Epilepsy Migraine - More than just a headache

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					     Cover Story
      Epilepsy & Migraine -
      More than just a headache
      Epilepsy and migraine: are the two connected? And how can migraines
      be managed to ease their sometimes crippling day-to-day impact?

      If you’ve ever had a migraine, you’ll know how         from a few a year to several a week.                    other words, people affected are symptom-free in
      much the pain and heightened sensitivity to light                                                              between recurrent attacks that are temporary and
      and sound affects your ability to function. The        Migraine stages                                         begin suddenly, and afterwards they fully recover.
      similarities between epilepsy and migraines and        Like epilepsy, migraines occur in the following            One epilepsy syndrome in particular shares
      the fact they can occur together in individuals is     distinct phases :                                       characteristics of migraine. Benign epilepsy of
      prompting research into common causes and                 1. Early warning symptoms (prodrome): Up to          childhood with occipital paroxysms causes partial
      therapies.                                                   24 hours beforehand, people may experience:       seizures sometimes preceded by visual symptoms
         Here, we explore the kinship of these two                 • mood changes, from elation to irritability      and followed in 25% to 40% of people by
      conditions, the discoveries made so far, and                 • nausea, appetite changes (intense hunger or     migraine-like headaches . In neurological
      consider ways to manage migraines and reduce                  lack of appetite), constipation, diarrhoea       disorders such as mitochondrial encephalomyopa-
      the level of disruption they cause in daily life.            • neurological changes, drowsiness, yawning,      thies – changes in cells resulting in muscle and
                                                                    difficulty finding words (dysphasia), dislike    nerve dysfunction – patients present with both
      Migraine or headache?                                         of light and sound                               seizures and migraine.
      Everyone has experienced a headache at some                  • behaviour changes from being obsessional           The similarities mean epilepsy and migraines
      time in their lives, for a variety of reasons and to          and hyperactive to lethargic                     can sometimes be mistaken for one another. Some
      varying degrees. Generally headaches can be                  • aches and pains                                 types of migraine can begin with loss of
      effectively treated with over-the-counter                    • fluid balance changes, thirst, passing more     consciousness and other symptoms, followed by a
      medication, however some people will experience               fluid, fluid retention                           headache. Meanwhile seizures that occur in the
      a more severe and debilitating form of headache           2. Aura: Accompanies migraine attacks in             lobe of the brain related to vision, the occipital
      called migraine.                                             about 20-30% of people. It temporarily            lobe, can be confused with migraine visual auras.
         The International Headache Society, an                    affects the visual field of both eyes and         Although there are differences that clinicians
      organisation made up of medical and allied health            lasts 5-60 minutes. Less commonly, aura           should be able to determine, such as shimmering
      professionals as well as researchers, has published          affects sensation or speech. Several aura         or zigzag uncoloured lines for migraine auras, and
      an internationally accepted classification of                symptoms may follow in succession.                coloured visual hallucinations for epilepsy.
      headaches. They define a headache as a migraine           3. Headache (the attack or ‘ictus’): People             Further, migraines and epilepsy often exist
      when:                                                        having a classical migraine (migraine with        together. Migraine is common in people with
         1. The pain can be classified by at least two             aura) may wait up to an hour from when the        epilepsy, whereas epilepsy is rare in migraineurs.
             of the following:                                     aura ends to when head pain starts, and may       Between 9-10% of the general population suffer
             • one sided                                           feel spaced out in between. Headaches are         migraines compared to the population of people
             • moderate to severe                                  similar with common migraine (migraine            with epilepsy, up to 20% of whom reportedly
             • throbbing                                           without aura). The associated symptoms of         experience migraine . Another hospital-based
             • aggravated by movement                              nausea and vomiting can be more distressing       study published this year reports that 25.6% of
         2. It occurs with a least one of these symptoms:          than the headache.                                participants with epilepsy had migraines
             • nausea                                           4. Resolution and recovery (postdrome):              compared to 15.2% of the control group who did
             • vomiting                                            Attacks end very differently. Sleep can           not have epilepsy .
             • photophobia (sensitivity to light)                  restore some, or being sick. Others find             Although headache often develops after an
             • phonophobia (sensitivity to noise)                  effective medication improves attacks. For a      epileptic seizure, it is extremely rare for a
         3. The headache lasts between 4 and 72 hours.             few, nothing has worked so far but the            migraine attack to trigger a seizure – a
      Other symptoms can include:                                  headache taking its course. Afterwards            phenomenon called ‘migralepsy’. In 2004, this
         • osmophobia (sensitivity to smell)                       people can feel drained for about 24 hours,       was defined in the International Classification of
         • aura (visual disturbances such as bright                or they can feel energetic – even euphoric.       Headache Disorders II as a migraine with aura,
          zigzag lines, flashing lights, difficulty                                                                  with a seizure that either occurs during or within
          focusing or blind spots lasting 20-45 minutes)     Similarities between migraine and epilepsy              one hour of the migraine .
         • difficulty concentrating, confusion               Seizures are thought to result from an excessive           This concurrence of epilepsy and migraine in
         • a general feeling of being extremely unwell       reaction to stimuli, migraines from a type of           some people suggests (among other possibilities )
         • problems with articulation or co-ordination       chronic pain syndrome fundamentally neurovascu-         that the two may share a pathophysiological or
         • diarrhoea                                         lar in nature – that is, relating to nerves supplying   genetic basis.
         • stiff neck and shoulders                          veins and arteries transporting blood to the brain.
         • tingling, pins and needles, numbness or even      Hence migraine and epilepsy have traditionally          Common pathophysiologic pathways – is
          one-sided limb weakness                            been considered separate disorders although a           there a biological link?
         • speech disturbance                                variety of antiepileptic drugs are now frequently       Recent discoveries into the basis of migraine have
         • paralysis or loss of consciousness (rare)         used to treat migraine.                                 resulted in a meeting of the theories of epilepsy
      Migraines may recur over years or decades at              Epilepsy and migraine do share defining              and migraine pathophysiology – the changes in
      greatly varying frequency in the same individual,      attributes . They are both episodic disorders. In       function associated with a disease or syndrome –

6   Epilepsy360º - December 2009
and the possibility one day of new common              activation in the brainstem has been documented        annual cost of medical care, including prescription
treatment approaches.                                  during migraine headache in humans.”                   drugs, for insured Americans.
   It is well recognised that whole families can          In the case of rare patients with familial
share a tendency to suffer migraine headaches.         hemiplegic migraine where paralysis occurs with        A better way
The risk of migraine is up to 50% greater in           migraine attacks, scientists have identified           Epilepsy and migraines can be very challenging
relatives of people with migraine than among           “mutations in genes encoding for components of         on their own. But people with epilepsy who suffer
relatives of people without migraine .                 sodium, potassium or calcium ion channels,” says       migraines experience the combined impacts of the
   Recently research into migraine has revealed        Zagami. “Some of these mutations also cause            two. In this instance, migraine management is
genetic abnormalities related to dysfunction in the    epilepsy in the same patients.”                        particularly important.
ion channels – valves that let ions such as               It has even been suggested that some headaches      Crucial steps include finding out more about
potassium, sodium and calcium in and out of the        could be epileptic seizures – and in some people,      migraine and its relationship to your epilepsy, plus
cell. This dysfunction could alter the brain’s         these might be the only sign of epilepsy. This         lifestyle changes and seeing a doctor to prescribe
response threshold to internal and external            could result from the interplay between the source     effective medication for during and between
triggers, causing auras and pain. Meanwhile, some      of the epileptic activity and its spread, which in     migraine attacks.
epilepsy disorders have also been traced to ion        turn may activate a common pathway for head            As researchers continue exploring the potential
channel dysfunction and dubbed                         pain – that is, the trigeminovascular system which     links between migraine and epilepsy, there is hope
‘channelopathies.’                                     consists of the trigeminal nerve and local cranial     of treatment breakthroughs that will in future
   “In the future a clarification of the role of ion   blood vessels.                                         improve quality of life for people affected by
channel dysfunction in migraine and epilepsy may                                                              either condition.
lead to this being a new target for effective          Impact on daily life
prophylactic (preventive) drugs for both               Depending on severity, migraine can impact life        References
conditions,” says Dr Alessandro Zagami, Senior         greatly, as can epilepsy. When the two occur             i     “Epilepsy and migraine” M.E. Bigal et al,
Staff Specialist at the Prince of Wales Hospital’s     together the effects are compounded. This                      Epilepsy & Behavior 4 2003
Institute of Neurological Sciences.                    particularly burdens children at a time when they        ii    “Common Pathophysiologic Mechanisms in
   Says Zagami, “Migraine is now considered a          are growing and developing their academic and                  Migraine and Epilepsy” M. A. Rogawski; Arch
primary disorder of the central nervous system         social skills.                                                 Neurol 2009
just as epilepsy is… Central dysfunction may lead         Migraine pain can be excruciating and can             iii   “Migralepsy: A call for a revision of the
to a momentary excitation of the brain cells           incapacitate sufferers for hours, even days.                   definition” G. Sances et al; Epilepsia 2009
followed by a prolonged spreading of a                 Prevalence peaks during the prime work and child         iv    “Epilepsy and migraine” M.E. Bigal et al,
depression-like inhibition of the brain cells          rearing ages of 25 to 55 . Many (53%) say their                Epilepsy & Behavior 4 2003
resulting in the aura of migraine in predisposed       headaches hinder activities or force bed rest, while     v     “Migralepsy: A call for a revision of the
patients.”                                             31% report missing work or school in a given                   definition” G. Sances et al; Epilepsia 2009
   “It may also result in dysfunction of brainstem     three-month period.                                      vi    Lipton RB, Silberstein SD. Why study the
and other nuclei that normally modulate sensory,          Most people (52% to 73%) report that migraine               comorbidity of migraine? Neurology 1994;44:4–5.
particularly painful input from the cranial blood      adversely affects their work and family relation-        vii Headache Australia,
vessel walls, as well as influencing the response of   ships. Further, it overloads the healthcare system –           www.headacheaustralia.org.au
the cranial blood vessels and blood flow. Such         a recent US study estimated an $11.07 billion

  Treatments and strategies                            prescribed for more severe migraine. Many are          fungus that grows on rye. They interact with
  Treatment and self-management strategies can         based on serotonin, which is a hormone that acts       receptors for the brain chemical serotonin, which
  help to prevent and ease the impact of migraine.     both as a chemical messenger transmitting              regulates pain awareness and blood vessel tone.
  Treatment is not just about taking a tablet but      signals between nerve cells and causes blood           These drugs reduce inflammation and cause the
  involves a person developing an individual           vessels to narrow. Sometimes stronger                  blood vessels to constrict, which helps relieve
  migraine management plan consisting of               non-steroidal anti-inflammatory drugs are              the throbbing nature of the pain of migraine.
  lifestyle modifications, medication and              required.                                                 Anti-emetic medications are important to
  complementary therapies.                             The latest medications target specific areas now       reduce the nausea common with migraine. The
                                                       believed to cause the pain. Although the exact         presence of nausea means the patient has
  Medication                                           mechanism for pain generation is still not             impaired absorption of oral medications leading
  Sometimes over-the-counter medications relieve       known, “the trigeminovascular system is                to reduced effectiveness.
  migraines. But many people find they can’t. If       believed to be crucial,” says the Prince of Wales
  you’re one – and your headaches change, or you       Hospital’s Dr Zagami.                                  Preventive treatment
  don’t know the cause or nature of your headache         “Activation of this system leads to                 Preventive medication is taken daily, whether or
  – consult your doctor. Even if your doctor           excitation… in the brainstem that in turn relays       not a headache is present, to reduce the number
  previously prescribed unsuccessful treatments,       pain signals to the relay system of the brain          and severity of headaches. These include
  it’s worth another visit. Migraines can be           called the thalamus as well as the cortex. It also     medications that block the beta-receptors, which
  managed but effective management relies on you       causes peripheral release of sensory neuropep-         affect the blood vessels and levels of adrenaline
  and your doctor working as partners.                 tides which are chemicals that act as messengers       in the nervous system; or antiepileptic drugs –
                                                       between the nerve cells, especially calcitonin         including valproic acid, topiramate and
  Acute treatment                                      gene-related peptide, or CGRP.”                        gabapentin – that are known to reduce migraine
  This is treatment given preferably at the onset of   Hence, he says, “the most effective acute              intensity. Calcium-channel blockers constrict
  a headache. Infrequent, less severe migraine may     anti-migraine drugs at present are the triptan         blood vessels while some antidepressants impact
  respond to over-the-counter medications such as      drugs because one of their effects is to block the     headache independently of their antidepressant
  paracetamol, aspirin (which is not recommended       release of CGRP.”                                      action.
  for young children), and non-steroidal               Other acute therapies include non-steroidal            While effective, these all have side-effects and
  anti-inflammatory drugs.                             anti-inflammatory drugs and ergot preparations.        need to be prescribed by a medical practitioner.
     Migraine-specific medications may be              Ergot drugs were originally derived from a

                                                                                                                                    Epilepsy360º - December 2009        7
            Headache types                                Location and symptoms                    Precipitating factors                          Treatment/prevention

            Allergy                                       Generalised; often occurs with           Seasonal; allergens such as                    May include anti-histamine
                                                          runny nose and sore eyes.                pollens trigger hay fever and                  medication and decongestant
                                                                                                   sinusitis.                                     nasal sprays.

            Cluster Headache                              Episodic or chronic; severe pain         None known.                                    Treatment of acute attacks may
                                                          centred around one eye. May                                                             include oxygen inhalation and
                                                          cause drooping eyelid, watering                                                         medications that constrict the
                                                          eye and nasal congestion. Most                                                          blood vessels and reduce
                                                          common in males.                                                                        transmission of pain signals.
                                                                                                                                                  Preventive medications may
                                                                                                                                                  include calcium channel blockers
                                                                                                                                                  and corticosteroids.

            Hangover                                      Migraine-like symptoms of                Alcohol, the breakdown products                Treat with liquids like broth.
                                                          throbbing pain and nausea, not           of which dilate and irritate blood             Consume fructose (e.g. honey,
                                                          localised to one side.                   vessels of the brain and                       tomato juice) to help burn
                                                                                                   surrounding tissue.                            alcohol. Drink alcohol in

            Ice-cream Headache                            Sharp pain in the front of the           Pain in the palate or throat from              Avoid ice-cream or icy drinks.
                                                          head – the middle of forehead or         swallowing very cold food or
                                                          in one temple – straight after           liquids may refer pain to the head
                                                          swallowing ice cream or an ice           through the trigeminal nerve
                                                          cold drink. Can cause pain behind        endings or the glossopharyngeal
                                                          the ear.                                 nerve. Migraine sufferers are
                                                                                                   prone to ice-cream headache.

            Tension-Type Headache                         A dull, non-throbbing pain, often        Emotional stress, hidden                       Avoid stress. Use biofeedback,
                                                          bilateral, with tightness of scalp       depression.                                    relaxation techniques,
                                                          or neck. Severity remains                                                               psycho-therapy, and treatment
                                                          constant.                                                                               with tricyclic anti-depressant
                                                                                                                                                  medication. Treat with rest,
                                                                                                                                                  aspirin, ibuprofen, naproxen
                                                                                                                                                  sodium, ice packs, and muscle

            Migraine                                      Severe, one-sided throbbing pain,        Many triggers, including                       Eating can help, especially
                                                          often with nausea, vomiting, cold        dehydration, certain foods,                    starchy foods; chemist or
                                                          hands, sensitivity to sound, light       insufficient food, hormones,                   prescription medications; bed
                                                          and smells. May occur with aura          environmental such as sudden                   rest; and complementary
                                                          i.e. visual disturbances, numbness       changes in weather, oversleeping               therapies including massage,
                                                          in arm or leg. Can last up to four       or too little sleep, physical factors          aromatherapy, yoga, physio-
                                                          days. Begins in children and may         such eye, dental problems,                     therapy, acupuncture and
                                                          last beyond the 60s.                     over-exertion or strenuous                     Alexander technique.
                                                                                                   exercise, certain medications.

           Definitions of headache types, migraine stages, triggers, symptoms and treatments adapted with permission from the Headache Australia website – an
           excellent source of information about headache and migraine.

       viii Headache Australia,www.headacheaustralia.org.au            xiii “Common Pathophysiologic Mechanisms in                         Neurol 2009
       ix    “Ictal headache and visual sensitivity” M. Piccioli            Migraine and Epilepsy” M. A. Rogawski; Arch            xvii “Migralepsy: A call for a revision of the
             et al; Cephalalgia 2008                                        Neurol 2009                                                    definition” G. Sances et al; Epilepsia 2009
       x     “Migralepsy: Is the Current Definition Too              xiv    “Common Pathophysiologic Mechanisms in                 xviii “Epilepsy and Migraine Headache: Is There a
             Narrow?” F. Maggioni et al; 2008                               Migraine an d Epilepsy” M. A. Rogawski; Arch                   Connection?” S. Stevenson; J Pediatr Health Care;
       xi    “Common Pathophysiologic Mechanisms in                         Neurol 2009                                                    2006
             Migraine and Epilepsy” M. A. Rogawski; Arch             xv     “Migraine headaches: Diagnosis and                     xix “Migraine headaches: Diagnosis and
             Neurol 2009                                                    management” H. Abel; Optometry 2009                            management” H. Abel; Optometry; 2009
       xii “Ictal headache and visual sensitivity” M. Piccioli       xvi    “Common Pathophysiologic Mechanisms in                 xx      “Migraine headaches: Diagnosis and
             et al; Cephalalgia 2008                                        Migraine and Epilepsy” M. A. Rogawski; Arch                    management” H. Abel; Optometry; 2009

8   Epilepsy360º - December 2009