Primary headache and epilepsy: a multicenter cross-sectional study

A comparison of comorbid headache between patients with temporal lobe epilepsy and juvenile myoclonic epilepsy

Headache is one of the most common symptoms of epilepsy comorbidities. However, the relationship between the epilepsy and headache still needs clarification. Previous studies mostly investigated the overall incidence and clinical features of the headache in patients with the epilepsy. Temporal lobe epilepsy (TLE) and juvenile myoclonic epilepsy (JME) are the common types of focal epilepsy and generalized epilepsy, respectively. Nevertheless, there was no study comparing the clinical features of headache between TLE and JME. This study aimed to analyze the headache features of these two types of epilepsy. Patients with either TLE or JME diagnosed with headache and referred to the West China Hospital of Sichuan University were consecutively recruited from June 2021 to June 2022. The duration of epilepsy was longer than 6 months in these patients. Data on headache and epilepsy were obtained through face-to-face questionnaires. The headache was classified according to the International Classification Headache Disorders-3rd edition (ICHD-III) criteria. χ2-test, t-test, rank-sum test, logistic regression modeling and Mann Whitney test were used to compare the clinical differences of the headache in TLE and JME. A total of 151 TLE patients and 30 JME patients were enrolled in this study. There was no significant difference in the family history of headache, epilepsy durations, headache types, proportion receiving analgesic therapy, the frequency of inter-ictal headache (inter-IH), and the quality of life in epilepsy -10 inventory (QOLIE-10) between the TLE and JME patients. Patients in the TLE group were significantly older (p = 0.004), and a lower percentage of them had a family history of epilepsy (p = 0.007) compared with the JME patients. The proportion of cases with refractory epilepsy was higher in the TLE group than that in the JME group (p < 0.001). The types of seizures in the TLE group varied from those in the JME group (p < 0.001). The composition of the antiseizure medications (ASM) applied in the TLE group differed from that in the JME group (p = 0.047), and the usage of oxcarbazepine was more frequently in the TLE group than in the JME group (p = 0.003). There was no difference in the headache types among patients with TLE or JME. Specifically, 67 (44.37%), 12 (7.95%), and 118 (7.95%) patients were found with inter-IH, pre-ictal headache (Pre-IH) and post-ictal headache (Post-IH) in the TLE group; while 8 (26.67%), 4 (13.33%) and 26 (86.67%) patients had inter-IH, Pre-IH and Post-IH in the JME group. Thirty-nine patients in the TLE group and 4 patients in the JME group were identified with more than one type of headaches, respectively. Tension-type headache (TTH) were found in 38 patients (25.17%) in the TLE group and 3 patients (10.00%) in the JME group, respectively; migraines were found in 10 patients (6.62%) in the TLE group and in 2 patients (6.67%) in the JME group. Patients in the TLE group had a higher headache-attributed lost time-90 days (HLT-90) score than those in the JME group (p = 0.019). The proportion of patients with inter-IH accompanied by nausea in the TLE group was higher than that in the JME group (p = 0.029), while the proportion of patients with frontal headache was lower than that in the JME group (p < 0.05). There was no significant difference in headache severity, quality, headache nature, unilateral/bilateral, and headache duration either in inter-IH or peri-ictal headache (Peri-IH) between the two groups. The logistic regression analysis suggested that except for HLT-90 (AUC = 0.622, p = 0.027), other factors were not found to be correlated with refractory epilepsy. The clinical features of headache differed between TLE and JME patients. TLE patients had a higher ratio of refractory epilepsy, more headache time loss compared with JME patients. HLT-90 was associated with the occurrence of refractory epilepsy in TLE patients. Taken together, we suggested that the comorbid headache may essentially be different between TLE and JME patients.

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.

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.

Pathophysiological Bases of Comorbidity in Migraine

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

Sex Differences in the Epilepsies and Associated Comorbidities: Implications for Use and Development of Pharmacotherapies

The epilepsies are common neurologic disorders characterized by spontaneous recurrent seizures. Boys, girls, men, and women of all ages are affected by epilepsy and, in many cases, by associated comorbidities as well. The primary courses of treatment are pharmacological, dietary, and/or surgical, depending on several factors, including the areas of the brain affected and the severity of the epilepsy. There is a growing appreciation that sex differences in underlying brain function and in the neurobiology of epilepsy are important factors that should be accounted for in the design and development of new therapies. In this review, we discuss the current knowledge on sex differences in epilepsy and associated comorbidities, with emphasis on those aspects most informative for the development of new pharmacotherapies. Particular focus is placed on sex differences in the prevalence and presentation of various focal and generalized epilepsies; psychiatric, cognitive, and physiologic comorbidities; catamenial epilepsy in women; sex differences in brain development; the neural actions of sex and stress hormones and their metabolites; and cellular mechanisms, including brain-derived neurotrophic factor signaling and neuronal-glial interactions. Further attention placed on potential sex differences in epilepsies, comorbidities, and drug effects will enhance therapeutic options and efficacy for all patients with epilepsy. SIGNIFICANCE STATEMENT: Epilepsy is a common neurological disorder that often presents together with various comorbidities. The features of epilepsy and seizure activity as well as comorbid afflictions can vary between men and women. In this review, we discuss sex differences in types of epilepsies, associated comorbidities, pathophysiological mechanisms, and antiepileptic drug efficacy in both clinical patient populations and preclinical animal models.

Headaches and their relationships to epileptic seizures

PURPOSE

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

PATIENTS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Migraine in mitochondrial disorders: Prevalence and characteristics

Background Migraine is a well-known feature of mitochondrial disorders (MDs). However, no systematic epidemiological data are available in large populations of patients. Aims The aim of this cross-sectional cohort study was to describe the prevalence and migraine characteristics in a large cohort of patients with mitochondrial encephalomyopathies. Methods We studied 93 consecutive patients with characterised MDs referred to our Neuromuscular Unit during a 12-month period. All patients (age range = 16-78 years; 31 men; 58 progressive external ophthalmoplegia [PEO], 12 myoclonic epilepsy with ragged red fibres [MERRF], eight mitochondrial encephalomyopathy, lactic acidosis and stroke-like episodes [MELAS], two mitochondrial neurogastrointestinal encephalomyopathy [MNGIE] and 13 other MDs) underwent a structured diagnostic headache interview using an operational diagnostic tool following the IHS criteria. If they met the criteria for migraine, they were included in the 'Migraine Group'. The other patients were counted in the 'No Migraine Group'. Patient demographic and migraine characteristics were examined. Clinical, neuroradiological and neurophysiological data were compared between groups. Results Migraine was reported in 35.5% of patients. Migraine without aura was the most common headache (81.8%). The migraine group showed younger age ( P < 0.01), increased prevalence of epilepsy ( P = 0.01), myoclonus ( P = 0.03), stroke-like episodes ( P = 0.03) and decreased prevalence of muscle weakness ( P < 0.01). Multivariate analysis showed that migraine was positively associated with absence of muscle weakness ( P = 0.04) and presence of EEG abnormalities ( P = 0.02). Conclusion Migraine has a higher prevalence in MDs compared with general population-based data, independently from genotype or phenotype. Migraine is not merely a phenotypic aspect of specific MDs but is rather the expression of vulnerability of the central nervous system, probably directly related with defects of the respiratory chain.

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.

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.

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.

The PACE study: past-year prevalence of tension-type headache and its subtypes in Parma's adult general population

The mean global prevalence of tension-type headache (TTH) in adult is 42 %. To date, there have been no Italian studies on TTH prevalence in the adult general population. Therefore, we conducted a cross-sectional study, called PACE, aimed at detecting the prevalence of primary headaches in the city of Parma's adult general population. 904 subjects representative of Parma's adult general population were interviewed face to face by a physician of our Headache Centre. Crude past-year prevalence for definite TTH was 19.4 % (95 % CI 16.8-21.9; 18.4 %, 95 % CI 14.6-22.3 in men, and 20.1 %, 95 % CI 16.6-23.6 in women), namely, 9.0 % (95 % CI 7.1-10.8) for infrequent TTH, 9.8 % (95 % CI 7.9-11.8) for frequent TTH, and 0.6 % (95 % CI 0.1-1) for chronic TTH. Crude prevalence for probable TTH was 2.3 % (95 % CI 1.3-3.3; 2 %, 95 % CI 0.6-3.4 in men, and 2.6 %, 95 % CI 1.2-3.9 in women). Our results indicate a TTH prevalence (19.4 %) at the lower limit of data ranges for Western countries, and prevalence rates for infrequent forms (9 %) do not appear different from those of frequent forms (9.8 %).

Chronification of migraine: what clinical strategies to combat it?

Once migraine becomes chronic and has transformed into a form of headache that occurs daily or almost, the treatment options available are few and complex. This makes it important to take action before this point is reached, using all the measures that can be obtained from our current knowledge of chronic migraine (or transformed migraine) on the one hand, and on the potential factors of chronification (or transformation) on the other. Therefore, in order to reduce the risk of migraine chronification, it would appear important to: (a) administer suitable preventive treatments for subjects who have been suffering from migraines ≥4 days a month for ≥3 months; (b) take special care not to overuse symptomatic medications, particularly when they contain substances with a sedative effect; and (c) investigate the concomitant presence of depression, hypertension and excess weight and administer appropriate treatment when present.

Prevalence of tension-type headache in adult general population: the PACE study and review of the literature

The mean global prevalence of tension-type headache (TTH) in adult is 42 %. To date, there have been no Italian studies on TTH prevalence in the adult general population. Therefore, we conducted a cross-sectional study, called PACE (PArma CEfalea, or "Headache in Parma"), aimed at detecting the prevalence and clinical features of primary headaches in the city of Parma's adult general population. Crude past-year prevalence for definite TTH was 19.4 % (95 % CI 16.8-21.9), namely 9.0 % (95 % CI 7.1-10.8) for infrequent TTH, 9.8 % (95 % CI 7.9-11.8) for frequent TTH, and 0.6 % (95 % CI 0.1-1) for chronic TTH. Crude prevalence for probable TTH was 2.3 % (95 % CI 1.3-3.3). Our study results indicate a TTH prevalence rate (19.4 %) at the lower limit of data ranges currently available for Western countries, and prevalence rates for infrequent forms (9 %) do not appear much different from those of frequent forms (9.8 %).

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.

"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.

Comorbidity in perimenstrual migraine

Comorbidity may be defined as the association of two or more diseases in individuals at a frequency greater than that expected statistically by chance. Studying the co-occurrence of two disorders requires a careful statistical analysis before any clear conclusion on causality is reached. Many studies have looked for an association between migraine and many diseases, reporting several sometimes controversial comorbidities in migraine subjects. Although migraine is more common in women than in men, very few studies have analyzed the comorbidity of perimenstrual migraine, a migraine sub-type characterized by attacks of migraine without aura related to menstruation. We review the studies on migraine comorbidities, particularly migraine without aura in women.