Ictal headache and visual sensitivity

LETTERS TO THE EDITOR Redefining headache diagnostic criteria as epileptic manifestation? Dear Sir Clinical (1–3) and genetic (3, 4) studies have documented an association between headache and epilepsy, raising even the possibility of a common monogenic defect in both occipital lobe epilepsy and migraine with aura (4). Sometimes the overlap between epilepsy and migraine/headache symptoms is even complete (1, 2). This is the case when non-convulsive status epilepticus has headache as sole manifestation (1). We recently described (2) a 14-year-old girl who had a photosensitive occipital epileptic seizure followed by a status migrainosus that lasted 3 days. An EEG revealed occipital status epilepticus during her migraine attack; intravenous administration of diazepam, under continuous EEG recording, suppressed both the epileptiform discharges and headache complaints. Three days later, we were able to evoke a visual aura and her migraine during an EEG recording with Intermittent Photic Stimulation (2). In this respect, we think that in the study by Deprez et al., concerning co-morbidity of migraine and occipito-temporal epilepsy, the migraine attacks with aura (4) are part of the occipito-temporal epilepsy syndrome itself. They found genetic linkage between migraine and occipito-temporal lobe epilepsy in a European multi-generational family (4) and identified a locus on chromosome 9q21-q22; a common monogenic defect for ‘both’ conditions, were considered by them as separate entity. There are, however, several observations, reported in that particular family (4), supporting our hypothesis of a complete clinical overlap of migraine with aura and epilepsy in most of the affecteds: (i) six out of 10 patients with occipito-temporal epilepsy had a visual aura; (ii) three out of 10 patients with occipitotemporal epilepsy had a history of photosensitivity; (iii) the one patient with migraine without aura had a different haplotype; (iv) two patients could not distinguish between their visual seizure and migraineous aura; (v) diminishment as well as increase in severity of migraine and epileptic seizures appeared simultaneously; three patients in that family had visually induced seizures; (vi) IPS did not show any epileptiform abnormalities or 408 headache complaints but this could be because the patients described (4) were older than 30 years and due to IPS method used (5). As far as this concept is concerned common neurophysiopathological mechanisms could lead both to epilepsy and headache/migraine (3, 6, 7). We would like to stress that excessive neuronal discharges can result in signs of headache/migraine as only recently has been documented (1, 2). We feel this is a relevant issue, since the International Classifications of both Headache and Epilepsy (8, 9), do not comprise criteria to consider headache/migraine as sole manifestation of an epileptic event (2). It is known that in headache/migraine the subcortical trigeminovascular system is responsible for the pain phase. Different cortical areas can produce this; in other words, there is no topographical correlation between specific cortical areas and headache/migraine onset, although the occipital area and photosensitivity seem to be involved more frequently (2, 5). Therefore, we suggest to revise the diagnostic criteria stressing among the major criteria the importance of EEG recordings with standardized IPS (5) in headache patients with uncommon visual auras or resistant to conventional treatment. Especially this should be investigated in those with a family history of epileptic seizures and migraine. In order to justify this we propose ‘ictal headache’ as new term for this condition in both classifications (8, 9). References 1 Ghofrani M, Mahvelati F, Tonekaboni H. Headache as sole manifestation in nonconvulsive status epilepticus. J Child Neurology 2007; 22:660–2. 2 Parisi P, Kasteleijn-Nolst Trenite DGA, Piccioli M, Pelliccia A, Luchetti A, Buttinelli C, Villa MP. A case with atypical childhood occipital epilepsy ‘Gastaut type’: an ictal migraine manifestation with a good response to intravenous diazepam. Epilepsia 2007; 48:2181–6. 3 Vanmolkot KR, Kors EE, Hottenga JJ, Terwindt GM, Haan J, Hoefnagels WAJ et al. Novel mutations in the Na+, K+-ATPase pump gene ATP1A2 associated with familial © Blackwell Publishing Ltd Cephalalgia, 2008, 28, 408–409 Letter to the Editor 4 5 6 7 8 9 hemiplegic migraine and benign familial infantile convulsions. Ann Neurol. 2003; 54:360–6. Deprez L, Peeters K, Van Paesschen W, Claeys KG, Claes LRF, Suls A et al. Familial occipitotemporal lobe epilepsy and migraine with visual aura. Linkage to chromosome 9q. Neurology 2007; 68:1995–2002. Kasteleijn-Nolst Trenité DGA, Pinto D, Hirsch E, Takahashi T. Photo sensitivity, visually induced seizures and epileptic syndromes. In: Roger J, Bureau M, Dravet CH, Genton P, Tassinari CA, Wolf P, eds. Epileptic syndromes in infancy, childhood and adolescence, 4th edn. UK: John Libbey & Co, 2005: chapter 26, 395–420. Ayata C, Jin H, Kudo C, Dalkara T, Moskowitz MA. Suppression of cortical spreading depression in migraine prophylaxis. Ann Neurol. 2006; 59:652–61. Somjen GG. Mechanisms of spreading depression and hypoxic spreading depression-like depolarization. Physiol Rev. 2001; 81:1065–96. Review. Headache Classification Subcommittee of the International Headache Society. The international classification of headache disorders, 2nd edition. Cephalalgia 2004; 24 (Suppl. 1):1–160. International League Against Epilepsy. Proposal for revised classification of epilepsies and epileptic syndromes. Commission on Classification and Terminology of the International League Against Epilepsy. Epilepsia. 1989; 30:389–99. Pasquale Parisi1, Marta Piccioli2, Snezana de Sneeuw3, Carolien de Kovel3, Onno van Nieuwenhuizen3, Carla Buttinelli2, Maria P Villa1, Dorothee GA Kasteleijn-Nolst Trenité2,3, 1Child Neurology, Paediatric Headache Centre & Paediatric Sleep Disorders Centre, Chair of Pediatrics, II Faculty of Medicine, ‘La Sapienza’ University, Rome, Italy e-mail: parpas@iol.it, pasquale.parisi@uniroma1.it, 2Chair of Neurology , II Faculty of Medicine, ‘La Sapienza’ University, Rome, Italy and 3Wilhelmina Children’s Hospital, UMCU, Utrecht, The Netherlands Author’s reply: Familial phenotype in migraine and epilepsy Dear Sir Headache can be an ictal epileptic manifestation (1–5), and is well illustrated by the case report of Parisi and colleagues. We have described several families with comorbidity of epilepsy and migraine and provided evidence for a single mutation causing both (6–8). In most of our patients, the distinction between epilepsy and migraine was evident. However, we agree with Parisi and colleagues that the distinction may be difficult in selected cases. We speculate that a single mutation in our families can give rise both to cortical spreading depression causing migraine, and to © Blackwell Publishing Ltd Cephalalgia, 2008, 28, 408–409 409 paroxysmal depolarizing shift, causing epileptic seizures, explaining the spectrum of phenotypes observed in these families. Since patients with a familial epilepsy–migraine syndrome can experience only epileptic seizures or only migraine, we believe that obtaining the familial phenotype is essential in establishing the correct diagnosis in all patients presenting with migraine in headache clinics or epilepsy in epilepsy clinics. Both classifications of headaches (9) and of epileptic syndromes (10) should reflect this new insight. References 1 Bernasconi A, Andermann F, Bernasconi N, Reutens DC, Dubeau F. Lateralizing value of peri-ictal headache: a study of 100 patients with partial epilepsy. Neurology 2001; 56:130–2. 2 Leniger T, Isbruch K, von den Driesch S, Diener HC, Hufnagel A. Seizure-associated headache in epilepsy. Epilepsia 2001; 42:1176–9. 3 Karaali-Savrun F, Goksan B, Yeni SN, Ertan S, Uzun N. Seizure-related headache in patients with epilepsy. Seizure 2002; 11:67–9. 4 Yankovsky AE, Andermann F, Mercho S, Dubeau F, Bernasconi A. Preictal headache in partial epilepsy. Neurology 2005; 65:1979–81. 5 Yankovsky AE, Andermann F, Bernasconi A. Characteristics of headache associated with intractable partial epilepsy. Epilepsia 2005; 46:1241–5. 6 Deprez L, Peeters K, Van Paesschen W, Claeys KG, Claes LR, Suls A et al. Familial occipitotemporal lobe epilepsy and migraine with visual aura: linkage to chromosome 9q. Neurology 2007; 68:1995–2002. 7 Simons PJ, Van Paesschen W, Palmini A, Dupont P, Van Driel G, Van Laere K. The development of hippocampal sclerosis in a patient with occipital lobe epilepsy and migraine. Neurology 2004; 62:1024–5. 8 Deprez L, Weckhuysen S, Peeters K, Deconinck T, Claeys K, Claes LRF et al. Epilepsy as part of the phenotype associated with ATP1A2 mutations. Epilepsia 2007; 19 November [Epub ahead of print]. 9 International Headache Society. The international classification of headache disorders, 2nd edition. Cephalalgia 2004; 24 (Suppl. 1):9–160. 10 International League Against Epilepsy. Proposal for revised classification of epilepsies and epileptic syndromes. Commission on Classification and Terminology of the International League Against Epilepsy. Epilepsia 1989; 30:389–99. W Van Paesschen1 and P De Jonghe2, 1Department of Neurology, University Hospital Gasthuisberg, Leuven and 2Neurogenetics Group, VIB, University of Antwerp, Department of Neurology, University Hospital Antwerp, Antwerpen, Belgium