Should "migralepsy" be considered an obsolete concept? A multicenter retrospective clinical/EEG study and review of the literature

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.

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.

Visual Disturbances Spectrum in Pediatric Migraine

Migraine is a complex neurological disorder with partially unknown pathophysiological mechanisms. The prevalence in childhood ranges from 7.7% to 17.8%, thus representing the most frequent primary headache. In half of the cases, migraine is accompanied or preceded by various neurological disturbances, among which the visual aura is the best known. In literature, other conditions, such as Alice in Wonderland Syndrome and Visual Snow syndrome, are characterized by visual manifestations and are often associated with migraine. The aim of this narrative review is to describe the spectrum of visual disturbances in pediatric migraine and their pathophysiological mechanisms.

Migraine with aura

This chapter describes the different types of aura including rare aura subtypes such as retinal aura. In addition, aura manifestations not classified in the International Classification of Headache Disorders and auras in headache disorders others than migraine are also described. The differential diagnosis of migraine aura comprises several neurological disorders which should be known to specialists. Migraine aura also has impact on the choice of migraine treatment; recommendations for the treatment of the migraine aura itself are also presented in this chapter.

Case report: An EEG captured case of migralepsy/migraine aura-triggered seizures

Introduction

Migraine and epilepsy are common chronic neurological disorders presenting with paroxysmal attacks of transient cerebral dysfunction, followed by subsequent return to baseline between episodes. The term “migralepsy” has been proposed to define migraine-triggered epileptic seizures classified by the ICHD-III as a complication of migraine with an aura.

Case

A 55-year-old man with a 30-year history of migraine without aura presented with a new onset left parietal pain accompanied by visual disturbances occurring up to 20 times per day. His visual distortions included kaleidoscopic vision, flashes of shadows, and a right superior quadrantanopia lasting 20 min. He described discrete 2-min episodes of scintillating scotomas in his right visual field. Ictal EEG demonstrated a left occipital onset focal aware seizure with his clinical symptoms. The patient was started on valproic Acid and has remained asymptomatic.

Discussion

The diagnostic criteria as set out by the ICHD-III for migralepsy and other syndromes with migrainous and ictal features remain confusing for practitioners as there is much overlap in clinical manifestations of these entities. EEG should be obtained when ictal features are noted among patients presenting with headache.

Headache in idiopathic/genetic epilepsies: Cluster analysis in a large cohort

OBJECTIVES

The link between headache and epilepsy is more prominent in patients with idiopathic/genetic epilepsy (I/GE). We aimed to investigate the prevalence of headache and to cluster patients with regard to their headache and epilepsy features.

METHODS

Patients aged 6-40 years, with a definite diagnosis of I/GE, were consecutively enrolled. The patients were interviewed using standardized epilepsy and headache questionnaires and their headache characteristics were investigated by experts in headache. Demographic and clinical variables were analyzed and patients were clustered according to their epilepsy and headache characteristics using an unsupervized K-means algorithm.

RESULTS

Among 809 patients, 508 (62.8%) reported having any type of headache; 87.4% had interictal headache and 41.2% had migraine. Cluster analysis revealed two distinct groups for both adults and children/adolescents. In adults, having a family history of headache, ≥5 headache attacks, duration of headache ≥24 months, headaches lasting ≥ 1 hour, and visual analog scale scores >5 were grouped in one cluster, and juvenile myoclonic epilepsy (JME), myoclonic, and generalized tonic-clonic seizures (GTCS) were clustered in this group (cluster 1). Self-limited epilepsy with centro-temporal spikes and epilepsy with GTCS alone were clustered in cluster 2 with the opposite characteristics. For children/adolescents, the same features as in adult cluster 1 were clustered in a separate group, except for the presence of JME syndrome and GTCS alone as a seizure type. Focal seizures were clustered in another group with the opposite characteristics. In the entire group, the model revealed an additional cluster, including patients with the syndrome of GTCS-alone (50.51%), with ≥ 5 attacks, headache lasting >4 hours, and throbbing headache; 65.66% of patients had a family history of headache in this third cluster (n=99).

SIGNIFICANCE

Patients with I/GE can be clustered into distinct groups according to headache features along with seizures. Our findings may help in management and planning for future studies.

Case Report: Migralepsy: The Two-Faced Janus of Neurology

We report three cases of pediatric patients suffering from migraine aura triggered seizures. This entity, also called migralepsy, still does not have a unique definition today. Migraine and epilepsy are both episodic neurological disorders with periods of interictal well-being; this is indicative of similar pathophysiological mechanisms, such as increased neuronal excitation and ion channel dysfunction. The purpose of this paper is to discuss the clinical and instrumental features of migralepsy through the description of three clinical cases in which the symptoms of the usual migraine aura developed into a generalized tonic–clonic or focal seizure.

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.

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.”

Short-lasting retroorbital pain attacks as a form of ictal epileptic headache: Case report

Background and objectives

Ictal epileptic headache is a rare form of painful seizure, habitually consisting of migrainous or tension-type headache. We describe a case of a patient with short-lasting, severe retroorbital pain attacks caused by frontal lobe epilepsy.

Case report

A 25-year-old male patient presented with recurrent attacks of paroxysmal, short-lasting, excruciating left periorbital and facial pain mainly occurring from sleep. After intracranial EEG exploration and resection of a right prefrontal focal cortical dysplasia, long-term seizure and headache remission was obtained.

Discussion

Our case extends the clinical and neuroanatomical spectrum of ictal epileptic headache and suggests that long-term remission can be obtained by resective epilepsy surgery. It also reinforces the role of the prefrontal cortex in the pain matrix and pain generation.

Conclusion

Despite its rarity, ictal epileptic headache should be suspected in selected patients, particularly those with other ictal symptoms and signs, history of epileptic seizures, or neuroimaging abnormalities.

Secondary Headaches in Children and Adolescents: What Not to Miss

INTRODUCTION

Headaches are a common occurrence in childhood and adolescence. Most children presenting with a chief complaint of headache have a self-limited infectious disorder or primary headache syndrome that should not require extensive workup.

PURPOSE OF REVIEW

Differentiating these conditions from other more serious causes of headache in children can sometimes be difficult. This article aims to provide information regarding "red flags" that should indicate a need for concern for disorders that require more urgent evaluation.

RECENT FINDINGS

Long-held beliefs about specific "red flags" that have been analyzed in recent years as to their validity and new criteria for the diagnosis of idiopathic intracranial hypertension have been elaborated based on study. These publications are reviewed in this article. Knowledge of past and current literature on secondary headache in children, combined with thorough history taking and examination, should help determine when there is concern for a serious secondary cause for headache in children and adolescents and direct workup.

Headache and Epilepsy

Headache, especially migraine, has long been associated with epilepsy, based on the common clinical features of these disorders. Both migraine and epilepsy have a genetic predisposition and share common pathophysiological mechanisms including an imbalance between excitatory and inhibitory factors that result in spells of altered brain function and autonomic symptoms. There are well-documented reports on the headache as a sole manifestation of epileptic seizure and headache is commonly associated with as preictal, ictal, and postictal symptoms in epilepsy patients. In addition, migraine and epilepsy are frequently described as highly comorbid conditions and several antiepileptic drugs are used for the patients with migraine as well as epilepsy. In the present review, we briefly discuss the connection between headache and epilepsy in various aspects, including classification, clinical features, epidemiology, genetics, pathophysiology, and treatment.

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.

Killing two birds with one stone: successful opioid monotherapy in intractable migraine-triggered epilepsy, a case series

The novel concept explored in this case series is the primacy of headaches in generating seizures in those patients who suffer from migraine-triggered epilepsy. In this series, once the migraine headaches were fully suppressed, via daily scheduled opioid therapy, the seizures also stopped. Seizures returned, however, after the patients stopped the opiate regimen for any reason. The above pharmacological scenario is reminiscent of a similar but naturalistic course of events reported on the salutary effects of ketogenic diet, or changes in life style, in similar cases of migraine-triggered epilepsy. The primacy of migraine in treating what has been named 'seizure headaches' is seen in two other scenarios (i.e. the salutary effect of ketogenic diet and lifestyle changes resulting in restoration of one's sleeping pattern) thus stopping the migraine as well as the seizures associated with the same. This case series recounts the same phenomenon via utilizing around-the-clock maintenance opioid therapy.

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.

Clinical and electroencephalographic abnormalities during the full duration of a sporadic hemiplegic migraine attack

Electroencephalographic (EEG) abnormalities have been reported during migraine attacks but their spatial and temporal distributions are not well known. We report the temporospatial dynamics of EEG during the full duration of a migraine attack with aura in a 19-year-old woman. She experienced episodes of hemiplegic migraine since the age of 2.5 years, with right hemibody paralysis preceded by visual symptoms. She reported severe pain of the right hemibody just before hemiplegia that was enventually suggestive of possible epileptic seizure, justifying diagnostic video-EEG monitoring. Sporadic hemiplegic migraine was diagnosed in the absence of family history. EEG was normal at the beginning of visual aura. After 15minutes, posterior slow waves appeared over the migrainous hemisphere, spreading progressively towards anterior regions: first the central region (5minutes after onset of contralateral hemiplegia), then the frontal region and over both hemispheres. A new de novo mutation was identified in the SCN1A gene.

The borderland of migraine and epilepsy in children

OBJECTIVE

To provide a review on the spectrum of migraine-epilepsy disorders in children.

BACKGROUND

The migraine-epilepsy continuum covers a fascinating array of disorders that share many clinical similarities but also differ fundamentally in pathophysiology. In the pediatric population, its study can be complicated by the young age of those affected and the lack of clear understanding of the neurobiology of these disorders within the developing brain.

DISCUSSION

This review serves to discuss the borderland of migraine and epilepsy in children. It will focus on epidemiology and comorbidity of the two disorders, possible mechanisms for shared pathophysiology informed by basic and translational science, and an overview of clinical similarities and differences. It will also discuss differentiation of migraine aura from childhood occipital epilepsies. Finally, the review concludes with a discussion of current classification methods for capturing cases on the migraine-epilepsy spectrum and a call for a united approach towards a better definition of this spectrum of disorders.

CONCLUSION

Recent advances examining the migraine-epilepsy spectrum show clinicopathological similarities between the two disorders in children. Epidemiology demonstrates reciprocally increased incidences of epilepsy in migraineurs and of migraines in children with epilepsy, however, prospective longitudinal in children are currently lacking. Clinically, the two disorders show similarity in preictal, ictal, and postictal phenomena, with close temporal association of the two conditions described by the controversial term of "migralepsy." Basic science research has contributed significant improvements in understanding the generation of both of these episodic neurological conditions, with common links seen at a cellular level involving synaptic glutamate release and the provocation of varying propagation methods including cortical spreading depression in migraine and the paroxysmal depolarizing shift in epilepsy. Despite these significant gains in understanding, improved classification methods are required to identify and further study these interrelated conditions and move towards improved diagnosis and treatment of disorders on the migraine-epilepsy continuum in children.

The Comorbidity of Migraine and Epilepsy in Children and Adolescents

Migraine and epilepsy share a number of clinical attributes, including pathophysiology and clinical expression. Both are paroxysmal in nature and thus constitute episodic disorders, yet either may be chronic and/or recurrent. Epileptic seizures and migraine headaches may be mistaken one for the other and may even overlap. In particular, occipital lobe seizures may be misdiagnosed as migraine auras. In this article, we review the relationship between migraine and epilepsy, including the known genetic contributions to both conditions, prodromal, ictal, and postictal headache and shared pathophysiology and treatment options. We describe clinical conditions in which both migraine and epilepsy are prominent features. Lastly, we discuss electronecephaographic abnormalities that have been known to occur in individuals with migraine.

Reappraisal of epileptic pain as a rare symptom of seizures

PURPOSE

To draw attention to epileptic pain which is a rare seizure symptom mostly causing wrong diagnosis and delayed treatment. We present nine patients in whom pain was a prominent initial or early ictal symptom.

METHODS

We reviewed the records of 4736 patients, and found nine patients who had pain as an aura or an early prominent symptom of their seizures. Seizure semiology, EEG, and cranial imaging features were evaluated retrospectively.

RESULTS

Age at seizure onset ranged from 6 months to 50 years, and the mean age during the study was 37.7±11.9 years. Pain was predominantly peripherally localized in four patients, whereas cephalic pain was detected in three patients, and abdominal pain was detected in two patients. Electroencephalography (EEG) revealed epileptic abnormalities on the temporoparietal and frontotemporal regions in three patients each. Photosensitive generalized epileptic discharges were detected in one and diffuse background slowing in the remaining two other patients. Electroencephalography abnormalities were lateralized to the contralateral site of the pain in four patients with strictly localized pain. Three patients revealed no abnormality on the cranial MR imaging, whereas others showed different types of abnormality such as heterotopias (n:1), mesial temporal lobe atrophy (n:1), white and gray matter sequela lesions (n:1), diffuse white matter lesion (n:1), chronic encephalomalacia and gliosis (n:1), and perivascular space dilatation (n:1).

CONCLUSION

Epileptic pain is a neglected, but important, semiologic symptom with localization and lateralization value in the patients with somatosensorial seizures of parietal as well as temporal lobe origin. It occurs mainly as peripherally localized, cephalic, or abdominal pain and is usually associated with a symptomatic etiology. Awareness of epileptic pain is important to avoid misdiagnosis and delayed treatment.

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.

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

PURPOSE

When we published the diagnostic criteria for "ictal epileptic headache" in 2012, we deliberately and consciously chose to adopt restrictive criteria that probably underestimate the phenomenon, rather than spread panic among patients and physicians who are reluctant to accept this entity.

METHODS

Here we discuss four intriguing clinical cases to highlight why we believe, to this day, that it is necessary to follow these restrictive diagnostic criteria.

CONCLUSIONS

EEG is not recommended as a routine examination for children diagnosed with headache, but it is mandatory and must be carried out promptly in cases of prolonged headache that does not respond to antimigraine drugs, if epilepsy is suspected or has been diagnosed previously. This is not a marginal or irrelevant question because possible isolated, non-motor, ictal manifestations should be taken into account before declaring that an epileptic patient is "seizure free" so as to ensure that any decision taken to suspend anticonvulsant therapy is safe.

Periictal and interictal headache including migraine in Dutch patients with epilepsy: a cross-sectional study

As early as in 1898, it was noted that there was a need to find "a plausible explanation of the long recognized affinities of migraine and epilepsy". However, results of recent studies are clearly conflicting on this matter. In this cross-sectional study, we aimed to define the prevalence and characteristics of both seizure-related and interictal headaches in patients with epilepsy (5-75years) seeking help in the tertiary epilepsy clinic SEIN in Zwolle. Using a questionnaire, subjects were surveyed on the existence of headaches including characteristics, duration, severity, and accompanying symptoms. Furthermore, details on epilepsy were retrieved from medical records (e.g., syndrome, seizure frequency, and use of drugs). Diagnoses of migraine, tension-type headache, or unclassifiable headache were made based on criteria of the International Classification of Headache Disorders. Between March and December 2013, 29 children and 226 adults were evaluated, 73% of whom indicated having current headaches, which is significantly more often when compared with the general population (p<0.001). Forty-nine percent indicated having solely interictal headache, while 29% had solely seizure-related headaches and 22% had both. Migraine occurs significantly more often in people with epilepsy in comparison with the general population (p<0.001), and the occurrence of tension-type headaches conforms to results in the general population. These results show that current headaches are a significantly more frequent problem amongst people with epilepsy than in people without epilepsy. When comparing migraine prevalence, this is significantly higher in the population of patients with epilepsy.

Headache in epilepsy patients: the (un)awareness of this phenomenon among Dutch neurologists

PURPOSE

Headache is a frequently heard complaint that can strongly influence quality of life. This is probably even more so in people with a chronic illness. Knowing that headache, and especially migraine, is more frequent among epilepsy patients, the knowledge concerning this problem has been studied among Dutch neurologists.

METHODS

Seven hundred and seventy two neurologists, working in 89 hospitals and two tertiary epilepsy clinics were asked to participate. Using a questionnaire, neurologists were surveyed on different subjects, e.g. whether they thought current headaches are more frequent in people with epilepsy than in the general population, their interest for epilepsy and how many patients with epilepsy visited their polyclinic per month.

RESULTS

In total, 334 questionnaires were returned (response rate of 43%) of which 18 were excluded. One third of neurologists responded affirmatively that current headaches are more prevalent among people with epilepsy and eight percent knows that this is, more specified, migraine. The number of years of experience does not influence knowledge on headaches in epilepsy patients. The interest in epilepsy and the number of epilepsy patients per month on the polyclinic does.

CONCLUSIONS

These results show that the occurrence of headache in people with epilepsy is underestimated by Dutch neurologists. This leaves an often bothersome and potentially treatable condition underexposed.

High prevalence of headaches in patients with epilepsy

Background

To examine the association between headaches and epilepsy.

Methods

Consecutive adult epileptic patients who went to the outpatient clinic of the Epilepsy Center of PLA General Hospital between February 01, 2012, and May 10, 2013, were recruited into this study. A total of 1109 patients with epilepsy completed a questionnaire regarding headaches.

Results

Overall, 60.1% of the patients (male: 57.2%; female: 63.8%) reported headaches within the last year. The age-weighted prevalence of interictal migraine was 11.7% (male 8.9%, female 15.3%), which is higher than that reported in a large population-based study (8.5%, male 5.4%, female 11.6%) using the same screening questions. The prevalence of postictal headaches was 34.1% (males 32.7%, females 35.2%), and the presence of preictal headaches was 4.5% (males 4.3%, females 5.2%). The prevalence of headache yesterday in the general population was 4.8% (male 3.0%, female 6.6%). Thus, the prevalence of headaches, including migraine, is higher in epileptic patients in China.

Conclusions

The high prevalence of postictal headaches confirms the frequent triggering of a headache by a seizure. A much lower frequency of preictal headaches, a condition in which the real triggering effect of the headache on the seizure might be difficult to prove.

Clinical factors associated with postictal headache in Chinese patients with partial epilepsy

PURPOSE

To investigate the incidence of postictal headache (PIH) and the factors potentially related to the occurrence of PIH in a Chinese epileptic center.

METHODS

Consecutive adult patients with epilepsy, referred to the outpatient clinic of the Epilepsy Center of the PLA General Hospital between February 01, 2012, and May 10, 2013, were recruited to this study. 854 patients with partial epilepsy completed a questionnaire regarding headache, 466 patients with temporal lobe epilepsy (TLE), 82 patients with occipital lobe epilepsy (OLE) and 306 patients with frontal lobe epilepsy (FLE). A semi-structured interview was performed in those who confirmed headache.

RESULTS

PIH occurred in 328 (38.41%) of the subjects. By type of epilepsy, PIH was found in 164 (35.19%) of the patients with TLE, 46 (56.01%) of the patients with OLE, and 118 (38.56%) of the patients with FLE. The incidence of PIH in OLE was significantly higher than in TLE and FLE (P<0.05). It occurs more frequently after generalized tonic-clonic seizures than other seizure types. Logistic regression analysis revealed that age at onset, type of seizure and classification of epilepsy were each significantly related to the occurrence of PIH.

CONCLUSION

The results of our study revealed possible relationships between PIH and the region of epileptic focus and area of spread of epileptic discharges.

Headache and comorbidity in children and adolescents

Headache is one of the most common neurological symptom reported in childhood and adolescence, leading to high levels of school absences and being associated with several comorbid conditions, particularly in neurological, psychiatric and cardiovascular systems. Neurological and psychiatric disorders, that are associated with migraine, are mainly depression, anxiety disorders, epilepsy and sleep disorders, ADHD and Tourette syndrome. It also has been shown an association with atopic disease and cardiovascular disease, especially ischemic stroke and patent foramen ovale (PFO).

"Headache and epilepsy"--how are they connected?

The relationship between headache and seizures is a complicated one, since these two conditions are related in numerous ways. Although the nature of this association is unclear, several plausible explanations exist: the two disorders coexist by chance; headache is part (or even the sole ictal phenomenon) of seizures or the post-ictal state; both disorders share a common underlying etiology; and epilepsy mimics the symptoms of migraine (as in benign childhood epilepsy). Seizures and headaches as well as their respective primary syndromes (epilepsy and headache/migraine) share several pathophysiological mechanisms. These mechanisms especially involve neurotransmitter and ion channel dysfunctions. Also, photosensitivity seems to play a role in the connection. In order to improve the care for patients with a clinical connection between migraine and epilepsy, it is necessary to try to understand more accurately the exact pathophysiological point of connection between these two conditions. Both experimental and clinical measures are required to better understand this relationship. The development of animal models, molecular studies defining more precise genotype/phenotype correlations, and multicenter clinical studies with revision of clinical criteria for headache/epilepsy-related disorders represent the start for planning future translational research. In this paper, we review the relationship between migraine and epilepsy in terms of epidemiology and pathophysiology with regard to translational research and clinical correlations and classification.

What have we learned about ictal epileptic headache? A review of well-documented cases

PURPOSE

The case report published in this issue by Wang et al. offers us an opportunity to review previously published "ictal epileptic headache" cases and draw attention to the criteria that have recently been published for this condition, taking into consideration not only the clinical-EEG and physiopathogenetic investigations required to diagnose this condition, but also the therapeutic aspects of the issue.

METHODS

To this aim we reviewed all well-documented cases that have been reported in the literature.

RESULTS

The relationship between headache and seizures is somewhat complicated. Although the nature of this association is not yet fully clear, several plausible explanations have been proposed. Further experimental and clinical investigations are, however, warranted to gain a better understanding of this relationship. Epilepsy and idiopathic headache/migraine share several pathophysiological mechanisms; a better understanding of these mechanisms will allow us to more accurately to assess the "real burden" and prevalence of the "ictal epileptic headache" phenomenon and its therapeutic implications.

CONCLUSIONS

The development of animal models and molecular studies and, above all, multicenter clinical studies conducted according to the proposed IEH criteria represent the starting point for a definitive international consensus on this intriguing topic. In addition, to improve the recognition of ictal epileptic headache, we should encourage the use of EEG recording in the emergency setting.

Benign epilepsy of childhood with centro-temporal spikes (BECTS) versus migraine: a neuropsychological assessment

PURPOSE

Epilepsy and migraine frequently show a clinical overlap. An increase in number of electroencephalographic abnormalities, such as centro-temporal spikes (CTS), may be observed in patients suffering from migraine, epileptic abnormalities that are typically in benign epilepsy of childhood with CTS (BECTS). The aim of this study is to better define the role of CTS in children with migraine compared to children with BECTS, in relation with their neuropsychological profile.

METHODS

Thirty-two children were enrolled and divided into three groups on the basis of their diagnosis: 16 children (eight males and eight females, aged 12.3 ± 2.58 years) affected by BECTS, 8 patients (four males and four females, aged 11.8 ± 3.47 years) affected by BECTS and migraine, and 8 children (four males and four females, aged 13.5 ± 1.79 years) affected by migraine showing CTS abnormalities. A cognitive and neuropsychological assessment was performed, using Wechsler Intelligence Scale for Children-third edition and NEPSY II, in all patients.

RESULTS AND CONCLUSIONS

A similar neuropsychological impairment was found in patients affected by BECTS and in those affected by BECTS and migraine; a significant deficit in short- and long-term verbal memory was evident in patients affected by migraine and CTS. CTS in patients with migraine can influence the neuropsychological tests, with a possible negative impact on language and learning development.

Ictal epileptic headache: an old story with courses and appeals

The term “ictal epileptic headache” has been recently proposed to classify the clinical picture in which headache is the isolated ictal symptom of a seizure. There is emerging evidence from both basic and clinical neurosciences that cortical spreading depression and an epileptic focus may facilitate each other, although with a different degree of efficiency. This review address the long history which lead to the 'migralepsy' concept to the new emerging pathophysiological aspects, and clinical and electroencephalography evidences of ictal epileptic headache. Here, we review and discuss the common physiopathology mechanisms and the historical aspects underlying the link between headache and epilepsy. Either experimental or clinical measures are required to better understand this latter relationship: the development of animal models, molecular studies defining more precise genotype/phenotype correlations as well as multicenter clinical studies with revision of clinical criteria for headache-/epilepsy-related disorders represent the start of future research. Therefore, the definition of ictal epileptic headache should be used to classify the rare events in which headache is the only manifestation of a seizure. Finally, using our recently published criteria, we will be able to clarify if ictal epileptic headache represents an underestimated phenomenon or not.