Migraine and Epilepsy

Comprehensive Care of the Epilepsy Patient-Control, Comorbidity, and Cost

Traditionally, control of seizures in patients with epilepsy is viewed as the most important clinical outcome. Yet, current antiepileptic drugs (AEDs) do not always achieve this. Around 30-40% of patients remain uncontrolled despite pharmacological intervention. Poor tolerability of AEDs is a large part of the problem and contributes as much to the overall effectiveness of therapy as efficacy. Comorbid conditions are present in many patients, and appropriate management of these can further improve seizure control and quality of life. Patients with epilepsy often experience--among other disorders--neuropsychological effects, migraines, and psychological problems (especially anxiety and depression). Sleep disturbances are also common and have been shown to contribute to the intractability of seizures in some patients. Many anticonvulsant treatments have the potential to improve--or in some cases worsen--these concurrent conditions, and these properties should therefore be considered in the total care of the patient. Finally, the costs of uncontrolled epilepsy are measured not only in terms of direct healthcare-related costs, but also in terms of lost productivity and opportunity. The indirect costs of epilepsy are substantial and account for 70-85% of total disease-related costs. Patients with uncontrolled seizures contribute disproportionately to healthcare costs, reinforcing the need for the development of newer AEDs with improved profiles of efficacy and tolerability, but with minimal adverse effects on behavior, cognition, and sleep.

Electroencephalography in migraine: a review with focus on quantitative electroencephalography and the migraine vs. epilepsy relationship

EEG-studies in migraine in the last decade has contributed modestly to the understanding of headache pathogenesis. Headache patient groups seem to have increased EEG responses to photic stimulation, but a useful biological marker for migraine in single patients has not been found. In future EEG and QEEG studies we recommend to use follow-up designs and record several EEGs across the migraine cycle. It is also important to use a blinded study design in order to avoid selection bias. A clinical EEG should be performed in patients with acute headache attacks when either epilepsy, basilar migraine, migraine with prolonged aura or alternating hemiplegia is suspected. Unequivocal epileptiform abnormalities usually suggest a diagnosis of epilepsy. In children with occipital spike-wave activity the probable diagnosis is childhood epilepsy with occipital paroxysms (CEOP). The final diagnosis of either an epilepsy syndrome or migraine must be mainly based on a clinical judgement [corrected].

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.

Familial adult onset myoclonic epilepsy associated with migraine

We report a new type of migraine associated epileptic syndrome in a family: adult onset myoclonic epilepsy with benign course and migraine. Affected members of the family had myoclonic and rare generalised tonic-clonic seizures. Most of the patients, but not all, had a history of migraine. Also, some cases of the family had only migraine. This family will be discussed because of two distinct features. Firstly, in this family a different type of epilepsy, adult onset myoclonic epilepsy was diagnosed that has not been classified in the ILAE 1989, classification(s), but was similar to that previously reported in Japanese families. Secondly, in most of the cases migraine was associated with the epilepsy.

Incidence of ponticulus posterior of the atlas in migraine and cervicogenic headache

BACKGROUND

The clinical significance of the ponticulus posticus is far from clear. It has been associated with headaches, Barré-Lieou syndrome, photophobia, and migraine. However, little epidemiologic evidence for this exists.

OBJECTIVE

This study investigated the relationship of ponticulus posticus on x-ray studies and headache symptoms in a series of chiropractic patients.

METHODS

Eight hundred ninety-five patients who visited a chiropractic clinic for the first time and whose conditions required cervical spine x-ray examinations were studied. Complaints were categorized as migraine with aura, migraine without aura, cervicogenic headache, neck pain only, and other conditions. The presence or absence of the ponticulus posticus (whether partial or complete) was determined by means of a lateral cervical film and noted as a positive or negative finding. The data were analyzed by frequency analysis and Pearson's chi 2 test.

RESULTS

Forty-six percent of the sample were men and the predominant complaint was neck pain (33%). Most patients were in the fourth decade of life. The frequencies of the other complaints were migraine with aura (7%), migraine without aura (4%), cervicogenic headache (22%), other conditions (33%). An 18% prevalence of ponticulus posticus was found. This finding was significantly associated with migraine without aura (chi 2 = 4.97; P = .03) and not with any other conditions.

CONCLUSION

In a chiropractic patient population that required cervical x-ray examinations, a significant association was found between ponticulus posticus and migraine without aura, with an odds ratio of 2.19:1 in favor of this complaint being present with the osseous anomaly. The mechanism for this remains obscure but may be related to ischemic compression of the vertebral artery or by dural tension at the craniocervical junction.

Partial cosegregation of familial hemiplegic migraine and a benign familial infantile epileptic syndrome

PURPOSE

We studied a large Dutch-Canadian family, in which two very rare hereditary paroxysmal neurologic disorders, familial hemiplegic migraine (FHM) and a "benign familial infantile epileptic syndrome" concur and partially cosegregate. FHM is a dominantly inherited subtype of migraine with attacks of hemiparesis, linked to chromosome 19p13 in 50% of the families tested. Recently mutations in a brain-specific P/Q-type Ca2+ channel alpha1 subunit gene (CACNL1A4) were identified in families with chromosome 19-linked FHM. The infantile epileptic syndrome resembles to two other dominantly inherited benign epilepsies occurring in the first year of life, benign familial neonatal convulsions (BFNC), assigned to chromosomes 20q13.2 and 8q, and benign infantile familial convulsions (BIFC), as yet unlinked.

METHODS

Linkage analysis was performed for the known locations of FHM and BFNC. The question whether the two conditions in this family can be caused by a single gene defect was addressed by additional linkage analysis.

RESULTS

We excluded linkage of the infantile convulsions to markers on chromosome 20q13.2, 8q, or 19p13. This indicates the existence of a third locus for benign familial convulsions in the first year of life. Linkage of FHM to these markers was not formally excluded but seems very unlikely. Statistical analysis of whether, in this family, both conditions are caused by a single gene defect was inconclusive.

CONCLUSIONS

We describe a "benign familial infantile epileptic syndrome" with attacks of FHM at a later age. Further genetic studies in this family may help to unravel the genetic basis of epilepsy or migraine or both.

Genetics of migraine

Although family studies and twin studies are not sufficiently reliable to establish this theory with certainty, migraine likely is influenced by hereditary susceptibility. The association of migraine with a large number of hereditary diseases opens the possibility to choose candidate chromosomes for linkage studies. A rare subtype of migraine, familial hemiplegic migraine, is linked to chromosome 19p and at least one other locus. The chromosome 19p also seems to be involved in "normal" migraine, although conflicting results have been reported.

Migraine and epilepsy

The epidemiology of the association between migraine and epilepsy is reviewed. Migraine-related epilepsy is categorized using defined diagnostic criteria. Migraine-induced epilepsy is only one of several migraine-related epileptic syndromes.

A family with hemiplegic migraine and focal seizures

Familial hemiplegic migraine is a distinctive form of migraine with autosomal dominant inheritance. The patients undergo attacks of migraine complicated by hemiplegia. Seizures have not been reported as comprising a part of this syndrome. We describe three generations of a family with hemiplegic migraine and focal seizures occurring concurrently with the migrainous attacks. There were five affected family members whose clinical features included unilateral headache and transient hemiplegia. Two family members also had focal seizures during the migrainous attacks. One of the patients was treated with carbamazepine with good results. The only associated neurological finding was ataxia which was found in the oldest patient. The presence of focal seizures during an episode of hemiplegic migraine suggests that the two phenomena of migraine and focal seizures may share the same underlying pathophysiology.