Lateralizing value of peri-ictal headache: A study of 100 patients with partial epilepsy

Somatosensory Auras in Epilepsy: A Narrative Review of the Literature

An aura is a subjective experience felt in the initial phase of a seizure. Studying auras is relevant as they can be warning signs for people with epilepsy. The incidence of aura tends to be underestimated due to misdiagnosis or underrecognition by patients unless it progresses to motor features. Also, auras are associated with seizure remission after epilepsy surgery and are an important prognostic factor, guiding the resection site and improving surgical outcomes. Somatosensory auras (SSAs) are characterized by abnormal sensations on one or more body parts that may spread to other parts following a somatotopic pattern. The occurrence of SSAs among individuals with epilepsy can range from 1.42% to 80%. The upper extremities are more commonly affected in SSAs, followed by the lower extremities and the face. The most common type of somatosensory aura is paresthetic, followed by painful and thermal auras. In the primary somatosensory auras, sensations occur more commonly contralaterally, while the secondary somatosensory auras can be ipsilateral or bilateral. Despite the high localizing features of somatosensory areas, cortical stimulation studies have shown overlapping sensations originating in the insula and the supplementary sensorimotor area.

Peri-ictal headache: An underestimated prognostic finding associated with idiopathic epilepsies

OBJECTIVE

There are a handful of studies investigating peri-ictal headache (PIH) and its clinical associations in patients with idiopathic/genetic epilepsies (I/GE). This multi-center study aimed to investigate PIH, which is an ignored comorbid condition in patients with I/GE, by headache experts and epileptologists working together.

METHODS

The data were collected from a cross-sectional large study, using two structured questionnaires for headache and epilepsy features, fulfilled by neurologists. Headaches were classified according to the International Classification of Headache Disorders, third edition, whereas seizure and syndrome types were diagnosed according to International League Against Epilepsy criteria. The patients with a headache starting 24 hours before the onset of the seizure (preictal) or within 3 hours after the seizure (postictal) were defined as patients with PIH. We compared demographic and clinical differences between two groups of patients with and without PIH statistically and used ROC curves to determine a threshold of the total number of seizure triggers associated with the occurrence of PIH.

RESULTS

Among 809 (531 females, 65.6%) consecutive patients with I/GE, 105 (13%) patients reported PIH (22 preictal, 82 postictal headaches, and one with both types). Peri-ictal headache was more frequently reported by females and those having a family history of migraine or epilepsy, and it was significantly associated with lower rates of seizure freedom for more than five years, drug resistance, and use of polytherapy, remarkably. Moreover, ROC curves showed that having more than 3 seizure triggers was associated with the presence of PIH.

CONCLUSION

Our findings revealed that PIH may be linked to poor outcomes in I/GEs and seems to be related to a lower ictal threshold precipitated by multiple triggers. Future prospective studies will illuminate the unknown underlying mechanisms and appropriate management strategies for PIH to improve the prognosis.

Reorganization of brain networks in patients with temporal lobe epilepsy and comorbid headache

OBJECTIVE

The white matter structural network changes remain poorly understood in patients with temporal lobe epilepsy and comorbid headache (PWH). This study aimed at exploring topological changes in the structural network.

METHODS

Twenty-five PWH, 32 patients with temporal lobe epilepsy without headache, and 22 healthy controls were recruited in this study. High-resolution structural MRI and diffusion tensor imaging data were acquired from these participants. A graph theory-based approach was employed to characterize the topological properties of the structural network. A network-based statistical analysis was employed to explore abnormal connectivity alterations in PWH.

RESULTS

Compared with healthy controls, PWH exhibited significantly decreased small-world index, shortest path length, increased clustering coefficient, global efficiency, and local efficiency. Patients with temporal lobe epilepsy and comorbid headache displayed a significantly reduced small-world index, shortest path length, and increased global efficiency when compared with patients with temporal lobe epilepsy without headache. In addition, PWH exhibited abnormal local network parameters, mainly located in the prefrontal, temporal, occipital, and parietal regions. Furthermore, network-based statistical analysis revealed that PWH had abnormal structural connections between the temporoparietal lobe, occipital lobe, insula, cingulate gyrus, and thalamus.

CONCLUSION

This study reveals the abnormal white matter structural network alterations in PWH, allowing a better insight into the neuroanatomical mechanisms that predispose epileptic patients to comorbid headaches from the network levels.

Seizure semiology: ILAE glossary of terms and their significance

This educational topical review and Task Force report aims to address learning objectives of the International League Against Epilepsy (ILAE) curriculum. We sought to extract detailed features involving semiology from video recordings and interpret semiological signs and symptoms that reflect the likely localization for focal seizures in patients with epilepsy. This glossary was developed by a working group of the ILAE Commission on Diagnostic Methods incorporating the EEG Task Force. This paper identifies commonly used terms to describe seizure semiology, provides definitions, signs and symptoms, and summarizes their clinical value in localizing and lateralizing focal seizures based on consensus in the published literature. Video-EEG examples are included to illustrate important features of semiology in patients with epilepsy.

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.

Headache in patients with mesial temporal lobe epilepsy with hippocampal sclerosis

OBJECTIVE

It is remarkable that epilepsy and migraine are similar diseases with many parallel clinical features, as well as sharing common pathophysiological mechanisms. However, the pathogenetic role of hippocampal sclerosis (HS) in epilepsy and headache coexistence has not been clarified. In this study, we aimed to investigate the frequency of headache/migraine and the relationship between headache and HS lateralizations in patients with mesial temporal lobe epilepsy (MTLE), accompanied by HS.

METHODS

Consecutive patients with mesial temporal lobe epilepsy with hippocampal sclerosis (HS-MTLE) followed up in epilepsy outpatient clinic were included in this study, with their demographic and clinical characteristics, HS lateralization, and side (unilateral-right-left, bilateral), which were recorded. Using the questionnaires, the type of headache [migraine, tension headache (TTH)] was determined. Patients in whom migraine and TTH could not be completely separated were recruited for the unclassified group. The temporal relationship of headache and seizures (peri-ictal and/or interictal), pain lateralization, and side (unilateral-right-left, bilateral, unilateral + bilateral) were likewise determined.

RESULTS

There were 56 patients (30 females, 26 males; mean age 36.9 ± 12.1 years; mean epilepsy duration 19.3 ± 12.5 years) included in the study. Thirty-one patients (55.4%) stated they had a headache: of these, eighteen (32.1%) had migraine and 9 (16.1%) had TTH. Migraine accounted for 58.1% of headaches and TTHs was 29%. Headache was unilateral in 15 patients, and bilateral or bilateral + unilateral in 16 patients. Of patients with migraine, pain was unilateral in 10, and bilateral or bilateral + unilateral in 8. HS was right-sided in 24 patients, left-sided in 30 patients, and bilateral in 2 patients. In patients with right-sided HS, it was an ipsilateral headache; bilateral headache was found to be more common in patients with left-sided HS (p = 0.029). No relationship was found between the lateralization of the headache and the side of HS in patients with migraine.

CONCLUSION

The results of our study showed that approximately half the patients with HS-MTLE did have a headache, with one third noting migraine type headache; this highlighted that HS may play a pathogenetic role in the development of headache, especially migraine, in patients with epilepsy. Further comprehensive studies will enable us to understand whether accompanying headache, especially migraine attacks in patients with epilepsy, can be determinant for HS-MTLE, as well as if it has a lateralizing value for HS.

Relationships between migraine and epilepsy: Pathophysiological mechanisms and clinical implications

Migraine and epilepsy are distinct neurological diseases with specific clinical features and underlying pathophysiological mechanisms. However, numerous studies have highlighted the complex and multifaceted relationships between the two conditions. The relationships between headache and epilepsy manifest themselves in different ways. Firstly, the clinical diagnosis of these disorders may be challenging in view of possible overlapping. While post-ictal headache is a frequent condition, ictal epileptic headache is a rare but challenging diagnosis. Both situations raise the question of the pathophysiological mechanism of headache triggered by seizures. Migraine aura and epilepsy can also exhibit overlapping symptoms leading to their misdiagnosis, in particular in the case of visual aura. Secondly, migraine with aura and epilepsy can occur as a co-morbid condition, particularly in familial hemiplegic migraine (FHM). From a pathophysiological perspective, the identification of genetic mutations in FHM has brought significant advances in the understanding of dysfunctions of neuronal networks leading to hyperexcitability. The purpose of this review is to present clinical situations encompassing headache and epilepsy that can be challenging in neurological practice and to discuss the underlying pathophysiological mechanism of such interactions.

Lateralization value of peri-ictal headache in drug-resistant focal epilepsy

OBJECTIVE

To examine the lateralizing value of unilateral peri-ictal and interictal headaches in patients with drug-resistant focal epilepsy (DRFE).

METHODS

Four-hundred consecutive patients undergoing presurgical evaluation for DRFE were interviewed. Patients with headache were broadly divided into two groups: peri-ictal and interictal headache. The lateralizing value of unilateral headache was compared in each group between three diagnoses: temporal lobe epilepsy (TLE), extratemporal lobe epilepsy (ETLE), and temporal-plus epilepsy (TEMP+ epilepsy).

RESULTS

Out of 400 patients, 169 (42.25%) had headaches. Peri-ictal headaches were experienced in 106 patients (26.5%) and interictal headaches were experienced in 63 (15.75%). In the peri-ictal group, unilateral headaches were present in 48 out of 60 patients (80%) with TLE; they were ipsilateral to the seizure focus in 45 out of 48 patients (93.75%). Unilateral headaches in patients with ETLE were present in 20 out of 31 patients (64.5%) and were ipsilateral to the seizure focus in 14 out of 20 patients (70%). In patients with TEMP + epilepsy, unilateral peri-ictal headaches were present in 9 out of 15 patients (60%); they were ipsilateral to the seizure focus in all 9 patients (100%). In the interictal headache group, unilateral headaches were ipsilateral the seizure focus in 9 out of 10 patients (90%) with TLE and 5 out of 6 patients (83.3%) with ETLE. None of the TEMP + epilepsy patients had a unilateral interictal headache.

CONCLUSION

Headache is a frequently encountered symptom in patients with DRFE. When occurring in a unilateral fashion, it has a high lateralizing value in temporal and extratemporal lobe epilepsies. This has been demonstrated to be true for both peri-ictal and interictal headaches. In the vast majority of patients with DRFE, unilateral headache occurs ipsilateral to the seizure focus.

Reliability of additional reported seizure manifestations to identify dissociative seizures

PURPOSE

Descriptions of seizure manifestations (SM), or semiology, can help localize the symptomatogenic zone and subsequently included brain regions involved in epileptic seizures, as well as identify patients with dissociative seizures (DS). Patients and witnesses are not trained observers, so these descriptions may vary from expert review of seizure video recordings of seizures. To better understand how reported factors can help identify patients with DS or epileptic seizures (ES), we evaluated the associations between more than 30 SMs and diagnosis using standardized interviews.

METHODS

Based on patient- and observer-reported data from 490 patients with diagnoses documented by video-electoencephalography, we compared the rate of each SM in five mutually exclusive groups: epileptic seizures (ES), DS, physiologic seizure-like events (PSLE), mixed DS and ES, and inconclusive testing.

RESULTS

In addition to SMs that we described in a prior manuscript, the following were associated with DS: light triggers, emotional stress trigger, pre-ictal and post-ictal headache, post-ictal muscle soreness, and ictal sensory symptoms. The following were associated with ES: triggered by missing medication, aura of déjà vu, and leftward eye deviation. There were numerous manifestations separately associated with mixed ES and DS.

CONCLUSIONS

Reported SM can help identify patients with DS, but no manifestation is pathognomonic for either ES or DS. Patients with mixed ES and DS reported factors divergent from both ES-alone and DS-alone.

Activation of Peripheral and Central Trigeminovascular Neurons by Seizure: Implications for Ictal and Postictal Headache

An epileptic seizure can trigger a headache during (ictal) or after (postictal) the termination of the event. Little is known about the pathophysiology of seizure-induced headaches. In the current study, we determined whether a seizure can activate nociceptive pathways that carry pain signals from the meninges to the spinal cord, and if so, to what extent and through which classes of peripheral and central neurons. To achieve these goals, we used single-unit recording techniques and an established animal model of seizure (picrotoxin) to determine the effects of epileptic seizure on the activity of trigeminovascular Aδ-, C-, wide-dynamic range, and high-threshold neurons in male and female rats. Occurrence of seizure activated 54%, 50%, 68%, and 39% of the Aδ-, C-, wide-dynamic range, and high-threshold neurons, respectively. Regardless of their class, activated neurons exhibited a twofold to fourfold increase in their firing, which started immediately (1 min) or up to 90 min after seizure initiation, and lasted as short as 10 min or as long as 120 min. Administration of lidocaine to the dura prevented activation of all neuronal classes but not the initiation or maintenance of the seizure. These findings suggest that all neuronal classes may be involved in the initiation and maintenance of seizure-induced headache, and that their activation patterns can provide a neural substrate for explaining the timing and duration of ictal and possibly postictal headaches. By using seizure, which is evident in humans, this study bypasses controversies associated with cortical spreading depression, which is less readily observed in humans.SIGNIFICANCE STATEMENT This preclinical study provides a neural substrate for ictal and postictal headache. By studying seizure effects on the activity of peripheral (C and Aδ) and central (wide dynamic range and high-threshold) trigeminovascular neurons in intact and anesthetized dura, the findings help resolve two outstanding questions about the pathophysiology of headaches of intracranial origin. The first is that abnormal brain activity (i.e., seizure) that is evident in human (unlike cortical spreading depression) gives rise to specific and selective activation of the different components of the trigeminovascular system, and the second is that the activation of all components of the trigeminovascular pathway (i.e., peripheral and central neurons) depends on activation of the meningeal nociceptors from their receptors in the dura.

A rare but treatable cause of recurrent chest pain - Ictal chest pain

Background

Chest pain as the primary manifestation of epilepsy is extremely rare and has only been reported once to date.

Case presentation

We herein describe a 47-year-old woman with recurrent chest pain for 3 years. The cause of her chest pain remained elusive despite extensive investigations including comprehensive cardiac work-up. She was referred to the neurology clinic for one episode of confusion. Video-electroencephalographic monitoring detected unequivocal ictal changes during her habitual chest pain events. She has remained chest pain (seizure) free with a single antiseizure drug.

Conclusions

This case underlines the importance of epilepsy as a rare yet treatable cause of recurrent chest pain. Further studies are required to determine the pathophysiology of ictal chest pain.

Headache in epilepsy: A prospective observational study

OBJECTIVE

To assess the frequency and characteristics of interictal and postictal headaches (using International Classification of Headache Disorders, 3rd edition criteria) in a population of patients with epilepsy admitted to the Mayo Clinic Rochester epilepsy monitoring unit and assess their localizing value.

METHODS

This was a cross-sectional study. Participants were voluntarily recruited upon admission to the epilepsy monitoring unit. Two separate questionnaires were then administered. The first was to assess the presence and character of headaches experienced in the past 12 months. The second was to assess characteristics of postictal headaches experienced during their admission including localization.

RESULTS

One-hundred and twenty subjects (77%) met inclusion criteria and completed the initial questionnaire. Mean age was 38.1 years (range 18-82), and 67 (55.8%) were female. Interictal headaches were reported in 97 of 120 (81%) subjects, and these met ICHD3 criteria for migraine in 48 (50%). Postictal headaches were reported by 75 of 120 (63%) subjects on the initial admission questionnaire, representing migraine in 38 (51%). Thirty-nine (32%) subjects completed the secondary questionnaire related to postictal headaches experienced during admission, of which nine (23%) met criteria for migraine. There was no seizure lateralizing or localizing value noted based on postictal headache localization.

SIGNIFICANCE

Migraine was frequent in this cohort and appears to be the dominant interictal and postictal headache type in patients with epilepsy. In this study, the first to assess incident postictal headache in the setting of an ictal EEG, headache localization was of no seizure localizing value. Few patients were being actively treated; suggesting headache management is often overlooked in the epilepsy population.

Ictal headache: Insights from two cases

Background

We report the first literature description of ictal epileptic headaches closely mimicking glossopharyngeal neuralgia and short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing.

Case 1

A 37-year-old man complained of short-lasting, electric-shock like headache, confined to the pharynx. During the episodes, he could not speak because he felt “words blocked at the throat”. An EEG recorded epileptic discharges concomitant with headache; a brain MRI disclosed frontal polymicrogyria.

Case 2

A 66-year-old man complained of short-lasting, right periocular headache, associated with ipsilateral ptosis, conjunctival injection and lacrimation. Some episodes were followed by tonic contraction of the right facial and limb muscles; on one occasion, headache was followed by a generalized seizure. A brain MRI revealed hippocampal abnormalities.

Discussion

These cases highlight the complex relationship between headache and epilepsy, and suggest a possible contribution of cortical structures to the genesis of paroxysmal headaches such as glossopharyngeal neuralgia and short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing.

Prevalence and clinical characteristics of headache in juvenile myoclonic epilepsy: experience from a tertiary epilepsy center

The comorbidity of headache and epilepsy is often seen in neurological practice. The objective of this study was to assess the prevalence, types of, and risk factors for headache in juvenile myoclonic epilepsy (JME). We assessed a total of 200 patients and 100 healthy controls in our study. Headache was classified in participants using a self-administered questionnaire. Demographical, clinical features and headache characteristics were recorded. Seizure and headache temporal profiles were noted. Headache was present in 111 (56%) patients and 50 (50%) healthy participants. From these patients, 47 (42.3%) JME patients had migraine [30 (27%) migraine without aura (MO), 17 (15.3%) migraine with aura (MA)], 52 (46.8%) had tension type headache (TTH), 4 (3.6%) had both migraine and TTH, and 8 (7.2%) had other non-primary headaches. In the healthy control group, migraine was detected in 16 (32%) subjects, TTH in 33 (66%), both migraine and TTH in 1 (2%) subject. A positive migraine family history and symptom relief with sleep were more frequent in JME patients (p = 0.01). Headache was classified as inter-ictal in 82 (79.6%) patients and peri-ictal in 21 (20.4%) patients. In conclusion, the present study revealed that headache frequency was not significantly different between JME patients and healthy controls (p > 0.05). However, migraine frequency was higher in JME patients than healthy controls. Some migraine and TTH characteristics were different in between groups. We suggest that our results support both genetic relationship and shared underlying hypothetical pathopysiological mechanisms between JME and headache, especially migraine.

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.

Ictal pain: occurrence, clinical features, and underlying etiologies

PURPOSE

We analyzed a series of patients with ictal pain to estimate its occurrence and characterize the underlying etiologies.

METHODS

We retrospectively reviewed all the long-term video-EEG reports from Jefferson Comprehensive Epilepsy Center over a 12-year period (2004-2015) for the occurrence of the term "pain" in the text body. All the extracted reports were reviewed, and patients with at least one documented episode of ictal pain in the epilepsy monitoring unit (EMU) were included in the study.

RESULTS

During the study period, 5133 patients were investigated in our EMU. Forty-six patients (0.9%) had at least one documented episode of ictal pain. Twenty-four patients (0.5%) had psychogenic nonepileptic seizures (PNES), 10 patients (0.2%) had epilepsy, 11 patients (0.2%) had migraine, and one woman had a cardiac problem. Pain location was in the upper or lower extremities (with or without other locations) in 80% of the patients with epilepsy, 33% of the patients with PNES (p=0.01), and none of the patients with migraine.

CONCLUSION

Ictal pain is a rare finding among patients evaluated in EMUs. Psychogenic nonepileptic seizures are the most common cause, but ictal pain is not specific for this diagnosis. Location of the ictal pain in a limb may help differentiate an epileptic cause from others.

Headache as an Aura of Epilepsy: Video-EEG Monitoring Study

BACKGROUND

Headache can be associated with epilepsy as a pre-ictal, ictal, or post-ictal phenomenon; however, studies of patients with headache as an epileptic aura are scarce. We performed the present study to investigate the incidence and characteristics of headache as an epileptic aura, via confirmation of electroencephalography (EEG) changes by video-EEG monitoring.

METHODS

Data of aura and clinical seizure episodes of 831 consecutive patients who undertook video-EEG monitoring were analyzed retrospectively. For patients who had headache as an aura, information on the detailed features of headache was acquired, including location, nature, duration, and the presence of accompanying symptoms. Video-recorded clinical seizures, EEG findings, and neuroimaging data were used to determine the ictal onset areas in the patients.

RESULTS

Six out of 831 (0.7%) patients experienced headache as aura (age range, 25-52 years), all of whom had partial seizures. The incidence of pre-ictal headache was 6.3% (25/831), and post-ictal headache was 30.9% (257/831). In patients with headache as aura, five patients described headache as the most frequent aura, and headache was the second most frequent aura in one patient. The characteristics of headache were hemicrania epileptica in two patients, tension-type headache in another two patients, and migraine-like headache in the remaining two patients. No patient met the diagnostic criteria of ictal epileptic headache or migraine aura-triggered seizure.

CONCLUSION

Our study showed that headache as an aura is uncommon in adult patients with epilepsy, and that headache can present as diverse features, including hemicrania epileptica, tension-type headache, and migraine-like headache. Further studies are necessary to characterize the features of headache as an epileptic aura in adult patients with epilepsy.

Headache in epilepsy: prevalence and clinical features

BACKGROUND

Headache and epilepsy are two relatively common neurological disorders and their relationship is still a matter of debate. Our aim was to estimate the prevalence and clinical features of inter-ictal (inter-IH) and peri-ictal headache (peri-IH) in patients with epilepsy.

METHODS

All patients aged ≥ 17 years referring to our tertiary Epilepsy Centre were consecutively recruited from March to May 2011 and from March to July 2012. They underwent a semi-structured interview including the International Classification Headache Disorders (ICHD-II) criteria to diagnose the lifetime occurrence of headache.χ(2)-test, t-test and Mann-Whitney test were used to compare clinical variables in patients with and without inter-IH and peri-IH.

RESULTS

Out of 388 enrolled patients 48.5 % had inter-IH: migraine in 26.3 %, tension-type headache (TTH) in 19.1 %, other primary headaches in 3.1 %. Peri-IH was observed in 23.7 %: pre-ictally in 6.7 %, ictally in 0.8 % and post-ictally in 19.1 %. Comparing patients with inter-ictal migraine (102), inter-ictal TTH (74) and without inter-IH (200), we found that pre-ictal headache (pre-IH) was significantly represented only in migraineurs (OR 3.54, 95 % CI 1.88-6.66, P < 0.001). Post-ictal headache (post-IH) was significantly associated with both migraineurs (OR 2.60, 95 % CI 1.85-3.64, P < 0.001) and TTH patients (OR 2.05, 95 % CI 1.41-2.98, P < 0.001). Moreover, post-IH was significantly associated with antiepileptic polytherapy (P < 0.001), high seizure frequency (P = 0.002) and tonic-clonic seizures (P = 0.043).

CONCLUSIONS

Migraine was the most represented type of headache in patients with epilepsy. Migraineurs are more prone to develop pre-IH, while patients with any inter-IH (migraine or TTH) are predisposed to manifest a post-IH after seizures.

Comorbidity between headache and epilepsy in a Chinese epileptic center

Here we investigated the characteristics and prevalence of headaches in patients with epilepsy in a Chinese epileptic center based on the International Classification of Headache Disorders, 2nd edition. We found that 60.14% (667/1109) of patients reported headaches. Headache was less prevalent in males (57.17%) than in females (63.75%). Interictal headaches were present in 34.62% of patients, and 139/1109 (12.53%) patients had interictal migraine, which was a higher percentage than reported in a large population-based study from the same area (9.3%) using the same screening question. In addition, 469 (70.31%) patients had postictal headache, migraine characteristics were present in 73.35% of these patients, and 15.35% also suffered from interictal migraine. Lastly, 8.85% patients had preictal headache. These results confirm that headache is very common in patients with epilepsy. Seizures often trigger postictal headaches with migraine features. The comorbidity of migraines and epilepsy should receive clinical attention, as it may influence antiepileptic drug choice, and the headache may require specific treatment.

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.

Relations between epileptic seizures and headaches

PURPOSE

To describe headaches in patients with epilepsy and try to identify relations between epileptic seizures and headaches.

METHODS

Cross-sectional study, with 304 patients from the epilepsy out-patient section of University Hospital of Federal University of Alagoas (Brazil) between February 2007 and February 2008. The presence of headaches and their relationships with the epileptic seizures were analyzed.

RESULTS

Frequent seizures were associated with a greater tendency of occurrence of headaches (odds ratio=1.6 times, p=0.077). Headaches occurred in 66.1% of the cases. The highest occurrence was of migraine (32.9% of the patients), followed by tension-type headaches (9.2%). Two syndromes with a continuum epilepsy-migraine in the same seizure are worth mentioning: migralepsy in 6.6% and epilepgraine in 10.2% of the patients with epilepsy.

CONCLUSIONS

A high prevalence of headaches in patients with epilepsy was observed, with emphasis on hybrid crises of epilepsy and migraine.

Pathophysiology of migraine

Migraine is a collection of perplexing neurological conditions in which the brain and its associated tissues have been implicated as major players during an attack. Once considered exclusively a disorder of blood vessels, compelling evidence has led to the realization that migraine represents a highly choreographed interaction between major inputs from both the peripheral and central nervous systems, with the trigeminovascular system and the cerebral cortex among the main players. Advances in in vivo and in vitro technologies have informed us about the significance to migraine of events such as cortical spreading depression and activation of the trigeminovascular system and its constituent neuropeptides, as well as about the importance of neuronal and glial ion channels and transporters that contribute to the putative cortical excitatory/inhibitory imbalance that renders migraineurs susceptible to an attack. This review focuses on emerging concepts that drive the science of migraine in both a mechanistic direction and a therapeutic direction.

Links between headaches and epilepsy: current knowledge and terminology

INTRODUCTION AND OBJECTIVES

Headaches (including migraines) and epilepsy have a high level of comorbidity and may be confused during diagnosis. Although physicians have known for centuries that these two conditions are somehow linked, their relationship remains poorly understood. Herein we describe the known associations between them, their underlying physiopathologic and genetic mechanisms, and the treatments recommended for them.

METHOD

We have reviewed the most relevant publication of headache/migraine and epilepsy by using the PubMed data base.

DESCRIPTION

An individual can suffer both from headaches (either migraine and/or other type of headache) and epilepsy, either by chance or because of a common underlying pathology. In these cases, the headache usually occurs at a different moment than the seizure ("interictal headache"). However, headaches sometimes occur simultaneously with, or very close in time to, the seizure: one that occurs at the same time as an epileptic seizure is known as an "ictal epileptic headache" or as "hemicrania epileptica"; one that precedes a seizure is known as a "pre-ictal headache"; and one that follows a seizure is known as a "post-ictal headache". There is a particular type of pre-ictal headache, known as "migralepsy", which occurs during or just after a migraine aura.

CONCLUSIONS

The terminology and concepts employed to describe possible associations between headaches (mainly migraines) and epilepsy have evolved over time with increasing clinical and physiopathogenic knowledge. Some researchers have suggested eliminating the term migralepsy and using the terms ictal epileptic headache and hemicrania epileptica exclusively and uniformly in all classification systems.

Ictal headache: headache as first ictal symptom in focal epilepsy

Headache may be associated with seizures as a preictal, ictal, or postictal phenomenon, but it is often neglected because of the dramatic neurological manifestations of the seizure. Headache can also be the sole or predominant clinical manifestation of epileptic seizures, although this is a relatively rare condition. We describe two cases of focal symptomatic drug-resistant epilepsy with headache as the first ictal symptom. In both cases, the headache, which lasted a few seconds, was contralateral to the ictal discharge and did not have the clinical features of migraine. Ictal headache is a rare epilepsy symptom that can help to localize ictal EEG discharges. Recently, the term ictal epileptic headache has been proposed in cases in which headache is the sole ictal epileptic manifestation Diagnosis requires the simultaneous onset of headache with EEG-demonstrated ictal discharges.

Peri-ictal and inter-ictal headache in children and adolescents with idiopathic epilepsy: a multicenter cross-sectional study

PURPOSE

Headache in epileptic population ranges from 8% to 15%. The aim of this paper was to study the clinical and temporal characteristics of primary headache comorbidity in idiopathic epileptic children.

METHODS

From June 2006 to June 2009, a cross-sectional multi-center study involving five Italian Child Neurology University Centers (two in Rome, one in Chieti, one in Naples, and one in L'Aquila) was conducted. Among 1,264 consecutively newly diagnosed, idiopathic, partial, or generalized, epileptic children, according to ILAE diagnostic criteria (aged between 5 and 15 years of age), we selected 142 children (11.2%) (130 of whom completed the study) who showed an associated peri-ictal and/or inter-ictal headache diagnosed according to the International Headache Society Criteria. Rare cases of "ictal epileptic headache", in which headache represents the sole ictal epileptic manifestation, were excluded from this study.

RESULTS AND CONCLUSIONS

Post-ictal headaches were most frequent (62%). Pre-ictal headaches were less common (30%). Inter-ictal headaches were described in 57.6%. Clear migrainous features were present in 93% of pre-ictal and 81.4% of post-ictal headaches. Inter-ictal headaches meet criteria for migraines in 87%. The association between partial epilepsy and migraine without aura is most common and reported in 82% of our patients with peri-ictal headache and in 76.5% of patients with post-ictal headache.

Headache, epilepsy and photosensitivity: how are they connected?

Although headache and epilepsy have often been associated, the precise electroclinical and pathophysiological interaction between these disorders and in particular its relations with photosensitivity is as yet to be fully understood in adults or children. The association between headache and epilepsy commonly occurs in all types of epilepsy and not only in occipital epilepsy. Generally, peri-ictal headache is often neglected, regardless of its severity, because patients are more concerned about their seizures. Altered cerebral cortex excitability may be the link between these two conditions and photosensitivity shows this. The physician should bear this association in mind when dealing with epileptic and migraine patients so as to be able to offer such patients an accurate diagnosis and appropriate treatment; this should be borne in mind when declaring epileptic patients ‘seizure free’. To date neither the International Headache Society nor the International League against Epilepsy mention that headache/migraine may, on occasion, be the sole ictal epileptic manifestation. Lastly, studies designed to investigate the triggering role of photosensitivity in both headache and epilepsy are warranted.

Postictal headache

Postictal headache (PIH) is defined by the International Classification of Headache Disorders as "headache with features of tension-type headache or, in a patient with migraine, of migraine headache, which develops within 3 hours following a partial or generalized seizure and resolves within 72 hours after the seizure." PIHs are prevalent, moderate to severe in intensity, last many hours, and frequently have characteristics of migraine. Young adults with a history of interictal headaches are at increased risk of developing PIH. Young age at onset and long duration of epilepsy, drug-resistant seizures, generalized tonic-clonic seizures, and possibly an occipital epileptic focus are additional risk factors. Although PIH is estimated to have a significant impact on the quality of life of people with epilepsy, it is frequently undertreated. Simple analgesics may prove beneficial. Epilepsy and headache share common pathophysiological mechanisms, as suggested by clinical and investigational findings, although the exact processes underlying these conditions are still largely unknown.

Headache attributed to non-vascular intracranial disorder

This chapter deals with non-vascular intracranial disorders resulting in headache. Headache attributed to high or low cerebrospinal fluid pressure is separated into headache attributed to idiopathic intracranial hypertension (IIH), headache attributed to intracranial hypertension secondary to metabolic, toxic, or hormonal causes, headache attributed to intracranial hypertension secondary to hydrocephalus, post-dural puncture headache, cerebrospinal fluid (CSF) fistula headache, headache attributed to spontaneous (or idiopathic) low CSF pressure. Headache attributed to non-infectious inflammatory disease can be caused by neurosarcoidosis, aseptic (non-infectious) meningitis or lymphocytic hypophysitis. Headache attributed to intracranial neoplasm can be caused by increased intracranial pressure or hydrocephalus caused by neoplasm or attributed directly to neoplasm or carcinomatous meningitis. Other causes of headache include hypothalamic or pituitary hyper- or hyposecretion and intrathecal injection. Headache attributed to epileptic seizure is separated into hemicrania epileptica and post-seizure headache. Finally headache attributed to Chiari malformation type I (CM1) and the syndrome of transient headache and neurological deficits with cerebrospinal fluid lymphocytosis (HaNDL) are described.

Peri-ictal headache in children: prevalence and character

Structured interviews regarding peri-ictal headaches and personal or family histories of interictal headaches were conducted on 101 children (aged 5-18 years), with generalized tonic-clonic or partial seizures. Epilepsy-specific details were collected by interviews and reviews of neurology clinic charts. Peri-ictal headaches were reported by 41% (29%, postictal only; 5%, preictal only; 7%, both). Clear migrainous features were present in 50% of preictal and 58% of postictal headaches. Most children described bilateral headaches. No demographic or epilepsy-specific correlates were identified that predicted peri-ictal headaches. Interictal headaches occurred in 24%, with 14% of children meeting criteria for migraines. However, neither interictal migraines nor a positive family history of migraines was significantly predictive of either peri-ictal headaches or migrainous peri-ictal headaches. Postictal headaches occurred reliably after most seizures in predisposed children, and interrupted activities in the majority. Whereas only half of children received abortive medications for these headaches, simple analgesics were effective in most cases. We conclude that peri-ictal headaches are common, affecting 41% of children with epilepsy. Their presence should be routinely queried, and if documented, treatment with simple analgesics appears beneficial and should be considered.

Headaches add to the burden of epilepsy

The objective was to investigate and classify headaches in 109 consecutive adult patients with epilepsy. A semi-structured interview was performed in those who confirmed such symptoms (65%). Interictal headaches were present in 52%; 20% had interictal migraine. Postictal headache was reported in 44%. Migraine characteristics were present in 42% of these, and most of them (74%) also suffered from interictal migraine. Six percent had preictal headache. In partial epilepsy, there was an association between headache lateralisation and interictal EEG abnormalities (p=0.02). We conclude that headache, including migraine, is very common in patients with epilepsy. Unilateral headache may represent a lateralising sign in focal epilepsy. Seizures often trigger postictal headaches with migraine features, which often are associated with interictal migraine. Migrainous headaches sometimes proceed into epileptic seizures. The comorbidity of migraine and epilepsy should receive ample clinical attention, as it may influence antiepileptic drug choice, and the headache may need specific treatment.

Lateralizing signs during seizures in focal epilepsy

This article reviews lateralizing semiological signs during epileptic seizures with respect to prediction of the side of the epileptogenic zone and, therefore, presurgical diagnostic value. The lateralizing significance of semiological signs and symptoms can frequently be concluded from knowledge of the cortical representation. Visual, auditory, painful, and autonomic auras, as well as ictal motor manifestations, e.g., version, clonic and tonic activity, unilateral epileptic spasms, dystonic posturing and unilateral automatisms, automatisms with preserved responsiveness, ictal spitting and vomiting, emotional facial asymmetry, unilateral eye blinking, ictal nystagmus, and akinesia, have been shown to have lateralizing value. Furthermore, ictal language manifestations and postictal features, such as Todd's palsy, postictal aphasia, postictal nosewiping, postictal memory dysfunction, as well as peri-ictal water drinking, peri-ictal headache, and ipsilateral tongue biting, are reviewed. Knowledge and recognition of semiological lateralizing signs during seizures is an important component of the presurgical evaluation of epilepsy surgery candidates and adds further information to video/EEG monitoring, neuroimaging, functional mapping, and neuropsychological evaluation.

Characteristics of postictal headache in patients with partial epilepsy

Migraine-like features sometimes characterize the headache that follows epileptic seizure (postictal headache, PIH). We compared patients with different types of epilepsy to investigate the association between migraine-like PIH and seizure type. Subjects comprised 364 patients with partial epilepsy. Epilepsy types were temporal lobe epilepsy (TLE, n = 177), frontal lobe epilepsy (FLE, n = 116), and occipital lobe epilepsy (OLE, n = 71). Patients participated in a structured interview pertaining to PIH as well as interictal headache and family history of migraine. Headaches were classified according to the International Headache Society criteria, which was modified for this study. Forty percent had PIH and 26% of these patients had migraine-like PIH. Migraine-like PIH occurred significantly more often in cases of TLE and OLE than in cases of FLE. In addition, the incidence of interictal migraine headache was significantly higher in patients with migraine-like PIH. These results suggest that migraine-like PIH is related to particular regions of epileptogenic focus and that susceptibility to migraine headache predisposes to migraine-like PIH.

Multi-center study on post-ictal headache in patients with localization-related epilepsy

The nature of post-ictal headache (PIH) remains unclear. A multicenter study was conducted in order to evaluate frequency and risk factors for PIH. The subjects consisted of 97 patients with temporal lobe epilepsy (TLE), 65 patients with frontal lobe epilepsy (FLE) and 37 patients with occipital lobe epilepsy (OLE). The subjects were asked about PIH at each institute. Clinical factors of epilepsy were reviewed for each patient and correlated with PIH. Post-ictal headache occurred in 41% of TLE patients, 40% of FLE patients and 59% of OLE patients. Logistic regression analysis revealed that the risk of PIH was significantly higher in OLE than in FLE. In contrast, there were no significant differences in the incidence of PIH between TLE and either OLE or FLE patients. Post-ictal headache occurred significantly more frequently in subjects with generalized tonic-clonic seizure (GTCS) than in those without GTCS. Other clinical factors, such as sex, age, age at onset, duration of illness, seizure frequency, family history of headache and interictal headache were found to have no associations with PIH. A difference was found in the incidence of PIH depending on classification of epilepsy, but only to a relatively slight extent. It was also found that GTCS was significantly related to PIH. These results suggest that both the location of epileptogenic focus and the involvement of certain cerebral areas in the spread of seizure discharges may be closely related to PIH.