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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
moderation.
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
relaxants.
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
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