By Mark W. Green, MD, Professor of Neurology, Director of Headache and Pain Medicine, Mount Sinai School of Medicine, New York, NY
A 21-year-old female consulted with me for both headaches and convulsions. She experienced headaches with light and sound sensitivity, as well as nausea, about three times a month. About three or four times a year, however, she experienced spells where she felt vaguely ill, then found herself on the floor with what witnesses described as convulsions that lasted a minute or two. Afterwards, she had a throbbing headache and some nausea, but no light or sound sensitivity. This lasted until she went to sleep in the evening. On occasion, she saw zigzag lines in the right side of her vision, which lasted about 10 minutes and preceded a headache. She believes she may have experienced the same phenomenon before some of her “fainting” spells. The seizures are more likely to occur during the time of menstruation, a time when she also experiences more severe headaches.
The zigzag lines this patient describes are typical of a migraine aura. Many epileptics also describe experiencing an aura before their attacks; this is usually a sensation of a rising feeling in the chest, but visual abnormalities can also occur. It is frequently difficult for us to distinguish the auras seen in migraine from those seen in epilepsy. To make it even more confusing, many seizures are followed by a headache.
It is our current understanding that the cortex of the brain of migraine sufferers is hyperexcitable. This is why people with migraine are sensitive to triggers that are innocuous to others, such as drinking a glass of wine, weather changes or hormonal cycles. Given that fact, it is not surprising that there is a relationship between migraine and epilepsy, another condition caused by an electrical storm in the cortex of the brain.
Migraine occurs in 12% of the population and epilepsy in 0.5% in the population. Given how prevalent migraine is, in most cases in which epileptics also have migraines, the relationship is a coincidence. However, in at least one form of migraine known to be genetically based, called familial hemiplegic migraine, epilepsy is particularly common. This raises the possibility that there may well be some abnormalities in these individuals that account for having both epilepsy and migraine.
When a seizure follows a typical migraine aura (generally within an hour) we often refer to this as “migralepsy.” Sometimes shared environmental risk factors, such as head injuries, increase the risk of having both epilepsy and migraine. However, when both conditions are present, it is most likely a result of epileptics and migraineurs both having easily “excitable” brains.
Cassie decided to do a new gastroenterological evaluation. Because she has a cousin with celiac disease, she wanted to make certain that gluten intolerance was not the cause of her abdominal pain. None of the tests revealed any abnormalities. She tried a high-fiber diet and then a gluten-free diet for a few months. Her symptoms continued unchanged.
The lack of a gastrointestinal cause for Cassie’s symptoms confirmed a diagnosis of abdominal migraine. She has been able to take propanolol, which reduces the frequency of the attacks, and has been given a triptan for treatment of acute attacks. This helps her to manage both the headaches and the abdominal pain.
MANAGING MIGRAINE AND EPILEPSY
Although occasionally epilepsy can mimic migraines, electroencephalograms (EEGs), which are used to diagnose epilepsy, should not be used as a routine study to evaluate migraine. Abnormalities similar to those seen in seizures can accompany a typical migraine without any evidence of an epileptic event. Also, a variety of abnormities can be seen on EEGs of migraineurs that do not predict epilepsy and are of no value in predicting which medications are best for a patient.
In my patient’s case, we did do an EEG and it was typical of those seen with a seizure disorder. Her migraines were also typical of migraines with aura. We diagnosed her with “migralepsy” since the seizures followed her auras.
In an individual with both migraine and epilepsy, our first treatment approach is to try to treat both conditions with the same medication. Because lowered magnesium levels in the brain can be seen in some migraineurs and some epileptics, we often recommend supplementing magnesium. Two anti-epilepsy medications, topiramate and divalproex, are effective and approved by the US Food and Drug Administration for the treatment of migraine, though most other epilepsy medications are ineffective or minimally effective for migraine treatment. My patient was treated with topiramate and had a significant reduction in both types of attacks.