Headaches A Hidden Disability Associated with Seizures
Abstract & Commentary
By Dara Jamieson, MD
Associate Professor of Clinical Neurology, Weill Cornell
Dr. Jamieson reports she is a retained consultant for Boehringer Ingelheim and Bayer, and is on the speakers bureau for Boehringer Ingelheim.
Synopsis: Periictal headaches are frequent, severe, and undertreated, and can be predicted by younger age at epilepsy onset, drug polytherapy, and tonic-clonic generalized seizures.
Source: Duchaczek B, et al. Interictal and periictal headache in patients with epilepsy. Eur J Neurol 2013;20:1360-1366.
All patients aged 18 years or older with epilepsy or one unprovoked epileptic seizure, who were seen in the tertiary epilepsy outpatient clinic of the Charité University Hospital between October 2006 and December 2007, underwent a semi-structured interview to determine the prevalence of interictal (IIH) and periictal (PIH) headache. Headaches that occurred within 1 year before or after an epileptic seizure were defined as IIH. PIHs were temporally divided into preictal (occurring until the onset of a seizure or beginning at least 24 hours before seizure), ictal (during a seizure without loss of consciousness), and postictal (occurring with the end of the seizure) headaches. IIH was considered to be migraine, tension-type headache, and "other" headache. PIHs were migrainous or tension-type headaches.
A total of 201 patients (median, 42 years; range, 18-83 years), including 95 (47.3%) female patients, were interviewed. Headaches were reported by 113 patients (56.2%) with migraine in 10.9% and tension-type headache in 19.4%. There were 69 patients (34.3%) suffering from IIH, 71 (35.3%) from PIH, and 27 (13.4%) from both headache types. Out of 69 patients with IIH, 22 (31.9%) suffered from migraine, 39 (56.5%) from tension-type headaches, and 10 (14.5%) from other types, with two patients reporting both migraine and tension-type headache. The vast majority of PIHs occurred postictally with either migrainous or tension-type headache. Analgesic treatment of IIH was more common than acute treatment of PIH. Multivariate analysis identified female sex as the only independent predictor of IIH, and low age at epilepsy onset and antiepileptic polytherapy as independent predictors of PIH. PIH was significantly associated with generalized tonic-clonic seizures. The vast majority of PIH occurred postictally and had either migrainous or tension-type headache-like characteristics. This study found that while IIH, and in particular migraine, did not occur more often in patients with epilepsy than expected in the general population, PIH occurred in more than a third of patients with epilepsy.
With headache being a virtually universal experience, an overlap between primary headaches (migraine and tension-type headaches) and other neurological diseases is to be expected. Determining whether there is an increased prevalence of headache in patients with a neurological disease, especially when the neurological disease and headaches occur in populations of predominantly the same age and gender, can be problematic. In this study of IIH in patients with epilepsy, the prevalence of tension-type headache (19%) and migraine (11%) was less than the prevalence predicted from epidemiological studies performed on the general population. More information is needed to analyze this finding, including whether the choice of antiepileptic drug (AED) could impact the prevalence of migraine headaches in an epileptic population.
PIH was frequently reported by patients with multiple seizures and was infrequently treated, even with over-the-counter analgesic medication. The disability associated with the actual seizure is often overt, but the head pain around the ictal event, while less evident to the health care provider, may be equally debilitating. The use of acute pain medications after a seizure should be encouraged in those with PIH. The impact of headaches associated with a seizure may dictate the choice of AED, with the possibility of dual therapeutic benefit.