Headache and epilepsy share many possible clinical interrelationships. (See Table: Migraine and Epilepsy) The disorders may exist independently or may be associated in certain syndromes. Migraine may trigger epilepsy, or epilepsy may initiate headache.

Headache is commonly associated with seizures as a preictal, ictal, or postictal phenomenon, but it is often neglected because of the dramatic neurologic manifestations of the seizure. Patients with migraine-triggered epilepsy seek medical attention because of seizures, which may overshadow the migraine and be overlooked by both patient and physician. Headache can also be the sole or most predominant clinical manifestation of epileptic seizures, although this is a relatively rare situation.51

Preictal and ictal headache

Preictal and ictal headaches are relatively rare and short-lived. The seizure itself may limit the patient’s ability to observe or recall the manifestations of these headaches.

Palmini and Gloor52 presented a descriptive study of auras in partial seizures. Auras were termed cephalic if the symptoms included nonvertiginous dizziness, lightheadedness, or pressure on the head. Auras of this type occurred in 22 of 196 patients.

In Blume and Young’s epilepsy unit, 2.8% of 858 patients had brief ictal pain and 1.3% (11 patients) had headache. Only 2 patients described the pain as throbbing; the others described it as sharp or steady. Headache preceded the seizure in 8 patients and accompanied the other ictal symptoms in 3, all of whom had partial seizures. The nature and location of EEG abnormalities varied considerably from patient to patient, however.

Isler et al.53 found that hemicranial attacks of pain coincided with seizure activity and lasted for seconds to minutes (hemicrania epileptica). Two exceptions were noted. In one case of complex partial status epilepticus, the headache lasted for hours. In another case, the headache lasted most of the 20 minutes of a recorded seizure. Overall, 20% of this group of patients with drug-resistant epilepsy had cephalic symptoms.

Postictal headache

Unlike preictal or ictal headaches, postictal headache (PIH) is common and can affect the patient's quality of life. It is most common with generalized tonic-clonic seizures, is also common with complex partial seizures, and is less common with simple partial seizures.54

Telephone interviews of 372 patients attending an epilepsy clinic found that 45% had experienced PIH, and 21% always had PIH.54 Of those who always had PIH, it was severe 39% of the time. For patients with occasional PIH, on the other hand, it was severe in only 10%. The headache was throbbing in more than two-thirds of patients. The duration of postictal headaches was:

  • less than 6 hours in 81%
  • 6 to 12 hours in no patients
  • 12–24 hours in 11%
  • more than 24 hours in 8%

Independent headaches that were usually similar to their seizure-related headaches affected 27% of patients.

Schön and Blau55 reported on 100 people with epilepsy, 51 of whom had PIH either always (n = 35), usually (n = 5), or 25–50% of the time (n = 11). PIH was more commonly associated with generalized tonic-clonic seizures than with focal seizures. The headaches were either bilateral or unilateral. They were associated with photophobia and phonophobia, throbbing pain, vomiting, nausea, and visual aura, and lasted 6 to 72 hours. Independent migraine attacks occurred in 9% of the patients. These patients recognized the postictal headaches as being similar to their migraines. Epileptic migraine responds to sumatriptan.56

The mechanism of ictal and postictal headache is uncertain. In recent years, the theory of migraine pathogenesis has focused on the trigeminovascular system. Activation of this system gives rise to neurogenic inflammation of cranial blood vessels and pain.44 In animal models, Moskowitz and coworkers have shown that seizures activate the trigeminovascular system, providing a potential mechanism for the associated headaches.

Adapted from: Silberstein, SD, and Lipton RB. Headache and epilepsy. In: Ettinger AB and Devinsky O, eds. Managing epilepsy and co-existing disorders. Boston: Butterworth-Heinemann; 2002;239–254. 
With permission from Elsevier (www.elsevier.com). 

Reviewed By: 
Steven C. Schachter, MD
Wednesday, March 31, 2004