Purpose: Headache and epilepsy are common neurological disorders and their relationship is still incompletely known. The purpose of our work was to estimate the most common types of primary headache syndromes and its relation to seizure timing in epileptic patients in Upper Egypt. Patients & Methods: In a cross-sectional study, we evaluated headaches in 100 consecutive patients with idiopathic epilepsy attending the neurology outpatient clinic and the epilepsy clinic at Sohag university hospital by complete medical history, physical and neurologic examination EEG and CT brain. Results: Of our study population, 78% of patients with epilepsy reported headaches. Migraine occurred in 70.6% of patients with headache followed by tension-type headache in 25.58% of patients and other types of headaches occurred in 2.56% of patients. There were 8 patients (10.1%) had a pre-ictal headache, 52 patients (66.5%) had a postictal headache and 39 patients (50%) had an interictal headache. In our study, we found that the occurrence of headache being linked to the female sex, lower mean age, lower mean age at the onset of epilepsy, focal epilepsy, longer duration of epilepsy, high frequency of seizures and the use of polytherapy of antiepileptics. Conclusion: Headache especially migraine is an important comorbidity of epilepsy and should receive more attention especially in female patients, patients with younger age, lower mean age at epilepsy onset, longer duration of the disease, patients on polytherapy, patients with higher frequency of seizures and patients with focal epilepsy.
More than 70 million people of variable ages, races, and social classes, especially in low and middle-income countries suffer from epilepsy worldwide [
Both epilepsy and headache are very common neurological disorders with episodic attacks. Patients with epilepsy may suffer from disabling headaches as one of the most common comorbidities that may add more burdens to those patients. A headache is often underdiagnosed because both physicians and patients are often paying more attention to epilepsy rather than a headache [
We aimed to estimate the most common types of primary headache syndromes and its relation to seizure timing in epileptic patients in Upper Egypt.
Across-sectional study was conducted at Sohag university hospital, Egypt. The study participants were recruited from the neurology outpatient and the epilepsy clinics of Sohag university hospital in the period from September 2016 till January 2018. The study included 100 consecutive patients with idiopathic epilepsy with disease duration of more than one year. Idiopathic epilepsy is defined as epilepsy in absence of significant past history of etiologic cause, abnormal neurological examination and/or structural brain abnormalities detected by brain imaging (CT or MRI). Patients with mental retardation, learning disabilities, behavioral disorders or other evident abnormalities that could compromise the ability to respond to the questionnaires and patients with secondary (symptomatic) epilepsy were excluded from the study by performing mini-mental state and CT brain. Informed consent was given by all patients and the study was approved by the Ethical Committee of Sohag Faculty of Medicine, Sohag University, Egypt.
Complete medical history, physical and neurologic examination were done for all patients. Electroencephalography in resting awake condition with eyes closed was done for all patients. The EEG data were acquired by a computer-based system (Nihon Kohden Neurofax, SN: 00429). Brain imaging (CT or MRI) and other laboratory investigations including complete blood count, renal functions, liver functions, random blood glucose, and serum electrolytes were done to exclude patients with symptomatic causes of epilepsy.
Direct interview with patients with epilepsy was done and the type of epilepsy was determined according to the criteria of the International League Against Epilepsy 2010, the seizure frequency divided into four grades (<1/year; ≥1/year to <1/month; ≥1/month to <1/week and ≥1/week) [
The type of headache was determined according to the International-Headache-Classification-III-ICHD-III-2013-Beta. According to the temporal relationship with seizures 1) a Peri-ictal headache which is further divided into a pre-ictal headache, ictal and post-ictal headache. A pre-ictal headache was defined as a headache appearing within 24 hours before the seizure. An ictal headache was present exclusively during the seizure. A post-ictal headache was defined as a headache which develops within 3 hours following a partial or generalized seizure and resolves within 72 hours after the end of the seizure. 2) An inter-ictal headache includes all headaches that manifested within a time period of the epileptic disease and whose attacks were not temporally related to an epileptic seizure (within more than 72 hours of the last seizure).
Data were analyzed using STATA intercooled version 12.1. Quantitative data were represented as mean ±SD for normally distributed data, and median (range) for abnormally distributed data. Student t-test or Mann-Whitney test were used for data analysis according to the normality of the distribution of the data. Qualitative data were presented as number and percentage and compared using either Chi square or fisher exact tests. P value was considered significant if it was less than 0.05.
One hundred patients with idiopathic epilepsy (mean age = 24.7 ± 8.20 years) participated in the study, 59% percent of the patients were females and 41% were males.
Seventy-four percent of the patients suffer focal seizures, 25% suffer generalized seizures, and one patient (1%) suffers unclassified seizures depending on the clinical history. The mean age at the onset of epilepsy is 16.26 ± 8.88 years. The mean duration of epilepsy is 8.39 ± 5.33 years. Three patients (3%) do not take antiepileptic medications, fifty patients (50%) take one antiepileptic drug (monotherapy) for treatment and forty-seven patients (47%) were taking more than one antiepileptic drug (polytherapy). Nineteen patients (19%) had a seizure frequency of <1 seizure per year, 17 patients (17%) had a seizure frequency of ≥1/year to <1/month, 44 patients (44%) had a seizure frequency of ≥1/month to <1/week and 20 patients (20%) had a seizure frequency of ≥1 seizure per week. Eleven patients (11%) had a previous history of febrile convulsions. Eighteen patients (18%) had a positive family history of epilepsy. Twelve patients (12%) had a positive family history of a chronic headache including migraine and its subtypes. Inter-ictal EEG was normal in 41 patients (41%), showed focal epileptiform discharges in 51patients (51%) while 8 patients (8%) have generalized epileptiform discharges. Of patients with focal epileptiform discharges, left hemispheric discharges were present in 27 patients (51%) and right hemispheric discharges in 24 patients (49%), temporal discharges in 23 patients (45%), frontal discharges in 23 patients (45%) and occipital discharges in 5 patients (10%).
Seventy-eight patients with epilepsy (78%) were suffering from headache. Migraine was diagnosed in 56 patients (70.6%; 6 patients suffered a migraine with aura, 45 patients suffered a migraine without aura, and 5 patients suffered probable migraine). The second most prevalent headache was tension type headache that occurred in 20 patients (25.58%) including 18 patients (23.08%) with tension type headache and 2 patients (2.56%) with probable tension headache. Only 2 patients (2.56%) had other types of headaches; one patient had episodic cluster headache and the other had a probable cluster headache. The degree of severity of headache in patients with headache was as the following: Mild degree in 10 patients (12.82%), moderate degree in 50 patients (64.10%) and severe degree in 18 patients (23.08%) [
There were 8 patients (10.1%) had a pre-ictal headache that evolved into seizures including 4 patients had only pre-ictal headache, 2 patients had both pre-ictal and post-ictal headaches and 2 patients had pre-ictal, post-ictal and inter-ictal headaches. There were 52 patients (66.5%) had a post-ictal headache who reported a headache after seizure including 33 patients (42.31%) had only post-ictal headache, 15 patients (19.23%) had a post-ictal and inter-ictal headache, 2 patients (2.56%) had post-ictal and pre-ictal and 2 patients (2.56%) had three types of pre-ictal, post-ictal and inter-ictal headaches. There were 39 patients (50%) had inter ictal headache who reported a headache in between seizures and not related to them including 22 patients (28.21%) had only inter-ictal headache, 15 patients (19.23%) had post-ictal and inter-ictal headache and 2 patients (2.56%) had post-ictal, inter-ictal and pre-ictal headache (
Population characteristics and intergroup differences analysis results regarding headache existence are shown in (
Patients | Timing of headache | |||||
---|---|---|---|---|---|---|
Peri-ictal | Inter-ictal | |||||
Pre-ictal | Pre & post-ictal | Post-ictal | Inter-ictal | Post & inter-ictal | Pre, Post & inter-ictal | |
Number | 4 | 2 | 33 | 22 | 15 | 2 |
Percentage | 5.13 % | 2.56% | 42.31% | 28.21% | 19.23% | 2.56% |
Variables | No headache N = 22 | Headache N = 78 | P value |
---|---|---|---|
Gender Females Males | 2 (9.09%) 20 (90.91%) | 57 (73.08%) 21 (26.92%) | <0.0001 |
Age/years Mean ± SD Median (range) | 28.05 ± 7.26 29.5 (15 - 40) | 23.76 ± 8.25 21 (12 - 50) | 0.02 |
Epilepsy type Focal Generalized Unclassified | 12 (54.55%) 9 (40.91%) 1 (4.55%) | 62 (79.49%) 16 (20.51%) 0 | 0.02 |
Age of onset of epilepsy Mean ± SD | 24.64 ± 6.94 | 13.90 ± 7.92 | <0.0001 |
Epilepsy duration Mean ± SD | 3.41 ± 2.41 | 9.79 ± 5.09 | <0.0001 |
Type of therapy No therapy Monotherapy Poly therapy | 0 20 (90.91%) 2 (9.09%) | 3 (3.85%) 30 (38.46%) 45 (57.69%) | <0.0001 |
Frequency of epilepsy <1/year ≥1/year, <1/month ≥1/month, <1/week ≥1/week | 9 (40.91%) 8 (36.36%) 3 (13.64%) 2 (9.09%) | 10 (12.82%) 9 (11.54%) 41 (52.56%) 18 (23.08%) | <0.0001 |
History of febrile convulsions No Yes | 21 (95.45%) 1 (4.55%) | 68 (87.18%) 10 (12.82%) | 0.45 |
EEG finding Normal Generalized Focal | 18 (81.82%) 1 (4.55%) 3 (13.64%) | 23 (29.49%) 7 (8.97%) 48 (61.54%) | <0.0001 |
Family history of epilepsy No Yes | 18 (81.82%) 4 (18.18%) | 64 (82.05%) 14 (17.95%) | 1.00 |
Family history of headache No Yes | 22 (100%) 0 | 66 (84.62%) 12 (15.38%) | 0.06 |
Patients suffering from headaches were more commonly polytherapy as regard antiepileptic drugs (57.69%) compared to those without headaches (9.09%) (P = <0.0001). Among patients with a headache only 34 patients (43.59%) use analgesic for the treatment of a headache and 44 patients (56.41%) didn’t use any medications for treatment. The majority of patients 26 patients (76.47%) used analgesics without seeking medical advice and only 8 patients (23.53%) used analgesics prescribed by a doctor after seeking medical advice.
Headache is very common among patients with epilepsy. However, its frequency is very variable among various studies. Some studies reported similar frequency and other studies reported lower frequency compared to our study. Mameniskiene et al. reported that 82.2% of patients with epilepsy suffered from headache in his study population [
As regard the type of headache, we found that migraine was the most frequent type of headache in patients with epilepsy including (57.69%) migraine without aura (6.69%), a migraine with aura and (6.41%) probable migraine and the second most frequent type is tension-type headache (25.64%). Similar findings were found in several studies [
We found that younger patients with epilepsy, especially females, are more liable to develop headache compared to older ones. This finding is similar to other studies [
Patients with epilepsy associated with headaches have a significantly lower age of onset and longer duration of epilepsy compared to those without headache. Many studies showed similar results to our study [
Similar to the results of other studies [
In our study, we found that there was no significant association between headache and family history of headache or epilepsy and the same findings were reported by some studies [
We found a significant association between headache and the focal onset seizures and this was reported also by many studies [
Our study has some limitations. First, our interview was dependent on patients’ memory of headaches. Second, the findings reported here were based on a sample size of 100 participants. Accordingly, future studies should focus on a larger pool. Thirdly, the use of routine EEG recording which gave us limited information about focality of epilepsy so in the next studies we will need other investigations to accurately assess seizure focality and correlates these findings with seizure semiology.
In conclusion, our study showed that patients with epilepsy frequently experience headaches. Migraine is the most prevalent type of headache in patients with epilepsy. Post-ictal headache occurs more frequently compared to inter-ictal headache. Pre-ictal and ictal headaches were rare. In our study we found that the occurrence of headaches was more in the female sex, lower mean age of the patient and lower mean age at the onset of epilepsy. Patients with focal epilepsy, longer duration of epilepsy, higher frequency of seizures and those in whom polytherapy is used suffer more headaches. Patient with abnormal EEG, especially those with focal abnormalities, were more commonly suffering from headache. The comorbidity between headache and epilepsy is extremely important, as headaches often receive less attention than the more dramatic symptoms of seizures. In epilepsy, questions concerning headache should be an integral part of the history as comorbidity may influence the antiepileptic drug choice, and the migraine may need specific treatment.
The authors declare no conflicts of interest regarding the publication of this paper.
Sayed, M.A., Ibrahim, H.K., Bekhit, A.S., Thabit, M.N. and Abdelmomen, M. (2019) Clinical Characteristics of Headache in Egyptian Patients with Idiopathic Epilepsy. Journal of Behavioral and Brain Science, 9, 144-153. https://doi.org/10.4236/jbbs.2019.93012