Ictal epileptic headache as “subtle” symptom in generalized idiopathic epilepsy

Abstract

SUMMARYEpilepsy and migraine are common neurologic chronic disorders with episodic manifestations characterized by recurrent attacks and a return to baseline conditions between attacks. Epilepsy and migraine are frequently observed in comorbidity, with the occurrence of one disorder increasing the probability of the other: Migraine occurs in about one-fourth of patients with epilepsy, whereas epilepsy is present in 8-15% of patients with migraine. The link between headache and seizures is controversial and multifactorial. In epilepsy, headache can be seen as a preictal, ictal, or postictal phenomenon. In this report, we describe a case of a 37-year-old patient, affected by both drug-resistant generalized idiopathic epilepsy and headache, who displayed the sudden onset of a headache attack referred during a 24-h electroencephalography (EEG). The EEG tracing during this event revealed the activation of subcontinuous epileptic activity consisting of generalized spike-wave discharges (GSWDs) and generalized polyspike and wave discharges (GPSWDs) that persisted for 60 min, that is, until the disappearance of the headache. The case we describe appears to be original in that it represents one of the few EEG-documented ictal epileptic headaches in generalized idiopathic epilepsy.

The Complex Relationship Between Epilepsy and Headache and the Concept of Ictal Epileptic Headache

“…mainly a peri-ictal phenomenon), but in some cases (whose number is probably largely underestimated) "the headache represents the only ictal phenomenon": we recently named this condition "ictal epileptic headache" (Parisi et al 2012a). Since 1971, fewer than 20 IEH cases diagnosed according to proposed criteria (Table 1, Parisi et al 2012b) have been reported (Grossman et al 1971;Walser and Isler 1982;Laplante et al 1983;Isler et al 1987;Niedermeyer 1993;Marks and Ehrenberg 1993;Walker et al 1995;Ghofrani et al 2006;Parisi et al 2007;Piccioli et al 2009;Perucca et al 2010;Belcastro et al 2011c;Fusco et al 2011;Italiano et al 2011;Fanella et al 2012;Cianchetti et al 2013). Verrotti et al recently published 16 other potential ictal epileptic headache cases from a large multicentre neuropediatric sample (Verrotti et al 2011b), stressing the concept of "probable underestimate phenomenon" (Parisi et al 2012a;Parisi et al 2013a, b).…”

“…Following the introduction of the migralepsy concept by Lennox and Lennox (1960), an increasing number of ictal epileptic headaches have been reported since the 1970s (Grossman et al 1971;Walser and Isler 1982;Laplante et al 1983;Isler et al 1987;Niedermeyer 1993;Marks and Ehrenberg 1993;Walker et al 1995;Ghofrani et al 2006;Parisi et al 2007;Piccioli et al 2009;Perucca et al 2010;Belcastro et al 2011c;Fusco et al 2011;Italiano et al 2011;Fanella et al 2012;Cianchetti et al 2013). It has also been suggested (Parisi and Kasteleijn-Nolst Trenité 2010;Belcastro et al 2011a;Verrotti et al 2011a, b;Striano et al 2011Striano et al , 2012Parisi et al 2012aParisi et al , 2013a that the migralepsy sequence may not exist at all and that the initial part of the "migralepsy sequence" may merely be an "ictal epileptic headache" (Parisi et al 2012a) followed by other ictal autonomic, sensory, motor or psychic features.…”

“…Intermittent photic stimulation evokes headache in patients with a positive photo-paroxysmal response, who may also have visually induced seizures (Table 1) (Parisi et al 2012b). With regard to the EEG abnormalities recorded in "ictal epileptic headache" cases (Grossman et al 1971;Walser and Isler 1982;Laplante et al 1983;Isler et al 1987;Niedermeyer 1993;Marks and Ehrenberg 1993;Walker et al 1995;Ghofrani et al 2006;Parisi et al 2007;Piccioli et al 2009;Perucca et al 2010;Belcastro et al 2011c;Fusco et al 2011;Italiano et al 2011;Fanella et al 2012;Cianchetti et al 2013), the same wide spectrum of different EEG patterns (spike-wave activity, "theta" or even "delta" shape, without any spike activity) associated with both CSD and/or seizures were also confirmed "in vivo" by electrocorticography (Fabricius et al 2008).…”

“…Indeed, different EEG patterns have been recorded during migraine-like complaints in both symptomatic and idiopathic cases (Grossman et al 1971;Walser and Isler 1982;Laplante et al 1983;Isler et al 1987;Niedermeyer 1993;Marks and Ehrenberg 1993;Walker et al 1995;Ghofrani et al 2006;Parisi et al 2007;Piccioli et al 2009;Perucca et al 2010;Belcastro et al 2011c;Fusco et al 2011;Italiano et al 2011;Fanella et al 2012;Cianchetti et al 2013). Moreover, when EEG anomalies are recorded, no specific cortical correlations emerge (e.g.…”

Ictal pain: occurrence, clinical features, and underlying etiologies

“…Epileptic ictal headache has usually been described with focal and rarely with generalized epilepsy syndromes [3][4][5]. Seizure-related headaches have been categorized depending on the time that headache occurs in relation to the epileptic seizure.…”