Hemicrania Epileptica Research Articles

The complex interrelations between two paroxysmal disorders: headache and epilepsy.

The interrelations between headache/migraine and epileptic seizures are an interesting topic, still lacking a systematization, which is the objective of the present revision. We organize the general setting on: (a) a distinction between pre-ictal, ictal, post-ictal and inter-ictal headaches, assuming "ictal" as epileptic seizure, and (b) the kind of headache, if it is of migraine type or not. Concerning pre-ictal migraine/headache, the necessity of its differentiation from an epileptic headache presenting as an aura of a seizure is stressed; this is connected with the indefiniteness of the term "migralepsy". The term "migraine aura-triggered seizure" should be used only in front of a proven triggering effect of migraine. Epileptic headache (called also "ictal epileptic headache") is a well-characterized entity, in which different types of head pain may occur and an ictal EEG is necessary for the diagnosis. It may present as an isolated event ("isolated epileptic headache"), requiring a differential diagnosis from other kinds of headache, or it may be uninterruptedly followed by other epileptic manifestations being in this case easily identifiable as an epileptic aura. Hemicrania epileptica is a very rare variant of epileptic headache, characterized by the ipsilaterality of head pain and EEG paroxysms. Ictal non-epileptic headache needs to be differentiated from epileptic headache. Post-ictal headaches are a frequent association of headache with seizures, particularly in patients suffering also from inter-ictal headache-migraine. The reported systematization of the topic led us to suggest a classification which is shown in Appendix.

Field testing of ICHD-3 beta criteria of periictal headaches in patients with focal epilepsy - a prospective diary study.

Background To date we are lacking prospective data for field testing of ICHD-3 beta criteria for periictal headache (PIH). Methods Patients with focal epilepsy diagnosed by means of prolonged video-EEG monitoring completed a paper-pencil diary for three months and recorded seizures and headaches on a daily basis. According to ICHD-3 beta, we classified PIH, defined as headache present on a day with at least one seizure, as "7.6 headache related to epileptic seizure", "7.6.1 hemicrania epileptica" or "7.6.2 postictal headache". In addition, we compared the ICHD-3 beta diagnoses to the diagnoses according to ICHD-2. Results Thirty two patients completed the diary. Data analysis included 2,668 patient days, 300 seizures and 37 episodes of PIH. Two of these episodes (5.4%) were classified as headache related to seizure, three (8.1%) fulfilled both the criteria of headache related to seizure and hemicrania epileptica and four (10.8%) were postictal headaches. Twenty eight episodes (75.7%) did not fulfil any of the ICHD-3 beta criteria of seizure-related headaches, mostly because headache onset was before seizure onset. Applying ICHD-2 criteria allowed only one single episode of PIH to be classified as postictal headache. Discussion Our study is the first to present prospective field testing data of the ICHD-3 beta criteria for three types of seizure-related headaches. The majority of PIH episodes do not fulfil any of these criteria. One quarter can be classified according to ICHD-3 beta, whereas purely clinical diagnosis of PIH is markedly restricted in ICHD-2 because of mandatory electroencephalographic evidence.

Pearls & Oy-sters: Hemicrania epileptica: Unfolding the mystery of an unremitting migraine.

Sheikh et al.1 described a typical migraine persisting for 3 days and resolving after antiepileptic treatment as hemicrania epileptica (HE). EEG recording showed focal status epilepticus and transient brain MRI abnormalities attributed to ongoing seizure. This condition is rare and the proposed criteria for HE bring about the temporal relationship between onset and cessation of migraine with ictal EEG discharges. While migraine and occipital seizures are sometimes difficult to differentiate solely on …

IV thrombolysis in very severe and severe ischemic stroke: Results from the SITS-ISTR Registry.

Editors' Note: In WriteClick this week, commenting on “IV thrombolysis in very severe and severe ischemic stroke: Results from the SITS-ISTR Registry,” Dr. Sharma suggests excluding posterior circulation strokes from the analysis, due to lower risk of hemorrhagic conversion, for more targeted results. Authors Mazya et al. report that this analysis was already performed and published in the online appendix and summarize their results. Dr. Belcastro et al. and authors Sheikh and Marks discuss hemicrania epileptica …

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

Headache can be associated with epilepsy as a pre-ictal, ictal, or post-ictal phenomenon; however, studies of patients with headache as an epileptic aura are scarce. We performed the present study to investigate the incidence and characteristics of headache as an epileptic aura, via confirmation of electroencephalography (EEG) changes by video-EEG monitoring. Data of aura and clinical seizure episodes of 831 consecutive patients who undertook video-EEG monitoring were analyzed retrospectively. For patients who had headache as an aura, information on the detailed features of headache was acquired, including location, nature, duration, and the presence of accompanying symptoms. Video-recorded clinical seizures, EEG findings, and neuroimaging data were used to determine the ictal onset areas in the patients. Six out of 831 (0.7%) patients experienced headache as aura (age range, 25-52 years), all of whom had partial seizures. The incidence of pre-ictal headache was 6.3% (25/831), and post-ictal headache was 30.9% (257/831). In patients with headache as aura, five patients described headache as the most frequent aura, and headache was the second most frequent aura in one patient. The characteristics of headache were hemicrania epileptica in two patients, tension-type headache in another two patients, and migraine-like headache in the remaining two patients. No patient met the diagnostic criteria of ictal epileptic headache or migraine aura-triggered seizure. Our study showed that headache as an aura is uncommon in adult patients with epilepsy, and that headache can present as diverse features, including hemicrania epileptica, tension-type headache, and migraine-like headache. Further studies are necessary to characterize the features of headache as an epileptic aura in adult patients with epilepsy.

O073. Proposal guidelines for epilepsy and headache.

Background Headache and epilepsy are two paroxysmal disorders with epidemiological and clinical comorbidity. Among the primary headaches, migraine, and in particular the subtype with aura (MA) has a significant correlation with epilepsy. Like epilepsy MA is a chronic condition characterized by recurrent focal neurological attacks that are variously accompanied by headache and inconstant autonomic features. Interictal electroencephalogram (EEG) findings are usually normal although several abnormalities, especially diffuse slowings, have been reported in migraineurs. EEG is not useful in MA with the exception of situations where seizure disorders are to be excluded. The relationship between headaches and epilepsy is covered in the International Classification of Headache Disorders in chapters 1 and 7 where migraine-triggered seizure (1.4.4), hemicrania epileptica (7.6.1) and post-ictal headache (7.6.2) are collocated. An interictal headache was defined as headache starting not earlier than three hours after a seizure or a headache never proceeding directly into an epileptic fit. Headache caused by an epileptic seizure, occurring during and/or after the seizure and remitting spontaneously within hours or up to 3 days [1,2]. The classification of the International League against Epilepsy does not refer to this type of disorder. In the last decade other terms for this association have been proposed (epileptic headache or ictal epileptic headache) and some Authors have proposed to abandon or modify some terms (hemicrania epileptica and migralepsy) [3-5].

EHMTI-0049. Headache, migraine and epileptic seizures

There are different possible temporal associations between epileptic seizures andheadache attacks wich have given rise to uncleare or controversal terminologies. Migraine endepilepsy have common pathophysichologic mechanisms and share essential anddefining attributes which distinguish them from other common neurologicaldisorders. They are both characterized by paroxysmal symptoms and episodic disorders. Occipital lobe to be thebrain structures most responsible for development of migraine and occipitallobe epilepsies Both are characterized by visual symptoms followed by headacheand other autonomic symptoms. Recognition of headache as an epilepticmanifestation per se still represents a challenge. The classification of the international league AgainstEpilepsy does not refer to this type of disorder, while the International Classification of headache Disorderdefines kinds of association _ migraine triggered seizures hemicrania epilepticaand post ictal headache. Epileptic headache or ictal epileptic headache is anepileptic manifestation per se, with onset and cessation if isolated ,coinciding with EE patern of an epileptic seizures EH maybe followed by other epleptic i manifestation /motor/ sensory/ autonomic/. Hemicrania epileptica is very rare variant . Post ictalor pre ictal headache _ when headache is followed during or short time aftertypical epi seizures Migraine attac maybe with or without aura, and seizures triggerring role is stole a subjectdebate. No conflict of interest.

Links between headaches and epilepsy: current knowledge and terminology

Introduction and objectivesHeadaches (including migraines) and epilepsy have a high level of comorbidity and may be confused during diagnosis. Although physicians have known for centuries that these two conditions are somehow linked, their relationship remains poorly understood. Herein we describe the known associations between them, their underlying physiopathologic and genetic mechanisms, and the treatments recommended for them. MethodWe have reviewed the most relevant publication of headache/migraine and epilepsy by using the PubMed data base. DescriptionAn individual can suffer both from headaches (either migraine and/or other type of headache) and epilepsy, either by chance or because of a common underlying pathology. In these cases, the headache usually occurs at a different moment than the seizure (“interictal headache”). However, headaches sometimes occur simultaneously with, or very close in time to, the seizure: one that occurs at the same time as an epileptic seizure is known as an “ictal epileptic headache” or as “hemicrania epileptica”; one that precedes a seizure is known as a “pre-ictal headache”; and one that follows a seizure is known as a “post-ictal headache”. There is a particular type of pre-ictal headache, known as “migralepsy”, which occurs during or just after a migraine aura. ConclusionsThe terminology and concepts employed to describe possible associations between headaches (mainly migraines) and epilepsy have evolved over time with increasing clinical and physiopathogenic knowledge. Some researchers have suggested eliminating the term migralepsy and using the terms ictal epileptic headache and hemicrania epileptica exclusively and uniformly in all classification systems.

Migralepsy: A Borderland of Wavy Lines

The special relationship between migraine and epilepsy has been recognized for centuries and was formally acknowledged by Gowers in his 1906 lecture "Borderland of Epilepsy." The term migralepsy was introduced by Lennox and Lennox in 1960, with multiple cases described in the literature since that time. In the ensuing years, the relationship between migraine and epilepsy has proven complex. The 2 conditions have been found to be comorbid with each other, suggesting a common underlying mechanism or genetic tendency. Specific diseases with both phenotypes provide further evidence of a common pathophysiology, and as the mechanism of migraine has been further elucidated, commonalities with seizure have been recognized. The terms "hemicrania epileptica" and "migraine triggered seizure" were defined by the International Headache Society, formalizing the concept that one can lead to the other. However, case reports and case series in the literature reveal that distinguishing between the 2 entities can be challenging. The concept of migralepsy is likely to evolve as greater understanding of both conditions is gained.

Sociodemographic, disability, and employment differences between persons with chronic and episodic migraine: CaMEO (chronic migraine epidemiology & outcomes) study results

WCN 2013 No: 898 Topic: 8 — Headache Sociodemographic, disability, and employment differences between persons with chronic and episodic migraine: CaMEO (chronic migraine epidemiology & outcomes) study results R.B. Lipton, D. Serrano, D.C. Buse, K. Fanning, A.N. Manack, M. Reed. Montefiore Medical Center, Bronx, NY, USA; Vedanta Research, Chapel Hill, NC, USA; Allergan, Inc., Irvine, CA, USA Background: Previous research suggests sociodemographic, headacherelated disability, and employment status differences between individuals with chronic migraine (CM) and episodic migraine (EM). Objective: To characterize sociodemographics, headache-related disability, and employment status among individuals with CM and EM in a large population-based sample. Methods: CaMEO prospectively recruited migraineurs from a 2.4 million member web-based panel, demographically matched with the general population. 16,789 of 80,783 (20.8%) respondents met ICHD-2-based definitions for CM (migraine diagnosis, ≥15 headache days/month) or EM and were eligible for inclusion. We used descriptive and inferential statistics to contrast those with CM and EM based on baseline survey responses. Results: Of the 16,789 eligible respondents, 1476 (8.8%) had CM and 15,313 (91.2%) had EM; these groups had comparable mean ages (40.6 y vs 41.0 y; P= 0.32). Compared with the EM group, the CM group had a greater proportion of women (81.1% vs 73.8%; P b 0.001) and whites (87.5% vs 83.3%, P b 0.001), experienced higher headacherelated disability (mean MIDAS, 60.5 vs 13.1; RR = 4.6, P b 0.001), completed fewer years of education (34.9% vs 45.9% had bachelor's degrees or higher; P b 0.001), were more likely to have individual and household incomes below the median (69.1% vs 59.1%; P b 0.001, and 59.8% vs 49.5%; P b 0.001, respectively), and less likely to be employed fullor part-time (56.4% vs 66.0%; P b 0.001). Conclusion: CM confers a greater financial and occupational burden than EM. Ongoing data collection will allow us to characterize the longitudinal course and consequences of CM and EM. Disclosure: Funded by Allergan, Inc. doi:10.1016/j.jns.2013.07.1795 Abstract — WCN 2013 No: 1138 Topic: 8 — Headache The temporal relationship between daily stress and delayed modulation of chronic headache pain WCN 2013 No: 1138 Topic: 8 — Headache The temporal relationship between daily stress and delayed modulation of chronic headache pain C.B. Clark, R.J. Allen. Neuroscience, University of Puget Sound, Tacoma, WA, USA; Physical Therapy/Neuroscience, University of Puget Sound, Tacoma, WA, USA Background: Although triggers are known for headache pain, many chronic headache patients do not know what causes episodic pain fluctuations. Previous fibromyalgia and complex regional pain syndrome studies report ten-day delays in pain flare onset following stressful events. Delayed neuropathic pain flares are associated with stress-released thyroxine modulation, which has latent effects due to attachments with serum thyroxine-binding globulins. Objective: The temporal relationship between reported stress levels and episodic headache pain intensity was investigated to determine if chronic headache shows latent stress-related pain modulation. Patients and methods: Two female subjects diagnosed with chronic migraine completed pain and stress inventories daily across ten weeks. Pain was assessed using the Visual Analog Pain Scale, McGill Pain Questionnaire Short Form, and modified pain-body diagram. The Visual Analog Stress Scale quantified daily stress. Results: Serial lag correlations revealed the highest correlation between stress and pain to occur after a ten-day lag in subject 1 (r =+0.63, p b 0.005). Subject 2 showed a high negative correlation between stress and pain ten and eleven days later (r = −0.37 and r =−0.46, respectively, p b 0.05). Conclusions: Patients manifested delayed pain changes following stress in diametrically opposed ways, where headache pain ten days later seemed to increase as a function of stress in one yet decreased in the other. This finding is consistent with existing literature on pain modulating effects from stress-related release of thyroxine, whereby some individuals increase thyroxine output as a result of psychogenic stress and others notably decrease thyroxine output. doi:10.1016/j.jns.2013.07.1796 Abstract — WCN 2013 No: 1226 Topic: 8 — Headache Hemicrania epileptica IHS code 7.61 WCN 2013 No: 1226 Topic: 8 — Headache Hemicrania epileptica IHS code 7.61 S. Dasyam. Neurology, SKS Neuro Hospital, Hyderabad, India Chronic headache of over a 3 month duration is a common disorder for which advice from a neurologist is invariably sought. Over 2500 cases of chronic headache seen between March 1998 and 2013 by Abstracts / Journal of the Neurological Sciences 333 (2013) e481–e518 e508

Migraine, Stroke and Epilepsy: Underlying and Interrelated Causes, Diagnosis and Treatment

Migraine, epilepsy and stroke are highly prevalent neurological disorders, often comorbid. They share diverse pathophysiological mechanisms that explain the use of similar drugs on certain occasions (i.e., the use of antiepileptic drugs in migraine prevention). Migraine with aura represents a risk for ischemic stroke, and avoiding contraceptives, tobacco use, and ergot alkaloids should be advised in those patients. Epilepsy bears a bidirectional relationship with headache. Only three entities are considered as seizure-related headaches: migraine-triggered seizure (migralepsy), hemicrania epileptica, and post-ictal headache. Topiramate (100-200mg daily) and valproic acid (500-1,000mg daily) are first-line drugs in migraine prevention, while older antiepileptics have no use in this setting. Stroke is the most common cause of symptomatic epilepsy in the adult. Therapy with lamotrigine, gabapentine, and levetiracetam is advised in late-onset (2weeks after stroke) stroke-seizures, while early-onset seizures usually do not require therapy.

Subtle temporal lobe epilepsy with headache as the major complaint: What can we learn from the long-delayed diagnosis?

The association between epilepsy and headache remains controversial. Among the three forms of epilepsy-related headaches (preictal, ictal, and postictal), ictal headache is the rarest and the least understood. Ictal headache, termed hemicrania epileptica in the International Classification of Headache Disorders, Second Edition (ICHD-II, 2004), was defined as a type of headache lasting seconds to minutes, occurring synchronously with partial (focal) epileptic seizures, ipsilateral to the ictal discharge, and resolving immediately after cessation of the discharges. However, a few recent cases challenged this definition of ICHD-II. According to the glossary and terminology of the International League Against Epilepsy (ILAE), ictal headache was ill-defined and was considered to be one of the manifestations of autonomic seizure.More recently, Parisi et al. proposed ‘‘ictal epileptic headache (IED)’’ as a dedicated term to define a condition where a headache attack is the only manifestation of an epileptic seizure, which seemingly intensified the long-standing debate. To date, there are about 20 convincing reports of ictal headache, and all attacks occurred in patients with epilepsy.Here we report a previously healthy young man presenting with paroxysmal, brief headaches only giving rise to misdiagnosis and inappropriate managements for as long as 2 years. The nature of his attacks was

Vínculos existentes entre cefalea y epilepsia: terminología y conceptos actuales

Introduction and objectivesHeadaches (including migraines) and epilepsy have a high level of comorbidity and may be confused during diagnosis. Although physicians have known for centuries that these two conditions are somehow linked, their relationship remains poorly understood. Herein we describe the known associations between them, their underlying physiopathologic and genetic mechanisms, and the treatments recommended for them. MethodWe have reviewed the most relevant publication of headache/migraine and epilepsy by using the PubMed data base. DescriptionAn individual can suffer both from headaches (either migraine and/or other type of headache) and epilepsy, either by chance or because of a common underlying pathology. In these cases, the headache usually occurs at a different moment than the seizure (“interictal headache”). However, headaches sometimes occur simultaneously with, or very close in time to, the seizure: one that occurs at the same time as an epileptic seizure is known as an “ictal epileptic headache” or as “hemicrania epileptica”; one that precedes a seizure is known as a “pre-ictal headache”; and one that follows a seizure is known as a “post-ictal headache”. There is a particular type of pre-ictal headache, known as “migralepsy”, which occurs during or just after a migraine aura. ConclusionsThe terminology and concepts employed to describe possible associations between headaches (mainly migraines) and epilepsy have evolved over time with increasing clinical and physiopathogenic knowledge. Some researchers have suggested eliminating the term migralepsy and using the terms ictal epileptic headache and hemicrania epileptica exclusively and uniformly in all classification systems.

Reply: “Comorbidity between epilepsy and headache/migraine: the other side of the same coin!”

Dear Sir, We thank Dr. Striano and co-workers for their interest in our two recently published papers on comorbidity between headaches, in particular migraine, and epilepsy [1–3]. Dr. Striano underlies the importance of neuronal hyperexcitability and increased susceptibility to cortical spreading depression, sustained by both genetic and non-genetic factors, as the main pathophysiological mechanism of this association, accordingly to other authors [2–4]. Dr. Striano correctly points out that large well-phenotyped samples and massive genotyping will give a chance to discover the genetic factors involved in the comorbidity between headache/migraine and epilepsy [1]. The two main aspects that complicate the analysis of the molecular mechanisms underlying the comorbidity between headache/migraine and epilepsy are: (1) that while some epileptic syndromes are monogenic, apart from the exception of hemiplegic migraine, common forms of migraine are multifactorial and polygenic diseases; (2) the neuronal depolarization that gives rise to a seizure and the cortical spreading depression that causes migraine share some pathophysiological mechanisms. We believe that some clinical markers (such as the presence of EEG photosensitivity, osmophobia, family history of epilepsy and headache, migraine aura) could help to select more homogeneous populations of patients for genotype analysis, therefore it is important to collect cases, prospectively, with extensive phenotypic characterization. For this purpose well-designed multicenter studies are desirable to achieve a high sample size. Another important point raised by Dr. Striano is the need to revise the international classification of both epilepsy and headache disorders and to introduce widely accepted and more precise diagnostic criteria of migralepsy, hemicrania epileptica, post-ictal headache and “ictal epileptic headache” [1, 5, 6]. Further studies are necessary to clarify the pathopshysiological mechanisms of the association between headache/migraine and epilepsy.

Migraine triggered seizures and epilepsy triggered headache and migraine attacks: a need for re-assessment

In this issue of the Journal, Belcastro and associates review terminology and classification issues for migralepsy, hemicrania epileptica, post-ictal and ictal headache [1]. They raise key points such as ictal headache and visual seizures are often misdiagnosed as migraine, “migralepsy” is unlikely to exist and an “epilepsy-migraine sequence” is much more common and well documented than the dominant view of a “migraine-epilepsy sequence”. Their relevant proposals need appropriate attention by the committee of the international classification of headache disorders (ICHD) as well as the physicians in their clinical practice because of the consequences that misdiagnosis may have on patients. Misdiagnosis between epilepsy and migraine is considerable though their differentiation should not be difficult on clinical grounds [2]. The problem is that emphasis is unduly placed on individual symptoms, rather than on a comprehensive synthetic analysis of their quality, chronological sequence and other clustering features. There are many examples of such errors where visual seizures are unquestionably diagnosed as acephalgic migraine and more often migraine with aura (if seizures are followed by post-ictal headache) or basilar migraine with occipital paroxysms (which does not exist, because this is a syndrome of idiopathic childhood occipital epilepsy). Elementary visual hallucinations of occipital seizures develop rapidly within seconds, are brief in duration (2–3 min), are usually coloured and circular. These are fundamentally different from the visual aura of migraine, which develops slowly in minutes, is longer lasting (≥5 min) and mainly achromatic with linear patterns [3].

Should “migralepsy” be considered an obsolete concept? A multicenter retrospective clinical/EEG study and review of the literature

The few reports that have been published on the current International Classification of Headache Disorders, Second Edition (ICHD-II), criteria for migralepsy and hemicrania epileptica have highlighted the considerable confusion regarding this “hot topic” within both headache and epilepsy classifications (ICHD-II and International League Against Epilepsy [ILAE]). Indeed, the ICHD-II describes a migraine-triggered seizure as a rare event in which a seizure occurs during migraine aura; on the other hand, hemicrania epileptica is described as an “ictal headache” that occurs “synchronously” with a partial seizure. To confuse matters even further, neither the term migralepsy nor the term hemicrania epileptica is included in the currently used ILAE classification. On the basis of both a review of “migralepsy” cases in the literature and 16 additional retrospective multicenter cases, we suggest that the term migraine-triggered seizure or migralepsy be deleted from the ICHD-II classification until unequivocal evidence is provided of its existence, and that the term ictal epileptic headache be introduced into the ILAE classification.

Headache Attributable to Nonvascular Intracranial Disorders

Headache attributable to nonvascular intracranial disorder is a basket of multiple, partly complex, and very diverse idiopathic or secondary disorders. By definition, the headache has to occur in a close temporal relationship to the intracranial disorder. Some of these headache disorders are caused by high or low cerebrospinal fluid pressure; noninfectious inflammatory diseases such as neurosarcoidosis, aseptic (noninfectious) meningitis, and lymphocytic hypophysitis; or intracranial neoplasm. Other nonvascular headaches, including hemicrania epileptica and postseizure headache, Chiari malformation type I, and the syndrome of transient headache and neurological deficits with cerebrospinal fluid lymphocytosis, are attributed to hypothalamic or pituitary hyper- or hyposecretion, intrathecal injection, or epileptic seizures. The clinical presentation of all these disorders can be diverse and often mimics the characteristics of primary headaches, which may delay the diagnosis.

Migralepsy, hemicrania epileptica, post-ictal headache and “ictal epileptic headache”: a proposal for terminology and classification revision

Despite the fact that migraine and epilepsy are among the commoner brain diseases and that comorbidity of these conditions is well known, only few reports of migralepsy and hemicrania epileptica (HE) have been published according to the current ICHD-II criteria. Particularly, ICHD-II describes “migraine-triggered seizure” (i.e., migralepsy) among complications of migraine at “1.5.5” (as a rare event in which a seizure happens during migrainous aura), while hemicrania epileptica (coded at “7.6.1”) and post-ictal headache (coded at “7.6.2”) are described among headaches attributed to epileptic seizure. However, to date neither the International Headache Society nor the International League against Epilepsy mention that headache/migraine may be the sole ictal epileptic manifestation. Based on the current knowledge, migralepsy is highly unlikely to exist as such. We, therefore, propose to delete this term until clear evidence its existence is provided. Moreover, we herein propose a revision of terminology and classification criteria to properly represent the migraine/headache relationships. We suggest the term “ictal epileptic headache” in cases in which headache/migraine is the sole ictal epileptic manifestation.