Ictal epileptic headache in young female

INTRODUCTION

Headache is an infrequent form of sensory seizure and makes diagnosis of seizures clinically inapparent as in our case. We should decipher the temporal association of headache with respect to ictus for the correct management of headache and seizure. The clinical history helps distinguish between each case and differentiate one episode of co-existing headache-epilepsy with another episode.¹ In ictal epileptic headaches the location of headaches is unrelated to the epicenter of epileptic aura or ictal discharges.

Epilepsy-associated headaches may be similar to the patient’s usual headaches or maybe a new type of headache.² A few cases of migraine with a visual aura precede occipital epilepsy, a condition correctly referred to as migralepsy (also known as pre-ictal headache), and ictus is often photically elicitable during the migraine. Hemicrania epileptica is a rare type of headache (EEG-demonstrated ictal epileptic headache) characterized by migrainous features such as unilateral, throbbing pain associated with nausea, vomiting, scintillating scotomas, and flashing lights occurring on the same side as ictal discharges (Table 1).^1-3

The clinical features common to both occipital epilepsy and migrainous aura are micropsia, macropsia, and metamorphopsia (Alice in Wonderland syndrome); visual auras unique to migraine are flashing lights and scintillating scotomas; unique visual auras of occipital lobe seizures include visual hallucinations which is supported by feature of ictus on EEG such as gradual ictal discharge build-up and post-ictal slowing of the electrical activity in the later.^4-5

CASE REPORT

A patient of acquired epilepsy after left sided occipital lobe meningioma excision, in her late twenties presented to the neurology clinic complaining of new headache. Patient has been taking twice daily tablets of oxcarbazepine 300 mg since surgery and was seizure-free post-operatively. The MRI showed wedge-shaped area of encephalomalacia with minimal perilesional gliosis involving left temporoparietal region and volume loss in form of prominence of regional cortical sulci and prominent occipital horn of lateral ventricle of same side. Patient was admitted to neurology in-patient care for further evaluation and 24-hour video EEG. Awake EEG showed left posterior lobe amplitude loss corresponding with lesions described in MRI. During photic stimulation, patient reluctantly sat up and sobbed. However, no photic epileptic activity or photomyogenic response noted. Soon after this, interictal epileptiform sharp theta wave discharges were seen restricted to left posterior hemisphere which were followed by 2 instances of focal aware (and no motor symptoms) ictal epileptic headaches of 50 sec duration each, located at left posterior hemispheric electrodes (Figure 1). Simultaneously with ictus on EEG, patient pointed to and complained of pain in left forehead and temple. She described flashing lights as a visual sensation in left hemifield. There were no lapses in consciousness, automatism, tonic-clonic movements, vision loss/loss of consciousness. Routine laboratory tests were in normal range. She diagnosed with pure/isolated epileptic headache which is a rare type of ictal epileptic headache and is a focal awareness seizure. The differential diagnosis based on temporal evolution of symptoms is occipital seizures, and migralepsy but it could easily be excluded because of the temporal evolution of symptoms.^6-10 We increased the dose of oxcarbazepine, which led to the resolution of the patient’s seizures and new headaches.

DISCUSSION

In the context of our case report, it is important to recognize that "ictal epileptic headache" denotes a headache that serves as either the exclusive or initial symptom of an epileptic seizure. This condition is diagnosed through EEG recordings, where no other convulsive seizure manifestations are present. A noteworthy observation in the literature is the resemblance of ictal epileptic headaches to conditions like glossopharyngeal neuralgia and short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing (SUNCT).^5-9

Pain is a unique sensory feature of epilepsy and, in some cases, maybe the sole manifestation of the seizures. Headache is the most common form of pain in epilepsy. Headache in epilepsy can clinically mimic migraine. We should watch for temporal association of visual migraine auras (flashing lights and scintillating scotomas) with respect to headache. The flashing of lights complained by our patient are probably sensory manifestation of the occipital ictal spikes.^2-3 Considering the evaluation of clinical attributes associated with ictal headache, it becomes evident that "migralepsy" should be acknowledged as a condition where a seizure begins with a headache. This understanding sheds light on the potential underestimation of the phenomenon of "ictal epileptic headache." The intricacy of diagnosing ictal headaches cannot be overstated, emphasizing the need to raise awareness of this clinical entity among the broader headache community. This discussion underscores the importance of further research and education on this subject. Physicians should have a low threshold for acquiring EEG in young patients with new headache.

CONCLUSION

In conclusion, it is important to recognize that ictal epileptic headaches can often resemble primary headache disorders, creating diagnostic challenges for healthcare professionals. These headaches manifest in various clinical forms, including ictal epileptic headache (IEH) and postictal headache (PIH), as officially recognized by the international classification of headache disorders, 3^rd edition. Achieving an accurate diagnosis of IEH requires a comprehensive assessment, encompassing clinical presentation and electroencephalography (EEG) examination. Moreover, it is advisable to consider (Video)-EEG recordings for patients experiencing prolonged migraines or headaches. The complex nature of ictal headaches underscores the necessity for heightened awareness and understanding of this condition within the community of headache experts.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: Not required

REFERENCES

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