Headache in epilepsy: prevalence and clinical features

Structural brain characteristics of epilepsy patients with comorbid migraine without aura

Migraine is a common bi-directional comorbidity of epilepsy, indicating potential complex interactions between the two conditions. However, no previous studies have used brain morphology analysis to assess possible interactions between epilepsy and migraine. Voxel-based morphometry (VBM), surface-based morphometry (SBM), and structural covariance networks (SCNs) can be used to detect morphological changes with high accuracy. We recruited 30 individuals with epilepsy and comorbid migraine without aura (EM), along with 20 healthy controls (HC) and 30 epilepsy controls (EC) without migraine. We used VBM, SBM, and SCN analysis to compare differences in gray matter volume, cortical thickness, and global level and local level graph theory indexes between the EM, EC, and HC groups to investigate structural brain changes in the EM patients. VBM analysis showed that the EM group had gray matter atrophy in the right temporal pole compared with the HC group (p < 0.001, false discovery rate correction [FDR]). Furthermore, the headache duration in the EM group was negatively correlated with the gray matter volume of the right temporal pole (p < 0.05). SBM analysis showed cortical atrophy in the left insula, left posterior cingulate gyrus, left postcentral gyrus, left middle temporal gyrus, and left fusiform gyrus in the EM compared with the HC group (p < 0.001, family wise error correction). We found a positive correlation between headache frequency and the cortical thickness of the left middle temporal gyrus (p < 0.05). SCN analysis revealed no differences in global parameters between the three groups. The area under the curve (AUC) of the nodal betweenness centrality in the right postcentral gyrus was lower in the EM group compared with the HC group (p < 0.001, FDR correction), and the AUC of the nodal degree in the right fusiform gyrus was lower in the EM group compared with the EC group (p < 0.001, FDR correction). We found clear differences in brain structure in the EM patients compared with the HC group. Accordingly, migraine episodes may influence brain structure in epilepsy patients. Conversely, abnormal brain structure may be an important factor in the development of epilepsy with comorbid migraine without aura. Further studies are needed to investigate the role of brain structure in individuals with epilepsy and comorbid migraine without aura.

A rare case of lupus cerebritis presenting as ictal epileptic headache: A case report

Ictal epileptic headache, characterized by headache as the sole symptom of a seizure attack, is a rare condition. In this case report, we present a 52-year-old female with a history of systemic lupus erythematosus who sought medical attention at the headache clinic due to a new type of headache. The headache was described as an intense painful wave followed by a dull headache, without autonomic symptoms or migrainous features. Magnetic resonance imaging revealed an enhancing lesion in the left hippocampus in addition to two other lesions in the corpus callosum and left parieto-occipital lobe. Electroencephalography during the headache episodes showed epileptic discharges originating from the left fronto-temporal region. The patient was initiated on levetiracetam, which resulted in the resolution of both the epileptic discharges and the headaches. This case underscores the significance of considering ictal epileptic headache as a potential secondary cause for headaches, particularly in patients with underlying conditions that may predispose them to epilepsy, such as systemic lupus erythematosus.

The broad-spectrum activity of perampanel: state of the art and future perspective of AMPA antagonism beyond epilepsy

Glutamate is the brain's main excitatory neurotransmitter. Glutamatergic neurons primarily compose basic neuronal networks, especially in the cortex. An imbalance of excitatory and inhibitory activities may result in epilepsy or other neurological and psychiatric conditions. Among glutamate receptors, AMPA receptors are the predominant mediator of glutamate-induced excitatory neurotransmission and dictate synaptic efficiency and plasticity by their numbers and/or properties. Therefore, they appear to be a major drug target for modulating several brain functions. Perampanel (PER) is a highly selective, noncompetitive AMPA antagonist approved in several countries worldwide for treating different types of seizures in various epileptic conditions. However, recent data show that PER can potentially address many other conditions within epilepsy and beyond. From this perspective, this review aims to examine the new preclinical and clinical studies-especially those produced from 2017 onwards-on AMPA antagonism and PER in conditions such as mesial temporal lobe epilepsy, idiopathic and genetic generalized epilepsy, brain tumor-related epilepsy, status epilepticus, rare epileptic syndromes, stroke, sleep, epilepsy-related migraine, cognitive impairment, autism, dementia, and other neurodegenerative diseases, as well as provide suggestions on future research agenda aimed at probing the possibility of treating these conditions with PER and/or other AMPA receptor antagonists.

Diagnosis of comorbid migraine without aura in patients with idiopathic/genetic epilepsy based on the gray zone approach to the International Classification of Headache Disorders 3 criteria

Background

Migraine without aura (MwoA) is a very frequent and remarkable comorbidity in patients with idiopathic/genetic epilepsy (I/GE). Frequently in clinical practice, diagnosis of MwoA may be challenging despite the guidance of current diagnostic criteria of the International Classification of Headache Disorders 3 (ICHD-3). In this study, we aimed to disclose the diagnostic gaps in the diagnosis of comorbid MwoA, using a zone concept, in patients with I/GEs with headaches who were diagnosed by an experienced headache expert.

Methods

In this multicenter study including 809 consecutive patients with a diagnosis of I/GE with or without headache, 163 patients who were diagnosed by an experienced headache expert as having a comorbid MwoA were reevaluated. Eligible patients were divided into three subgroups, namely, full diagnosis, zone I, and zone II according to their status of fulfilling the ICHD-3 criteria. A Classification and Regression Tree (CART) analysis was performed to bring out the meaningful predictors when evaluating patients with I/GEs for MwoA comorbidity, using the variables that were significant in the univariate analysis.

Results

Longer headache duration (<4 h) followed by throbbing pain, higher visual analog scale (VAS) scores, increase of pain by physical activity, nausea/vomiting, and photophobia and/or phonophobia are the main distinguishing clinical characteristics of comorbid MwoA in patients with I/GE, for being classified in the full diagnosis group. Despite being not a part of the main ICHD-3 criteria, the presence of associated symptoms mainly osmophobia and also vertigo/dizziness had the distinguishing capability of being classified into zone subgroups. The most common epilepsy syndromes fulfilling full diagnosis criteria (n = 62) in the CART analysis were 48.39% Juvenile myoclonic epilepsy followed by 25.81% epilepsy with generalized tonic-clonic seizures alone.

Conclusion

Longer headache duration, throbbing pain, increase of pain by physical activity, photophobia and/or phonophobia, presence of vertigo/dizziness, osmophobia, and higher VAS scores are the main supportive associated factors when applying the ICHD-3 criteria for the comorbid MwoA diagnosis in patients with I/GEs. Evaluating these characteristics could be helpful to close the diagnostic gaps in everyday clinical practice and fasten the diagnostic process of comorbid MwoA in patients with I/GEs.

Antiseizure Medications for the Prophylaxis of Migraine during the Anti- CGRP Drugs Era

Migraine and epilepsy are fundamentally distinct disorders that can frequently coexist in the same patient. These two conditions significantly differ in diagnosis and therapy but share some widely- used preventive treatments. Antiseizure medications (ASMs) are the mainstay of therapy for epilepsy, and about thirty different ASMs are available to date. ASMs are widely prescribed for other neurological and non-neurological conditions, including migraine. However, only topiramate and valproic acid/valproate currently have an indication for migraine prophylaxis supported by high-quality evidence. Although without specifically approved indications and with a low level of evidence or recommendation, several other ASMs are used for migraine prophylaxis. Understanding ASM antimigraine mechanisms, including their ability to affect the pro-migraine calcitonin gene-related peptide (CGRP) signaling pathway and other pathways, may be instrumental in identifying the specific targets of their antimigraine efficacy and may increase awareness of the neurobiological differences between epilepsy and migraine. Several new ASMs are under clinical testing or have been approved for epilepsy in recent years, providing novel potential drugs for migraine prevention to enrich the treatment armamentarium and drugs that inhibit the CGRP pathway.

Migraine in people with epilepsy: a treatable and neglected co-morbidity

Migraine and epilepsy account for more than 40% of neurology outpatients and are leading causes of disability. They often co-exist and can be confused, because of shared clinical features. The borderlands and links between migraine and epilepsy have fascinated neurologists for centuries, and unresolved questions remain. Greater understanding of the relationship between migraine and epilepsy may give insight into shared mechanisms. It is already clear that treating co-existing migraine is an important therapeutic opportunity and may improve epilepsy.

Primary headache disorders in epileptic adults

Background

Epilepsy and primary headache disorders are two relatively common neurological disorders and their relationship is still a matter of debate. We aimed to estimate the prevalence and clinical features of primary headache disorders in patients with epilepsy.

Methods

62 subjects aged ≥ 18 years were recruited from the hospital’s neurology outpatient clinic in the period from January to April 2018. The subjects were further divided into two equal groups, epileptics and non-epileptics. They underwent a semi-structured interview including the ILAE 2017 epilepsy classification and the ICHD III-beta criteria for headache. Patients' demographic data and clinical characteristics of epilepsy and headache and temporal relationships between them were assessed. Patients who experienced headaches were grouped based on the type of headaches and on whether their headaches occurred in the pre-ictal, post-ictal or inter-ictal period.

Results

Primary headache disorders were more common in epileptic group (61.3%) than the non-epileptic group (32.2%) (p = 0.021). The tension-type headache was the most common (45.2%) followed by migraine-type headache (12.9%) in the epileptic group. Post-ictal headache was the most common type (29%). Inter-ictal headaches were significantly related to "focal to bilateral tonic–clonic" seizures (p = 0.046). The prevalence of headache among patients on polytherapy (69.2%) was higher than that of patients on monotherapy (52.9%).

Conclusions

In this study, headache was more common in epileptic patients. TTH was the most represented type of headache in patients with epilepsy. Headache occurred in patients with epilepsy most frequently during the post-ictal period.

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.

Perampanel may represent an effective treatment for the prevention of migraine comorbid with epilepsy

INTRODUCTION

Migraine is a common comorbidity in patients with epilepsy. Considering the proven associations and the common pathophysiological features linking epilepsy and migraine, some anti-seizure medications (ASMs) have been considered as a treatment for both disorders. This study aimed at assessing both the effectiveness of perampanel (PER) on epileptic seizures and migraine attacks in patients with epilepsy and comorbid migraine, as well as the reduction in the monthly mean rate usage of rescue migraine medications.

METHODS

This observational, multi-centre study included adult patients with epilepsy and comorbid migraine who started PER to better control epileptic seizures and who were followed up for 12 months.

RESULTS

Thirty-one patients were included (mean age 40.13 ± 13.13 years; 67.0% female). At the 12-month follow-up visit, 27 patients were continuing PER concomitantly with 1 (45.2%) or 2 ASMs (54.8%). A significant reduction in epileptic seizures, migraine attacks, and the monthly use of rescue migraine medications between baseline and both 6- and 12-month follow-up visits was documented.

CONCLUSION

PER demonstrated good effectiveness in reducing both epileptic seizures and migraine attacks in patients with comorbid epilepsy and migraine. Future studies with possibly larger samples are needed to evaluate the efficacy of PER in migraine other than 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.

Borderlands of Migraine and Epilepsy

Background

The complex relationship between migraine and epilepsy has frequently been described to represent a clinical and electrographic "borderland." These two conditions share clinical expressions such as paroxysmal and chronic nature, as well as semiology, particularly visual phenomenon.

Objective

We aimed to review the current literature on the overlapping phenomena of migraine and epilepsy.

Materials and Methods

We searched the PubMed for relevant literature and conducted a narrative review on migraine and epilepsy.

Results

Migraine and epilepsy share a complex and pathophysiologically intriguing relationship. The International Classification of Headache Disorders, 3^rd edition (ICHD-3) makes diagnostic provisions for migraine aura-triggered seizures (Subchapter 1.4.4) and headache attributed to epileptic seizure (Subchapter 7.6), the latter being further categorized as 7.6.1 Ictal epileptic headache, and 7.6.2  post-ictal headache. Neurological conditions such as certain channelopathies and epilepsy syndromes exhibit both conditions within their phenotypic spectrum, suggesting shared genetic and molecular underpinnings. Diagnostic confusion may arise, particularly between occipital epilepsy and the visual aura of migraine. Antiseizure medications may be effective for the treatment of migraines that occur in concert with epilepsy.

Conclusions

Migraine and epilepsy share several clinical features and have intertwined genetic and molecular underpinnings, which may contribute to common pathogenesis. Electroencephalography may be useful as a diagnostic tool in selected cases.

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.

Headaches Associated with Seizure: A Prospective Comparative Cohort Study

INTRODUCTION

The purpose of the present study is to examine the frequency of headaches based on their relationship with seizures in epileptic patients as well as types of these headaches, and their clinical characteristics.

METHODS

100 patients with epilepsy (60 female, 40 male), who applied to the epilepsy outpatient clinic of Faculty of Medicine of Uludağ University, were included in the study after accepting their consent forms. Patients with symptomatic epilepsy, secondary headaches and mental retardation were excluded from the study. Patients with epilepsy were divided into two groups as the patients with or without headaches associated with seizure. In addition, according to their temporal relationships with seizures, headaches were grouped as preictal, ictal and postictal headaches and the characteristics of headaches associated with seizure were examined and the patients with and without headache associated with seizure were compared in terms of their demographic and clinical features.

RESULTS

In this study, the prevalence of headache associated with seizure was found as 42%. Headaches associated with seizure were more frequent in the postictal period and they were mostly characterized as migraine-like headache. According to the seizure periods, 22 (52.3%) of the patients experienced pain during every seizure period. It was determined that preictal headache was frequently migraine-like compared to postictal headache and this headache was more frequently accompanied by aura.

CONCLUSION

Headache and epilepsy are the most frequent paroxysmal neurological conditions. However, because the symptoms of epilepsy are more remarkable, and its clinical presentation has a more dramatic picture, additional neurological conditions may be overlooked. Since both epilepsy and headache symptoms decrease the quality of life, it is important to treat both conditions. Examination of the correlation between these two situations can guide the physicians for selecting the treatment type, as well as helping them to improve the quality of life.

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.

Kopfschmerz bei Parietal- und Okzipitallappenepilepsien

Epilepsiepatienten leiden überdurchschnittlich häufig unter Kopfschmerzen. Dies gilt insbesondere für Patienten mit idiopathisch generalisierten und parietookzipitalen Epilepsien. Die Häufigkeit des gemeinsamen Auftretens von Kopfschmerzen und Epilepsie überschreitet dabei die rechnerische Koinzidenz, sodass von einer Komorbidität beider Syndrome auszugehen ist. Bestärkt wird diese Hypothese durch überlappende genetische Veränderungen sowie gemeinsame pathophysiologische Mechanismen. Bis zu 62 % der Patienten mit z. B. Parietal- und Okzipitallappenepilepsie (POLE) geben Kopfschmerzen an. Diese treten v. a. nach dem Anfall (postiktal) auf und manifestieren sich am häufigsten als Migräne-ähnlicher Kopfschmerz oder Spannungskopfschmerz. Seltener kommt es zu Kopfschmerzen vor (periiktal), während (iktal) oder zwischen (interiktal) epileptischen Anfällen. Bei transienten neurologischen Ausfallsymptomen mit begleitenden Kopfschmerzen ist differenzialdiagnostisch neben der Migräne an vaskuläre Ereignisse wie Synkopen oder eine transiente ischämische Attacke zu denken.

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.

Peri-ictal headaches in the paediatric population - prospective study

INTRODUCTION

The co-occurrence of headache and epilepsy is well-documented in the adult population. The aim of the prospective study was to analyse in the paediatric population the correlations between the types of peri-ictal headaches and types of seizures. Furthermore, an attempt was made to find trends in characteristic features of peri-ictal headaches.Material: A total of 57 children with peri-ictal headache were enrolled in the study. The participants' guardians were asked to keep a diary of the seizure and peri-ictal headache episodes during a 180-day period. During follow-up visits, systematic history regarding peri-ictal headaches was taken.

RESULTS

A total of 913 seizure and 325 peri-ictal headache episodes were noted during the study. Post-ictal headaches were most common, occurring in < 1 h after the seizure, lasting minutes to hours and more likely to occur after generalised seizures, whereas pre-ictal headaches occurred 30-240 min before the seizure. In the analysed group, peri-ictal headaches were most often moderate in intensity. Only 30% of patients took analgesic medication, usually to treat post-ictal headaches.

CONCLUSION

Peri-ictal headaches are a significant health problem for patients with epilepsy. The most common type are post-ictal headaches, and they are most likely to appear after a generalised seizure.

The epidemiology of headaches among patients with epilepsy: a systematic review and meta-analysis

Background

Headache is the symptom of pain in the face, head or neck that causes disability in most people with medical and neurological disorders. It frequently co-occurs with most chronic diseases such as epilepsy and significantly impacts the quality of life. However, epidemiologic data from different studies showed different rates of prevalence. Therefore, we conducted this review to summarize the available epidemiologic evidence on the topic and formulate recommendations for future research and clinical practice.

Methods

We followed the preferred reporting items for systematic review and meta-analysis (PRISMA) guidelines. We systematically searched the literature using popular databases such as PubMed, EMBASE, Psych-INFO, and SCOPUS. We further scanned the reference lists of the eligible studies to supplement our electronic search. The Comprehensive Meta-Analysis software version 3.0 (CMA 3.0) was used to conduct a meta-analysis. Subgroup and sensitivity analysis were performed and Cochran’s Q- and the I²- test were used to assess the source of heterogeneity. The funnel plot and Egger’s regression tests were used to assess potential publication bias.

Results

A total of 17 studies conducted both in developed and developing countries including 5564 study participants were combined in this meta-analysis. The pooled estimated prevalence of headache among patients with epilepsy was 48.4%. The pooled estimated prevalence of Inter-Ictal headache (IIH) (42.2%) and Postictal headache (PIH) (43.1%) were higher when compared to tension-type headache (TTH) (26.2%), migraine with aura (26.0%) and migraine without aura (10.4%). The pooled prevalence of headache was 50.6% and 49.5% for developed and developing countries respectively. The pooled prevalence of headache among patients with epilepsy was considerably higher among females (63.0%) when compared to males (33.3%). Moreover, the pooled estimated prevalence of headache among patients with epilepsy was ranging from 46.0% to 52.2% in a leave-one-out sensitivity analysis.

Conclusion

The pooled estimated prevalence of headache among patients with epilepsy was considerably high (48.4%). Screening and appropriate management of headaches among patients with epilepsy are warranted.

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.

The comorbidity of headaches in pediatric epilepsy patients: How common and what types?

OBJECTIVE

To estimate the prevalence and characteristics of headache in pediatric epileptic patients.

METHODS

This cross-sectional study was performed over 6 months period from January 2018 to June 2018 at King Abdullah Specialist Children Hospital, King Abdulaziz Medical City, Riyadh, Kingdom of Saudi Arabia using a structured questionnaire in pediatric patients with epilepsy.

RESULTS

There were 142 patients enrolled (males, 57.7%; average age, 10.7+/-3.1 years) with idiopathic epilepsy (n=115, 81%) or symptomatic epilepsy (n=27, 19%). Additionally, patients had focal epilepsy (n=102, 72%) or generalized epilepsy (n=40, 28%), and among them, 11 had absence epilepsy. Overall, 65 (45.7%) patients had headaches compared with 3/153 (2%) in the control group (p<0.0001). Among the 65 patients with headaches, 29 (44.6%) had migraine-type, 12 (18.4%) had tension-type, and 24 (36.9%) had unclassified headache. There was no significant difference in age, gender, type of epilepsy syndrome, and antiepileptic used except in patients with or without headache. For migraine patients, there was a lower headache prevalence in the subgroup treated with valproic acid compared with other treatments.

CONCLUSION

Headache, predominantly migraine, is a common problem in pediatric epileptic patients and choosing valproic acid when possible can be important in preventing migraine in these patients.

Treatment of migraine attacks and prevention of migraine: Guidelines by the German Migraine and Headache Society and the German Society of Neurology

In collaboration with some of the leading headache centres in Germany, Switzerland and Austria, we have established new guidelines for the treatment of migraine attacks and the prevention of migraine. A thorough literature research of the last 10 years has been the basis of the current recommendations. At the beginning, we present therapeutic novelties, followed by a summary of all recommendations. After an introduction, we cover topics like drug therapy and practical experience, non-effective medication, migraine prevention, interventional methods, non-medicational and psychological methods for prevention and therapies without proof of efficacy.

Comorbidity of Migraine and Epilepsy in Pediatrics: A Review

Migraine and epilepsy are classified as chronic paroxysmal neurologic disorders sharing many clinical features, as well as possible treatment options. This review highlights the similarities between migraine and epilepsy in pediatrics, focusing on epidemiologic, pathophysiological, genetic, clinical, and pharmacologic aspects. Despite the fact that several syndromes share symptoms of both migraine and epilepsy, further research is needed to clarify the pathophysiological and genetic basis of their comorbidity. Drugs used for prophylactic therapy of migraine and epilepsy have similar pharmacologic properties. The role of epileptic pharmacotherapy in the prophylaxis of migraine is assessed, including the use of conventional antiepileptic drugs, calcium channel blockers, and nonpharmacologic methods such as dietary therapy, supplements, and vagal nerve stimulation. Further randomized, controlled clinical trials assessing pharmacologic and nonpharmacologic methods for the treatment of both disorders are essential, in order to initiate new therapeutic approaches.

Association between epilepsy and headache

OBJECTIVE

Similar clinical characteristics of epilepsy and migraine and the prevalence of their comorbidity have been investigated for years. The present study investigated the relationship between epilepsy and headache.

METHODS

A total of 420 epilepsy patients, who visited epilepsy outpatient clinic within 6-month period between January 2016 and June 2016, were questioned whether they have headache. Age, gender, duration of epilepsy, type of seizures, and temporal relationship of headache with seizure were investigated in the patients with headache.

RESULTS

Headache was detected in 111 (26%) of 420 epilepsy patients. The prevalence of migraine was 15%. When the temporal relationship of headache with seizure was evaluated, interictal headache was found to be the most common type with a percentage of 74.8%. No significant difference was determined between the patients with migraine and non-migraine headache in terms of age, gender, duration of epilepsy, age at the onset of epilepsy, type of seizure, and electroencephalography findings. The prevalence of interictal headache was statistically significantly higher in migraine patients as compared to that of non-migraine patients (p < 0.001); however, the prevalence of preictal headache and the prevalence of postictal headache were significantly lower (p = 0.001 and p < 0.001, respectively).

CONCLUSION

The prevalence of headache and the prevalence of migraine, which are considered to be pathogenetically linked to epilepsy, were not different in epilepsy patients as compared to that of the general population. Different outcomes and percentages in other studies suggest that pathogenesis of headache is multifactorial and that different diagnostic criteria might have been taken into consideration.

Prodrome in epilepsy

BACKGROUND

Prodromal symptoms (PS) of epileptic seizures are clinically well-recognized but relatively little researched. The purpose of this review was to examine the evidence in the literature for the existence of prodrome and the reported frequency and nature of prodromal characteristics.

METHODS

We performed a PubMed review of the clinical characteristics, frequency, and duration of PS in papers published between 2007 and 2017. We also reviewed findings from prospective studies into the predictive performance of prodrome. In a second analysis, we reviewed studies reporting a single symptom/sign of prodrome.

RESULTS

In 8 studies reporting on the prevalence of prodrome, we found a mean frequency of 21.9%. The most frequent symptoms were "funny feeling" (10.4%), confusion (9.0%), anxiety (8.6%), and irritability (7.7%), but other features were also reported. The duration of prodrome was typically between 10min and 3days, with most prodromes lasting for between 30min and 24h. In studies that reported a single prodromal symptom/sign, headache was the most frequent: 8% with a range of between 1.2 and 30%.

CONCLUSIONS

Prodromes are characterized by a broad spectrum of preictal symptoms that may be experienced for a duration of between 10min and several days, which usually persist until seizure onset. Opinion is divided on their precise nature and value as predictors of seizures. A greater understanding of prodromes might offer insights into the preictal period and hold promise for new seizure management therapies.

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.

Epileptic headache: A rare form of painful seizure

PURPOSE

To describe the concept, features and mechanisms of epileptic headache (EH).

METHODS

Analysis of all published articles concerning EH and related subjects.

RESULTS

There are more than 30 published case studies of patients with headache as the only manifestation of a seizure, a condition that has been variously called "EH", "ictal epileptic headache", "hemicrania epileptica", "cephalic pain seizure". It is necessary to differentiate EH from "migralepsy" and "ictal non-epileptic headache". EH may be an isolated event or the initial phase of a seizure followed by other manifestations. An isolated EH is clinically relevant because it is often symptomatic of structural brain disease; this underlines the importance of a differential diagnosis as the head pain of EH has no specific diagnostic characteristics. The described cases indicate that the location of the foci may vary, thus suggesting the involvement of different parts of the pain network. EH is a "focal aware" seizure, but there are a few reports of cases in which it was associated with generalised epileptiform activity. A correct diagnosis of EH requires an ictal EEG recording showing epilepsy-compatible discharges that coincide with the onset and cessation of the headache. A rapid response to the acute administration of an antiepileptic drug may support the diagnosis.

CONCLUSIONS

EH is a particular type of pain seizure that has a complex pathophysiology and, when isolated, requires differential diagnostic consideration. We believe that, although it is not frequent, pain as an ictal symptom should be highlighted in the operational classification of seizure types.

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.

Migraine in childhood: biobehavioural or psychosomatic disorder?

It is well documented that headache is a multifactorial disorder which includes not only genetic, biological, medical and neuropsychological factor but also psychological and personality traits. The close relationship between stress and migraine attacks and the significant psychiatric comorbidities in migraine provide evidence of a “paradigm” of tight interaction between somatic and psychological aspects in paediatric migraine. In particular in younger children, an uncomfortable situation, a psychological problem or an emotional distress is rarely expressed directly but usually through physical symptoms. So migraine may be considered as a disorder of psychobiological adaptation in which genetic predisposition interplays with internal and/or external environmental influences such as psycho-emotional, climatic, hormonal, dietary or other factors.