Ictal Epileptic Headache Research Articles

Ictal epileptic headache: A painful seizure. A report of three cases

Ictal epileptic headache: A painful seizure. A report of three cases

Ictal epileptic headache in young female

Ictal epileptic headache in young female

Headache in patients with epilepsy: ictal epileptic headache and postictal headache

The relationship between headache and epilepsy is complex, and the nature of this association remains unclear. The terms ictal epileptic headache (IEH) and postictal headache (PIH) have been increasingly used in the last 10 years to define a headache as an isolated symptom of epileptic seizure, and these terms are now recognized in the criteria of the International Classification of Headache Disorders, 3rd edition. A clinical depiction and electroencephalography in patients with suspected IEH are mandatory to achieve a correct diagnosis. PIH is often a comorbidity in patients with epilepsy. However, this condition is usually neglected in clinical practice because the motor manifestations and other features of a seizure are sometimes comparatively more dramatic and impactful for patients and their families. This review discusses IEH criteria and the clinical, historical, epidemiological, and pathophysiological characteristics of IEH itself. In addition, issues regarding the prevalence, characteristics, and clinical predictors of PIH are presented. Key words: Headache; Epilepsy; Ictal epileptic headache; Postictal headache.

Frontal headache in a patient with right temporal epilepsy: A video‐EEG case report of ictal epileptic headache

Ictal epileptic headache (IEH) is caused by a focal epileptic seizure. The diagnosis can be challenging when the headache is isolated without any other symptoms. A 16-year-old girl presented with a 5-year history of bilateral frontotemporal headaches with severe intensity lasting for 1-3 min. Past medical, physical, and developmental histories were unremarkable. Head magnetic resonance imaging showed right hippocampal sclerosis. The diagnosis of pure IEH was confirmed by video-electroencephalographic monitoring. The onset and cessation of frontal headache correlated with a right temporal discharge. The patient was diagnosed with right mesial temporal lobe epilepsy. Two years later, her seizures increased despite antiseizure medications. A right anterior temporal lobectomy was performed. The patient remained seizure-free and headache-free for 10 years. IEH should be considered in the differential diagnosis of brief and isolated headache, even if the headache is diffuse or contralateral to the epileptogenic focus.

Relationships between migraine and epilepsy: Pathophysiological mechanisms and clinical implications.

Migraine and epilepsy are distinct neurological diseases with specific clinical features and underlying pathophysiological mechanisms. However, numerous studies have highlighted the complex and multifaceted relationships between the two conditions. The relationships between headache and epilepsy manifest themselves in different ways. Firstly, the clinical diagnosis of these disorders may be challenging in view of possible overlapping. While post-ictal headache is a frequent condition, ictal epileptic headache is a rare but challenging diagnosis. Both situations raise the question of the pathophysiological mechanism of headache triggered by seizures. Migraine aura and epilepsy can also exhibit overlapping symptoms leading to their misdiagnosis, in particular in the case of visual aura. Secondly, migraine with aura and epilepsy can occur as a co-morbid condition, particularly in familial hemiplegic migraine (FHM). From a pathophysiological perspective, the identification of genetic mutations in FHM has brought significant advances in the understanding of dysfunctions of neuronal networks leading to hyperexcitability. The purpose of this review is to present clinical situations encompassing headache and epilepsy that can be challenging in neurological practice and to discuss the underlying pathophysiological mechanism of such interactions.

Borderlands of Migraine and Epilepsy

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. We aimed to review the current literature on the overlapping phenomena of migraine and epilepsy. We searched the PubMed for relevant literature and conducted a narrative review on migraine and epilepsy. Migraine and epilepsy share a complex and pathophysiologically intriguing relationship. The International Classification of Headache Disorders, 3rd 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. 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.

Ictal Epileptic Headache: When Terminology Is Not a Moot Question

The relationship between headache and epilepsy is complex and despite the nature of this association is not yet clear. In the last few years, it has been progressively introduced the concept of the “ictal epileptic headache” that was included in the recently revised International Classification of Headaches Disorders 3rd edition (ICHD-3-revised). The diagnostic criteria for ictal epileptic headache (IEH) suggested in 2012 were quite restrictive thus leading to the underestimation of this phenomenon. However, these criteria have not yet been included into the ICHD-3 revision published in 2018, thus creating confusion among both, physicians and experts in this field. Here, we highlight the importance to strictly apply the original IEH criteria explaining the reasons through the analysis of the clinical, historical, epidemiological and pathophysiological characteristics of the IEH itself. In addition, we discuss the issues related to the neurophysiopathological link between headache and epilepsy as well as to the classification of these epileptic events as “autonomic seizure.”

Ictal epileptic headache: Is it a rare phenomenon?

Objectives Ictal epileptic headache (IEH) is a rare condition. Missing electroencephalographic (EEG) data, isolated ictal headaches can be linked to tension or migraine's headaches even among epileptic patient with substantial therapeutic implications [1] , [3] . Results Here we report the case of two female aged 12 and 40 year-old. Both were followed for epilepsy with Gastaut type benign occipital lobe epilepsy in the first case and focal symptomatic epilepsy due to right mesial temporal sclerosis in the second case. Medical history of migraine was found in the eldest case. At psychiatric evaluation, our youngest patient exhibited histrionic personality. Our two patients were adherent to their anti-epileptic drugs. However, they became complaining from recurrent episode with sudden brief headache, tightening in quality. EEG recording of our first case showed right posterior discharge of sharp theta rhythms concomitant with headache. In our second case, one typical seizures was evidenced during scalp EEG recording with only headache synchronous to discharges starting in the right temporal derivation and spreading to the contralateral side. Anti-epileptic drug was then adjusted in both cases. Conclusion The association between epilepsy and migraine, reported in our second case, make the situation more conflicting when suggesting subtle seizure manifesting as IEH [1] , [3] . Further, psychiatric comorbidity frequent in epileptic patients, as was our first case, made it often difficult to identify epileptic nature of headache [2] . Thus, in patients with epilepsy, the occurrence of isolated headache should be taken into account before stating that a patient is seizure-free. In patent without history of epilepsy, IEH is long time assimilated to migraine or tension type headache as EEG is not recommended as a routine examination in patients with isolated headache.

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.

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.

Ictal epileptic headache in adult life: Electroclinical patterns and spectrum of related syndromes.

Both headache and epilepsy are frequent paroxysmal disorders that often co-occur or are related in numerous ways. Although ictal epileptic headache has become the focus of several studies, this remains a very rare and not well-known phenomenon. Electroclinical features, pathophysiology, and syndromic context are heterogeneous. We investigated the electroclinical and neuroimaging findings in a population of adult patients with ictal epileptic headache. We retrospectively examined 8800 EEG recordings of almost 4800 patients admitted to our video-EEG laboratory from 2010 to 2013 with a history of well-documented epilepsy. We selected patients who reported headache closely related to a seizure documented by video-EEG or 24-hour ambulatory EEG. We analyzed ictal electroclinical features of headache, and we defined the related epileptic syndromes. We identified five patients with ictal epileptic headache. Two patients described tension headache during an epileptic seizure. In three patients, the headache was accompanied by other "minor" neurological symptoms mimicking a migrainous aura. In all cases, the headache stopped with the end of the epileptic activity. Three patients had a history of partial symptomatic epilepsy with cerebral lesions (low grade glioma, astrocytoma, porencephalic cyst) in the left posterior regions, whereas two patients were affected by idiopathic generalized epilepsy. This study confirms the rarity of ictal epileptic headache. To date, well-documented video-EEG cases remain as exceptional reports, especially in cases of idiopathic generalized epilepsies. Moreover, we confirm the main involvement of posterior regions in patients with ictal epileptic headache affected by partial symptomatic epilepsies.

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].

Diagnostic criteria currently proposed for “ictal epileptic headache”: Perspectives on strengths, weaknesses and pitfalls

PurposeWhen we published the diagnostic criteria for “ictal epileptic headache” in 2012, we deliberately and consciously chose to adopt restrictive criteria that probably underestimate the phenomenon, rather than spread panic among patients and physicians who are reluctant to accept this entity. MethodsHere we discuss four intriguing clinical cases to highlight why we believe, to this day, that it is necessary to follow these restrictive diagnostic criteria. ConclusionsEEG is not recommended as a routine examination for children diagnosed with headache, but it is mandatory and must be carried out promptly in cases of prolonged headache that does not respond to antimigraine drugs, if epilepsy is suspected or has been diagnosed previously. This is not a marginal or irrelevant question because possible isolated, non-motor, ictal manifestations should be taken into account before declaring that an epileptic patient is “seizure free” so as to ensure that any decision taken to suspend anticonvulsant therapy is safe.

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.

Ictal epileptic headache: a review of current literature and differentiation from migralepsy and other epilepsies.

Ictal headaches are increasingly becoming the focus of research as more data demonstrate headaches existing as a sole manifestation of an epileptic event. Due to the difficulty in diagnosing the event as an epileptic phenomenon as opposed to a migraine, the condition is often misdiagnosed. This paper seeks to review the current published literature on ictal epileptic headaches as well as provide differentiation between ictal headaches and similarly presenting conditions. In doing so, we hope to improve the diagnosis of ictal headaches and thus improve patient care. We review two case studies that exemplify the potential of multiple conditions with comparable symptoms to ictal headaches, and discuss how to differentiate the variable diagnoses. As of the writing of this paper, there is no universally agreed upon set of features of ictal headaches; however, reviewing the current literature, there do seem to be several features that should be noted when treating patients. More research on the pathophysiology of ictal epileptic headaches needs to be done before the condition can be fully understood.

Pure epileptic headache and related manifestations: a video‐EEG report and discussion of terminology

We present the first video-EEG recording of episodes of "epileptic headache". The case reported is that of a 9-year-old girl with brief episodes (of a few minutes) of severe frontal headache, which corresponded to the presence of concurrent spikes and slow waves, starting in the right temporal area. A dysplastic lesion of the right temporal lobe was observed by MRI and the patient received surgery, with subsequent disappearance of headaches. This case highlights ictal EEG as the main diagnostic tool for epileptic headache. We discuss the terminology regarding this type of manifestation and believe that cases without subsequent epileptic manifestations, as in the present case, should be more appropriately referred to as "pure ictal epileptic headache" or simply "pure epileptic headache". [Published with video sequences].

Is it migralepsy? No evidence yet

There is a wide consensus about the need of an urgent revision of the current ICHD-II and ILAE criteria to properly represent the migraine/seizure relationships and to avoid confusion among neurologists subspecialized in headache or epilepsy treatment [1, 2]. In fact, the habit of epileptologists is to define an electroclinical event by EEG recordings while a classificative approach is commonly used by neurologists specialized in headache. The scepticism surrounding the concept of migralepsy, as a migraineepilepsy sequence, deriving by the findings of a recent work by Sances and colleagues [3]. Interestingly, the authors underscored the high prevalence of purely epileptic disorders among cases reported as migralepsy and, in particular, among the 50 potential migralepsy cases identified in the literature only two meet the current ICHD-II criteria supporting a diagnosis of migralepsy [3]. Colombo et al. [1] recently described the case of a usual episode of visual aura, lasting 15 min, followed by the appearance of clonic palpebral movements and a generalized seizure in a 43-year-old woman patient who suffered of migraine with aura. The authors conclude that the sequence of the clinical picture supports the diagnosis of migralepsy in this case, accordingly to the current ICHD-II criteria [1]. Unfortunately, Colombo et al. failed to provide any ictal EEG recording of the sequence visual aura-generalized seizure. In this sense, the ictal recordings of the sequence are necessary to achieve firm conclusions about the epileptic nature of the visual aura that appear before a generalized seizure. Interestingly, their patient showed clonic palpebral movements before the generalized seizure onset. Noteworthy, patients with idiopathic generalized epilepsy experience visual aura and this visual phenomenon is more frequent in eyelid myoclonia patients with absences syndrome [4]. Thus, in our opinion, the concept of migralepsy should be revised keeping in the mind that visual symptoms can be the epileptic ‘‘aura’’ of a seizure, as it has been shown in the case description of patients with a partial status epilepticus in occipital lobe epilepsy [2] or migralepsy [3]. Of note, the EEG recording reported after the generalized seizure showed a focal epileptic discharge during the complaining of a severe migraine attack by the patient [1]. This finding reinforces the new introduced concept of ictal epileptic headache (IEH) [5, 6]. In fact, over the last 10 years, several cases of headache/migraine as sole manifestation of an epileptic seizure have been well documented by EEG recordings and the term IEH have been proposed to define an epileptic seizure with migraine/ headache like features [6, 7]. Unlike IEH, the clinical picture of migralepsy according to the ICHD-II criteria represents a very rare and no recurrent phenomenon in clinical practice. This feature should be kept in the mind because migraine and epilepsy are the prototypes of chronic diseases with paroxysmal episodes. On the other hand, there seems to be more V. Belcastro (&) Neurology Clinic, S. Anna Hospital, 22020 Como, Italy e-mail: vincenzobelcastro@libero.it

Clinical, EEG and neuroimaging features of ictal epileptic headache

Migraine end epilepsy have common pathophysiologic mechanisms and share essential and defining attributes which distinguish them from other common neurological disorders. They are both characterized by paroxysmal symptoms and are, therefore, episodic disorders. Occipital lobe to be the brain structures most responsible for development of migraine and occipital lobe epilepsies Both are characterized by visual symptoms followed by headache and other autonomic symptoms. Recognition of headache as an epileptic manifestation per se still represents a challenge.

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