 years, and average epilepsy duration was 13.5±10.9 years. The types of epileptic seizures were partial in 19.8% of patients, generalized in 57.9%, and secondary generalized in 20.3% of patients. Some 43.6% of the patients did not experience headaches, and 26.9% had migraine and 17.2% tension-type headaches. Headaches could not be classified in 12.3% of patients. The headaches occurred preictally in 9.6%, postictally in 41.6% and interictally in 8.6% of patients. The ratio of headaches was lower in male patients compared with females, and females experienced migraine-type headaches more frequently compared with males (p=0.006). Migraine-type headaches were less frequent a mong patients who experienced less than one seizure per year, but more frequent (p=0.017) among those who experienced more than one seizure per month, but less than one seizure per week. Migraine-type headaches were significantly more frequent (p=0.015) among patients receiving polytherapy compared with patients receiving monotherapy.

CONCLUSION

The results of this study suggest that headaches, particularly migraine-type headaches, were frequently experienced by patients with epilepsy, postictal headaches were more common, and the frequency of migraine attacks could be linked with seizure frequency and the type of treatment.

Exploring two novel cases of suspected ictal epileptic headache, a rare form of paediatric epilepsy

AIM

Ictal epileptic headache (IEH) is a rare and underestimated epileptic form, characterised by epileptiform discharges and headache attacks without any other ictal sensory-motor manifestations. IEH is difficult to diagnose, because the epileptiform discharges have to be registered during the headache attack and the headache has to disappear after the intravenous administration of an anti-epileptic drug, according to the last diagnostic criteria. This study explored the clinical, neuro-physiological and therapeutic features of IEH in the paediatric population.

METHODS

We analysed two novel cases of adolescent female patients with chronic headache and a long history of unsuccessful analgesic oral therapy and without any other ictal sensory-motor events. We also reviewed the entire literature on paediatric IEH.

RESULTS

The clinical history and diagnostic process led us to highly suspect IEH in both patients, and the successful therapy with oral anti-epileptic drugs, namely topiramate and ethosuximide, which resolved the chronic headache, enforced our diagnostic hypothesis. Our literature review highlighted the rarity of IEH clinical reports, particularly in the paediatric population, mainly due to the stringent diagnostic criteria.

CONCLUSION

Our study sheds further light on IEH in the paediatric population and on the importance of diagnostic electroencephalograms in the clinical management of paediatric patients suffering from chronic headache.

Epileptic Angina

Purpose

To investigate the probable ictal origin of unexplained episodic chest pain and if possible to lateralize and localize the epileptic focus.

Methods

A 14 year old boy presented with episodic short lasting localized chest pain. His cardiac and other systemic work-up were normal. MRI brain did not reveal any structural pathology. Video telemetry was done for characterization of the paroxysms.

Results

Interictal record showed left fronto-central epileptiform discharges. A left hemispheric, predominantly centroparietal ictal rhythm was identified. The possible localizations of this unusual semiology are somatosensory areas I and II, supplementary sensorimotor area, posterior insula and cingulate cortex. Patient responded remarkably to antiseizure drugs.

Conclusion

Pain is a rare manifestation of epilepsy observed in less than 1% of patients. When present, it is usually accompanied by other focal features. This rare occurrence of epileptic seizures masquerading as angina is a novel observation.

The burden of headache in people with epilepsy

PURPOSE

To investigate and classify headaches in adult people with epilepsy, to evaluate the burden of headaches, and to compare findings with a population-based epidemiological study.

METHODS

Two hundred eighty (61.4% women) people with epilepsy (mean age 37.8±14.5, mean duration of epilepsy 13.2±11.9years) completed a questionnaire collecting socio-demographic and clinical data, questions clarifying their type of a headache, a Qolie-10 questionnaire and a Headache-Attributed Lost Time (HALT) index. An experienced neurologist also interviewed them.

RESULTS

83.2% of respondents reported some type of headache. From those with inter-ictal headaches (77.9%), 39% reported tension-type headache, 31.7% reported migraine, and 7.8% reported medication-overuse headache and 16% reported possible persistent headache attributed to traumatic head injury. The impact of headache assessed through the HALT grading showed that 40.4% were grade 1, 9.6% grade 2, 14.7% grade 3 and 35.3% grade 4. Although, the prevalences of different headache types were similar to those in our population-based study, migraine seemed to be more common in males with epilepsy than in general population, and medication-overuse headache was more common in people with epilepsy than in the general population.

CONCLUSIONS

People with epilepsy experience headaches irrespective of their sex or age. The burden of headaches is very important in patients with epilepsy, since headaches usually cause a moderate or severe burden to their quality of life and suggest a clear clinical need. Clinicians should recognize headache as a common comorbidity of epilepsy, as it may influence antiepileptic drug choice, and may need specific treatment.

Correlation between headaches and affective symptoms in patients with epilepsy

Headaches are a neglected entity in patients with epilepsy (PWE), although PWE have a high chance of suffering from seizure-related as well as seizure-unrelated headaches. We aimed to identify the prevalence and characteristics of headaches and investigate the correlation between headaches and affective symptoms in PWE. Consecutive PWE who visited our tertiary outpatient clinic were interviewed about headaches and epilepsy. Affective symptoms were evaluated using the Korean version of the Beck Depression Inventory-II (BDI-II), Beck Anxiety Inventory (BAI), and suicidality portion of the Mini-International Neuropsychiatric Interview. We classified headaches as interictal or seizure-related headaches (SRHs; pre- and postictal). Tension-type headache and migraine were defined based on International Classification of Headache Disorders criteria. From the initial cohort of 177 patients (92 men, mean age: 37.1years), 73 (41.2%) reported suffering from interictal (N=34, 19.2%), preictal (N=3, 1.7%), and postictal (N=48, 27.1%) headaches. Univariate analysis revealed significantly higher BDI and BAI scores in the headache group. Tension-type headaches were the most frequent, and half of the interictal headaches and most of the SRHs were untreated. Spearman's partial correlation analyses showed that headaches overall were significantly related with depression and anxiety. Interictal headaches were correlated with depression only, and postictal headaches were correlated with depression as well as suicidality, separately. These results show that investigating and controlling headaches may relieve affective symptoms and ultimately improve the quality of life of PWE.

Stroke and migraine is there a possible comorbidity?

The association between migraine and stroke is still a dilemma for neurologists. Migraine is associated with an increased stroke risk and it is considered an independent risk factor for ischaemic stroke in a particular subgroup of patients. The pathogenesis is still unknown even if several studies report some common biochemical mechanisms between these two diseases. A classification of migraine-related stroke that encompasses the full spectrum of the possible relationship between migraine and stroke includes three main entities: coexisting stroke and migraine, stroke with clinical features of migraine, and migraine-induced stroke. The concept of migraine-induced stroke is well represented by migrainous infarction and it is described in the revised classification of the International Headache Society (IHS), representing the strongest demonstration of the relationship between ischaemic stroke and migraine. A very interesting common condition in stroke and migraine is patent foramen ovale (PFO) which could play a pathogenetic role in both disorders. The neuroradiological evidence of subclinical lesions most typical in the white matter and in the posterior artery territories in patients with migraine, opens a new field of research. In conclusion the association between migraine and stroke remains an open question. Solving the above mentioned issues is fundamental to understand the epidemiologic, pathogenetic and clinical aspects of migraine-related stroke.

Ictal epileptic headache revealing non convulsive status epilepticus in a case of eyelid myoclonia with absences

Epileptic seizures and headache attacks are two common neurologic phenomena characterized by paroxysmal alteration of brain functions followed by complete restauration of the baseline condition. Headache and epilepsy are related in numerous ways, and they often co-occur. Although the link between these two diseases is not completely clear, several clinical, physiopathological and therapeutic features overlap. Headache is reported in association with epileptic seizures as a pre-ictal, ictal or post-ictal phenomenon. We present the case of a 40 year-old woman affected by eyelid myoclonia with absences (EMA) with a history of prolonged headache attacks. A video-EEG recording performed during one of these episodes showed subcontinuous epileptic activity consisting of generalized spike-and-wave discharges (GSWDs), clinically associated with tensive headache. Our work represents one of the few well EEG-documented cases of ictal epileptic headache in idiopathic generalized epilepsy (IGE).

Ictal epileptic headache in adult life: Electroclinical patterns and spectrum of related syndromes

OBJECTIVES

Both headache and epilepsy are frequent paroxysmal disorders that often co-occur or are related in numerous ways. Although ictal epileptic headache has become the focus of several studies, this remains a very rare and not well-known phenomenon. Electroclinical features, pathophysiology, and syndromic context are heterogeneous. We investigated the electroclinical and neuroimaging findings in a population of adult patients with ictal epileptic headache.

METHODS

We retrospectively examined 8800 EEG recordings of almost 4800 patients admitted to our video-EEG laboratory from 2010 to 2013 with a history of well-documented epilepsy. We selected patients who reported headache closely related to a seizure documented by video-EEG or 24-hour ambulatory EEG. We analyzed ictal electroclinical features of headache, and we defined the related epileptic syndromes.

RESULTS

We identified five patients with ictal epileptic headache. Two patients described tension headache during an epileptic seizure. In three patients, the headache was accompanied by other "minor" neurological symptoms mimicking a migrainous aura. In all cases, the headache stopped with the end of the epileptic activity. Three patients had a history of partial symptomatic epilepsy with cerebral lesions (low grade glioma, astrocytoma, porencephalic cyst) in the left posterior regions, whereas two patients were affected by idiopathic generalized epilepsy.

CONCLUSION

This study confirms the rarity of ictal epileptic headache. To date, well-documented video-EEG cases remain as exceptional reports, especially in cases of idiopathic generalized epilepsies. Moreover, we confirm the main involvement of posterior regions in patients with ictal epileptic headache affected by partial symptomatic epilepsies.