Migralepsy, hemicrania epileptica, post-ictal headache and “ictal epileptic headache”: a proposal for terminology and classification revision

Despite the fact that migraine and epilepsy are among the commoner brain diseases and that comorbidity of these conditions is well known, only few reports of migralepsy and hemicrania epileptica (HE) have been published according to the current ICHD-II criteria. Particularly, ICHD-II describes “migraine-triggered seizure” (i.e., migralepsy) among complications of migraine at “1.5.5” (as a rare event in which a seizure happens during migrainous aura), while hemicrania epileptica (coded at “7.6.1”) and post-ictal headache (coded at “7.6.2”) are described among headaches attributed to epileptic seizure. However, to date neither the International Headache Society nor the International League against Epilepsy mention that headache/migraine may be the sole ictal epileptic manifestation. Based on the current knowledge, migralepsy is highly unlikely to exist as such. We, therefore, propose to delete this term until clear evidence its existence is provided. Moreover, we herein propose a revision of terminology and classification criteria to properly represent the migraine/headache relationships. We suggest the term “ictal epileptic headache” in cases in which headache/migraine is the sole ictal epileptic manifestation

Distúrbio cognitivo transitório associado a atividade epileptiforme generalizada ou difusa durante o eletrencefalograma Transient cognitive impairment during generalized or diffuse epileptiform EEG discharges

Atividade epileptiforme (AE) no eletrencefalograma (EEG) é achado comum entre as crises epilépticas e, menos freqüentemente, em outras condições clínicas. AE "subclínica" pode estar acompanhada de distúrbio cognitivo transitório (DCT). Foram estudados 30 pacientes (27 com epilepsia) com AE generalizada ou difusa, freqüente, em EEG inicial. Em EEG subseqüente, foi avaliado o desempenho em testes de classificação visual de animais e objetos, discriminação de cores, memória verbal e auditiva, reconhecimento de padrões e estimação de tempo. Foi comparado, estatisticamente, o número de respostas corretas ou incorretas durante a AE e fora dela. DCT foi caracterizado em 43,3% dos casos. Em 23,3% a AE foi rara, não permitindo avaliação de DCT. Assim, pôde ser caracterizado comprometimento transitório de atividades cognitivas durante AE até então considerada "subclínica". Há necessidade de pesquisar a importância desse fator em pacientes com comprometimento cognitivo e de caracterizar as situações de eventuais benefícios na medicação dirigida à AE.<br>Epileptiform EEG discharges (EED) are a frequent finding in people with epilepsy, and may occur in other clinical conditions. Formal testing during EEG recording may demonstrate transitory cognitive impairment (TCI). Thirty patients (27 with epilepsy) with generalized or diffuse EED on a previous examination were studied. The interaction between EED and cognitive tasks was evaluated on subsequent EEG. The numbers of correct or incorrect answers were compared with the occurrence or absence of EED. Results were analyzed by non parametric tests. TCI was characterized in 43.3% of the patients. In 23.3% the EED were rare and it was not possible to evaluate the occurrence of TCI. The findings confirm that otherwise subclinical EED may be accompanied by TCI. There is a need of researchs to evaluate the relevance of TCI and to determine when EED should be treated

Optimizing the Patient’s History: A Modern Approach

Medical history taking is the starting point of the diagnostic process and still maintains its leading role today, despite the current development of laboratory tests and neuroimaging techniques. Subjects with photosensitivity have high susceptibility for an epileptic seizure provoked by visual stimuli and require a specific approach in gathering information, especially to ascertain the occurrence of reflex seizures and to identify triggering factors. This chapter addresses the way to ascertain: (a) the presence of reflex seizures induced by visual stimuli; (b) the triggering factors and environmental risk; (c) signs and symptoms to be investigated on the basis of the patient’s age and the main syndromes where photosensitivity is involved; (d) the occurrence of self-induced seizures with their psychosocial aspects. In these patients the medical history should be based on a multimodal approach: (a) face-to-face interviews with the patient and/or parents in the case of children; (b) specific questionnaire on environmental context and living habits; (c) to require collaborative patients to take photographs of stimuli they consider triggering; and (d) to ask them to draw the visual symptoms occurring during seizures. Since the clinical history should be conducted with a specific approach and targeted questions, it would be advisable to develop professional training courses on how to collect the medical history in epileptic patients with photosensitivity