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.     

Migraine and Intercalated Seizures With Occipital EEG Paroxysms: Observations on a Family

SYNOPSIS
A 12-year-old girl presented three distinct attacks of classic migraine. In all attacks, an occipital seizure with impairment of consciousness was intercalated between the visual prodrome and the headache. A right occipital epileptogenic focus was detected by the EEG. Neurologic examination was normal. CT-scan and laboratory work were unremarkable. Flunarizine treatment controlled both the migraine and seizure components. Periodic migraine episodes with visual phenomena occurred in three other female components of the same family. However, the attacks were never associated with epileptic manifestations. Only the 10-year-old sister, who suffered from common migraine, showed sporadic interictal EEG abnormalities in the right posterior leads.
The possible neurophysiologic interplay between classic migraine and epilepsy in intercalated attacks may be explained on the basis of the "spreading depression" mechanism. The intense neuronal excitation preceding the migraine aura might play a "triggering" role on the occipital epileptogenic focus.
Similarities and differences between this benign though unusual syndrome and other forms of epilepsy in childhood, are also discussed.     

MIGRAINE PATHOPHYSIOLOGY

Objective: To investigate the central trigeminal circuits in migraine patients.
Materials and Methods: Short latency responses can be recorded in sternocleidomastoid (SCM) muscles after stimulation of the trigeminal nerve (trigemino-cervical reflex). This brainstem reflex was investigated in 20 healthy subjects, in 20 patients suffering from migraine with aura (MWA) and in 20 patients suffering from migraine without aura (MWOA) during and between the attacks.
Results: The trigemino-cervical responses were bilaterally abnormal in 17 patients with MWA and 15 patients with MWOA during the headache attacks, in 11 patients with MWA and in 10 patients with MWOA during the interictal period. In the patients with normal trigemino-cervical responses during the pain-free phase the triptan was significantly more effective at relieving headache.
Conclusions: Our findings further support and emphasise [ sic ] the role of the trigeminal system in the pathogenesis of migraine. The bilateral location of the abnormalities suggests a centrally located dysfunction. Therefore, the trigemino-cervical reflex is sensitive in disclosing a disturbed brainstem activity and may be an index of neuronal activity in the human brainstem; moreover their assessment may help as valuable prognostic tool for predicting the efficacy of triptans therapy.     

Basilar migraine with electroencephalographic findings of occipital spike-wave complexes: a long-term study in seven children

Basilar migraine is characterized by headache preceded by prodromal symptoms and signs of posterior cerebral circulation dysfunction. Few studies have focused on EEG findings in this condition or on the prognosis of occipital spike-wave complexes observed in either migraine or epilepsy. We now report a long-term follow-up (8–16 years) in seven children affected by basilar migraine who had EEG findings of occipital spike-wave complexes. Basilar migraine resolved and the EEG became normal in all subjects during the observation period, as did migraine with aura and seizures which developed in some of the patients after basilar migraine attacks ceased.     

Clinical characteristics of patients with comorbidity of migraine and epilepsy

OBJECTIVE: Neuronal hyperexcitability might explain the comorbidity of migraine and epilepsy. Spreading depression, a postulated pathophysiological mechanism of epileptic seizures and migraine with aura, may hypothetically be the link between the disorders in these comorbid conditions. The aim of the present study was to determine whether certain clinical characteristics associated with spreading depression are overrepresented in patients with comorbidity. METHODS: In an outpatient clinic-based series, clinical characteristics of 61 patients with a comorbidity of migraine and epilepsy were compared to those of 280 patients with epilepsy alone and 248 patients with migraine alone. Patients were interviewed with a standardized questionnaire. RESULTS: The proportion of females was significantly higher in patients with comorbidity and patients with migraine as compared to patients with epilepsy (P <.001). Comparing patients with epilepsy and comorbidity, the frequency of epilepsy syndromes and seizure types was not significantly different. Comparing patients with migraine and comorbidity, migraine with aura was significantly more frequent in patients with comorbidity (P =.019). Other migraine features such as moderate to severe pain intensity, worsening of pain on activity, phonophobia, and photophobia were significantly more frequent in patients with comorbidity as compared to patients with migraine (P < or =.001). CONCLUSION: No specific epileptic characteristics could be found in patients with comorbidity. Altered cerebral excitability resulting in an increased occurrence of spreading depression may explain the differences in migraine attacks in patients with comorbidity as compared to patients with migraine alone.     

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.     

Cortical Spreading Depression and Estrogen

Cortical spreading depression (CSD) is an electrophysiological phenomenon characterized by a wave of excitation followed by inhibition. The aura phase that precedes migraine headache in about 20-30% of migraineurs shares overlapping characteristics with CSD. Studies of rare autosomal-dominant forms of migraine with aura provide strong evidence that the threshold for evoking CSD and aura are related to neuronal excitability. Although the relationship between CSD and migraine without aura is not completely understood, the molecular abnormalities that predispose to migraine with aura illustrate the importance of physiologic events associated with neuronal hyperexcitability, and provide a basis for understanding a more generalized view of migraine.     

Comorbidity between headache and epilepsy in a pediatric headache center

The purpose of this study was to analyse the comorbidity between headache and epilepsy in a large series of children with headache (1,795). Fifty-six cases (3.1%) suffered from idiopathic headache and idiopathic or cryptogenic epilepsy or unprovoked seizures. There was a strong association between migraine and epilepsy: in migraineurs (46/56) the risk of epilepsy was 3.2 times higher when compared with tension-type headache, without significant difference between migraine with and without aura (P = 0.89); children with epilepsy had a 4.5-fold increased risk of developing migraine than tension-type headache. In cases with comorbidity, focal epilepsies prevailed (43/56, 76.8%). Migraineurs affected by focal epilepsies (36/56) had a three times higher risk of having a cryptogenic epilepsy (27/36, 75%) than an idiopathic epilepsy (9/36, 25%) (P = 0.003). In migraine with aura, epilepsy preceded migraine in 71% of cases. Photosensitivity (7/56, 12.5%) and positive family history for epilepsy (22/56, 39%) were frequent in cases with comorbidity.     

Ictal and interictal EEG findings in children with migraine

Abstract We describe the electroencephalographic findings in nine pediatric migraineurs during the ictal phase of pain. We observed abnormal patterns on electroencephalography (EEG) in seven patients with migraine with aura and in two patients with basilar migraine. These patients were also evaluated with EEG during headache-free interval, at least 7 days after the ictal event; these interictal findings were unremarkable, confirming the observations reported in the literature. Finally, we review migraine and its EEG characteristics as reported in the literature, and discuss the value of EEG performed during interictal and ictal phases of migraine.     

Clinical neurophysiology in childhood headache

Electrophysiological studies in childhood headache are of interest because of the need to make a clinical diagnosis and also because of the efficacy of physiopathological studies in juvenile age attributable to the recent outcome of the illness, with less clinical modification by environmental factors or drug use. Electrophysiological studies in childhood headache are concerned with migraine and electroencephalographic (EEG) evaluations; evoked potentials, event-related potentials and, less often, electromyographic studies are also reported. Visual analysis of EEG suggests an association between migraine and epilepsy; quantitative EEG, visual and event-related evoked potentials show fluctuating abnormalities, depending on the occurrence of the migraine attacks and permanent anomalous patterns related to the basic mechanisms underlying the disease. Blink reflex studies might suggest a primary dysfunction of the nociceptive control central system in children affected by tension-type headache and migraine. The use of neurophysiological procedures in juvenile migraine is considered limited in clinical practice and of particular interest in neurophysiological studies of headache.     

Migralepsy: Is the Current Definition Too Narrow?

The relationship between epilepsy and migraine is complex and remains to be determined. We report 3 cases that address 2 questions on this topic. The first and second cases showed an association between migraine without aura and the onset of epileptic seizures. The third case report describes a patient in whom migraine with aura occurred and was followed by the development of status epilepticus, which occurred 2 or 3 hours after the attack of migraine with aura. We discuss the present definition of migralepsy and reassess its definition by suggesting possible extensions to its current definition.     

Symptomatic occipital epilepsy misdiagnosed as migraine

Two young patients with symptomatic occipital lobe epilepsy due to discrete lesions of cysticercosis were misdiagnosed and treated for 2 years as migraine with visual aura. The patients suffered from frequent visual seizures often followed by migraine-like headache. Seizures manifested with colored and mainly circular elementary visual hallucinations of up to 1 minute duration. Headache, often severe and of long duration, was frequently associated with nausea, photophobia, and phonophobia. Both patients became seizure-free with appropriate treatment of the underlying disease and epileptic seizures.     

EEG spectral analysis in migraine without aura attacks

In 16 patients suffering from migraine without aura, we examined quantitative EEG and steady-state visual evoked potentials (SSVEPs) at 27 Hz stimulation during the critical phase of migraine and in attack-free periods. The main spontaneous EEG abnormalities found during the critical phase were the slowing and asymmetry of the dominant frequency in the alpha range. The amplitude of the SSVEP F1 component was significantly reduced during the attack phase compared with the intercritical phase; in the latter condition the visual reactivity to 27 Hz stimulus was increased over almost the entire scalp compared with normal subjects. The EEG abnormalities confirm a fluctuating modification of alpha activity during the migraine attack, probably related to a functional disorder. The suppression of visual reactivity during the migraine attack could be related to a phenomenon of neuronal depolarization such as spreading depression, occurring in a situation of central neuronal increased excitability predisposing to migraine attacks.     

Electroencephalographic brain mapping and migraine

Several studies have investigated brain bioelectrical activity with the aid of electroencephalographic brain mapping in migraine patients examined in the interictal period or during a spontaneous attack. The principal finding obtained between attacks was an increase in the power of the rapid activities, particularly in the range of the beta bands and especially in the temporal regions, in migraine patients both with and without aura. Another frequent occurrence between attacks is an increase in the absolute and relative powers of the slow theta and delta bands, which can be focal or diffuse. In our experience, the increase in the relative power of the theta band was prevalent bilaterally in the temporal-parietal regions in migraineurs with and without aura. Other authors detected interhemispheric asymmetries relative to alpha bands, more consistent in patients with migraine with aura. During attacks the most relevant result is the decrease and asymmetry of dominant alpha activity, particularly on the side of the pain during attacks in patients with migraine without aura. In addition to changes in the alpha activities, an increase in the power of the slow delta and/or theta bands was found during attacks of migraine with aura. Although difficult to summarize in an integrated view, results of EEG brain mapping support the occurrence of bioelectrical abnormalities, which are present even between attacks and contribute towards defining the attack threshold, and which are accentuated near and during migraine crises as a consequence of neuronal events that underlie the pathogenic mechanisms of attacks.     

Migraine-related seizures in an epileptic population

A relationship between epilepsy and migraine has long been postulated, but the nature of this interaction is still debated. We studied adult patients with epilepsy and investigated the relationship between migraine and epilepsy. Fourteen percent ( n = 412) of adult patients with seizures were identified with a diagnosis of migraine. We also found a direct relationship between migraine and epilepsy (a migraine-induced epilepsy) in 1.7% (seven patients) of the patients with seizures. Patients were at increased risk for both conditions if they had migraine with aura and catamenial epilepsy. The seizure began during or shortly after the migraine aura in all of the cases and preceded the headache. Three of four patients who were refractory to management with antiepileptic drugs using either mono or combination therapy improved seizure control with combination antimigraine and antiepileptic drugs.     

Acute and interictal allodynia in patients with different headache forms: an Italian pilot study

OBJECTIVE: To investigate allodynia in patients with different primary headaches. BACKGROUND: Many migraineurs have allodynia during headache attacks; some may have allodynia outside attacks; allodynia may also be associated with other primary headaches. METHODS: A total of 260 consecutive primary headache patients presenting for the first time at a headache center, and 23 nonheadache controls answered written questions (subsequently repeated verbally) to determine the presence of acute and interictal allodynia. RESULTS: We divided the patients into: episodic migraine (N = 177), subdivided into only migraine without aura (N = 114) and those sometimes or always reporting migraine with aura (N = 63); episodic tension-type headache (N = 28); chronic headaches (headache > or = 15 days/month, N = 52), including chronic migraine, chronic tension-type headache, and medication-overuse headache; and other headache forms (N = 3). Acute allodynia was present in 132 (50.7%), significantly more often in patients sometimes or always suffering migraine with aura, and those with chronic headache forms, compared to patients with migraine without aura and episodic tension-type headache. Interictal allodynia was present in 63 (24.2%) patients, with significantly higher frequency in those having migraine with aura attacks than controls and common migraine patients. CONCLUSIONS: Allodynia is not specific to migraine but is frequent in all headache patients: acute allodynia was reported in half those interviewed and in over a third of patients in each headache category; interictal allodynia was reported by nearly 25%.     

Seizures with prolonged EEG abnormalities during an attack of migraine without aura

The term "migralepsy" indicates a particular condition in which seizures occur during a migraine attack. Several cases of seizures associated with migraine with aura and characterized by transient MRI abnormalities have been published. We report the case of a patient who presented 2 generalized seizures during an attack of migraine without aura and with a transient, diffuse, irregular, high voltage slow activity without clear epileptiform abnormalities in subsequent EEG recordings.     

The Non-epileptiform Basilar Artery Migraine

SYNOPSIS
Five patients with basilar artery migraine (BAM) are described. One, while exhibiting electroencephalographic(EEG) interictal discharges and photo-paroxysmal responses entirely suppressed by carbamazepine orvalproate, had no improvement of her attacks. Subsequent therapy with propanolol did improve the attacksdespite persistence of EEG abnormalities. A second patient had paroxysmal abnormalities and improved withisometheptene mucate. Three other patients had normal ictal and interictal EEGs, including after activationprocedures. A population of patients with basilar artery migraine exists with normal EEG recordings or withparoxysmal activity independent from that of migraine; these patients may respond to drugs other thananticonvulsants.     

Trigemino-cervical reflex abnormalities in patients with migraine and cluster headache

BACKGROUND: Head pain arises within the trigeminal nociceptive system. Current theories propose that the trigeminal system is intimately involved in the pathogenesis of migraine. Short-latency responses can be recorded in sternocleidomastoid muscles after stimulation of the trigeminal nerve (trigemino-cervical reflex). This brainstem reflex could be a suitable method to evaluate the trigeminal system in migraine and CH. OBJECTIVE: The aim of the present study was to further elucidate the pathophysiology of migraine and cluster headache (CH) with special reference to the involvement of the central trigeminal system in the different forms of primary headache. METHODS: The trigemino-cervical reflex was investigated in 15 healthy subjects, in 15 patients having migraine with aura, in 15 patients with migraine without aura, and in 10 patients with CH. RESULTS: Significant abnormalities were observed in a great number of patients with both types of migraine and CH during the headache attacks, but only in migraine patients during the interictal period. The alterations are bilateral in migraine, unilateral in CH. CONCLUSIONS: Our results further support the relevance of brainstem mechanisms in the pathogenesis of migraine rather than of CH. These data, taken together with that from experimental head pain and functional imaging studies, demonstrate that primary headache syndromes may be distinguished on a functional basis by areas of activation specific to the clinical syndrome.     

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.