Original Article
Relationship between Primary Headache and Epilepsy in Children and Adolescents Mohamed Y. El-Senousey, Yasser A El-Heneedy, Azza A Ghali, Wafik S Bahnasy Department of Neuropsychiatry, Tanta University; Egypt
ABSTRACT Background: Migraine and epilepsy are paroxysmal disorders that can precede or follow each other, or occur simultaneously. Objective: The aim of this study is to identify the possible link between epilepsy and certain types of primary headache in childhood and adolescence period from the clinical and neurophysiological point of view. Methods: Eighty one children and adolescents consecutively diagnosed as primary headache, attending Department of Neuropsychiatry, Tanta University Hospital, were included in this study. These patients were classified according to the types of primary headache into four groups: group I: migraine with aura (MWA) including 14 patients (17.5%); group II: Migraine without aura (MWoA) including 36 patients (43.75%); group III: Tension type headache (TTH) including 25 patients (31.25%); and group IV: Non classifiable headache (NCH) including 6 patients (7.5%). Results: Positive family history of headache and epilepsy was significantly higher in MWA than other groups. Comorbidity between headache and epilepsy was found in 18 patients (22.22%): 6 cases (7.41%) had febrile convulsions, 9 cases (11.11%) had single seizure without fever, 1 case (1.23%) had focal epilepsy, and 2 patients (2.47%) had generalized epilepsy. Febrile convulsions and focal epilepsy were most common in the group of patients suffering from migraine with aura but without statistical significant difference between this group and the other groups. On the other hand, single seizure and generalized epilepsy were most common in the group of patients suffering from migraine with aura with statistical significance between this group and the other groups. Conclusion: Our results confirm a strong association between migraine and epilepsy, with significant difference between MWA and other types of primary headache. [Egypt J Neurol Psychiat Neurosurg. 2011; 48(3): 223-228] Key Words: Primary headache, Migraine, Epilepsy, Comorbidity, Children, Adolescent
INTRODUCTION Migraine and epilepsy are both disorders with recurrent and paroxysmal manifestation of disturbed brain function; they can precede or follow each other, or occur simultaneously1. Many researchers have supported the hypothesis of alteration of cortical hyperexcitability as the main pathological mechanism underlying the onset of migraine2. Different biochemical pathways involving the cellular structures (signaling molecules, transporters, receptors and ion channels) may increase or decrease the excitability of the neuronal cellular membrane3. In a rare autosomal dominant subtype of migraine, familial hemiplegic migraine, mutations in a gene encoding a brain specific P/Q type calcium channel were identified in about 50% of families indicating that at least this rare form of migraine results from calcium channelopathy 4. Different types of epilepsy have been associated with mutations in human genes encoding subunits of voltage-gated sodium and potassium channels5. So, channelopathies Correspondence to: Azza A Ghali, Department of Neuropsychiatry, Tanta University Hospital. Tel.:+20127984473. Email:
[email protected].
might be the link or part of the link between epilepsy and migraine in particular migraine with aura (MWA)1. This is supported by the evidence of the proven efficacy of certain headache prophylactic drugs such as calcium channel blockers and anticonvulsants such as sodium valproate, gabapentin and topiramate which alter the properties of ion channels and consequently, the neuronal cell excitability6. However, this association between epilepsy and migraine has been demonstrated in several studies, mainly based on adults affected by epilepsy. In children an association between migraine and some epilepsy syndrome has been reported. Aim of the work The aim of this work is to identify the possible link between epilepsy and certain types of primary headache in children and adolescents from the clinical and neurophysiological point of view.
PATIENTS AND METHODS This study was performed on 81 patients diagnosed as primary headache in childhood and adolescence period attended the outpatient clinic of
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El-Senousy, et al.: Primary headache & epilepsy in Children and Adolescents
the Department of Neuropsychiatry, Tanta University Hospitals in the period from the first of October 2009 to July 2010. Children below the age of six years, mentally retarded children, patients with progressive systemic or neurologic disorders, patients with secondary headache or symptomatic epilepsy, and patients with history of drug abuse were excluded from the study. Also, history of seizures was taken either from the patients or from their parents with stress on history of febrile convulsions, age of onset of seizures, characters of seizures, frequency of seizures, family history of epilepsy, and treatment response. Thorough neurological and general examinations were done. EEG with standard 10-20 system was carried out. Electrodes were positioned according to the international 10–20 system. The recording was achieved for 20 minutes with hyperventilation for 3 minutes and photic simulation at low, moderate and high frequency. None of the patients submitted an EEG during a headache attack or within 24 hours from the last one. Primary headache was diagnosed and classified according to the International Headache Society (IHS) diagnostic criteria for headache 7. Epilepsy was diagnosed and classified according to the International league against epilepsy classification of seizures and epilepsy8,9. All the data were entered into a database and analyzed with SPSS statistical package (version 17). Data were analyzed by a chi-square and ANOVA statistic techniques
RESULTS This study was performed on 81 patients suffering from primary headache in childhood and adolescence period. Their age was ranged from 6 to 18 years (mean=11.74±4.23). They were 41 males and 40 Females. These patients were classified according to the types of primary headache into four groups: group I: migraine with aura (MWA) including 14 patients (17.5%); group II: migraine without aura (MWoA) including 36 patients (43.75%); group III: tension type headache (TTH) including 25 patients (31.25%); and group IV: non classifiable headache (NCH) including 6 patients (7.5%). The highest mean of age was found in the group of patients suffering from migraine without aura while the lowest mean age was found in the group of patients suffering from tension type headache without statistical significant difference in age distribution among the studied groups. Also it was found that female sex was predominant in patients suffering from migraine with aura and tension type
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headache, male sex was predominant in patients suffering from migraine without aura while in the group of patients suffering from non classifiable headache, both sexes are equally distributed without statistical significant difference in sex distribution among the studied groups (Table 1). Positive family history of headache was found in 45 patients (55.56%) while positive family history of epilepsy was found in 8 patients (9.88%). The highest percentage of positive family history of headache was found in the group of migraine with aura followed by the group of migraine without aura then the group of tension type headache while the lowest percentage was found in the group of non classifiable headache with statistical significant difference in family history of headache between the group of migraine with aura and the other groups. Moreover, The highest percentage of family history of epilepsy was found in the group of migraine with aura followed by the group of migraine without aura then the group of tension type headache while there is no family history of epilepsy was found in the group of non classifiable headache with statistical significant difference in family history of epilepsy between the group of migraine with aura and the other groups (Table 2). Considering the overall clinical history, seizures and epilepsy unrelated to the headache attacks were found in 18 patients (22.22%): 6 cases (7.41%) had febrile convulsions, 9 cases (11.11%) had single seizure without fever, 1 case (1.23%) had focal epilepsy, and 2 patients (2.47%) had generalized epilepsy. Febrile convulsions and focal epilepsy were most common in the group of patients suffering from migraine with aura but without statistical significant difference between this group and the other groups. On the other hand, single seizure and generalized epilepsy were most common in the group of patients suffering from migraine with aura with statistical significance between this group and the other groups (Table 3). Regarding the temporal relationship between headache and epilepsy as shown in table 4, it was found that in most of patients (two thirds of patients) epilepsy occurred before headache while in one sixth of patients epilepsy and headache occurred together in the same year and in one sixth of patients, epilepsy occurred after the onset of headache. Specific EEG abnormalities were found in 12 patients (14.81%). The highest percentage of specific EEG abnormalities was found in the group of patients suffering from migraine with aura with statistical significant difference in between this group of migraine and the other groups (Figure 1).
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El-Senousy, et al.: Primary headache & epilepsy in Children and Adolescents
Table 1. Age and sex distribution among the studied groups.
Age
Range Mean ±SD Male
Sex Female
No. % No. %
Group I MWA (No.14)
Group II MWoA (No.36)
Group III TTH (No.25)
Group IV NCH (No.6)
(8-14) 11.14±2.315
(8.5-18) 13.43±3.111
(9-14) 12.4±3.012
(7.5-13.5) 11.5±2.54
F=0.875
0.711
6 42.8% 8 57.2%
20 55.56% 16 44.44%
12 48% 13 52%
3 50% 3 50%
X2= 0.583
0.9
P-value
F:- ANOVA X2:- Chi-square MWA migraine with aura, MWo migraine without aura, NCH non-classified headache, TTH tension type headache
Table 2. Family history of headache and epilepsy among the studied groups.
Family history of headache
Family history of epilepsy
Positive Negative positive Negative
Group I MWA (No.14)
Group II MWoA (No.36)
Group III TTH (No.25)
Group IV NCH (No.6)
No.
12
20
12
1
%
85.71%
55.56%
48%
16.67%
No.
2
16
13
5
%
14.29%
44.44%
52%
83.33%
No.
5
2
1
0
%
35.71%
5.6%
4%
0%
No.
9
34
24
6
%
64.29%
94.44%
96%
100%
Chi-square X2
P-value
9.410
0.024٭
12.883
0.004*٭
MWA migraine with aura, MWo migraine without aura, NCH non-classified headache, TTH tension type headache * Significant at p
