clinical and epidemiological aspectsyns-yemen.com/newwebsite2/jemenii.pdf · • macro-, micropsia...
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EylertEylert BrodtkorbBrodtkorb
Dept. for Neurology and Clinical NeurophysiologyDept. for Neurology and Clinical Neurophysiology
TrondheimUniversityTrondheimUniversity Hospital, NorwayHospital, Norway
Epilepsy & Migraine:Epilepsy & Migraine:
Clinical and Epidemiological AspectsClinical and Epidemiological Aspects
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Epilepsy & Migraine
are linked by their
• symptom profiles
• comorbidity
• treatment
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Migraine
Recurrent headache in attacks of 4-72 hours
Typical characteristics:
• Unilateral• Pulsating• Moderate/severe• Aggravation by physical activity• Nausea and/or vomiting• Photo-and phonophobia
-without aura
-with aura IHS 2004
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Epilepsy
Recurrent spontaneous epileptic seizures
Epileptic seizure
A clinical manifestation resulting from
an excessive discharge of a set of neurons
in the brain
ILAE 1993
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Epilepsy & Migraine
• Pathophysiology
• Symptomatology
• Epidemiology
• Pharmacology
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Epilepsy & Migraine
• Pathophysiology
• Symptomatology
• Epidemiology
• Pharmacology
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Migraine aura: Spreading depression
Process which spreads anteriorly by diffusion
(volume transmission: K+, glutamate?)
“Trigger wave”: Spreading depression
Occipital
pole
3 mm/min
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ExcitatoryExcitatoryFiberFiber
Inhibitory FiberInhibitory FiberPostsynaptic NeuronPostsynaptic Neuron
Glutamate
GABA
PathophysiologyPathophysiology of Epilepsyof Epilepsy
EPSPEPSP
→→→→→→→→++ IPSPIPSPThresholdThreshold
Summated Summated
PotentialPotential
Excessive synaptic
action potentials
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HyperexcitabilityHyperexcitability
Spreading
depression
Neuronal
hypersynchrony
Non-synaptic
Synaptic
MIGRAINEMIGRAINE
EPILEPSYEPILEPSY
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HyperexcitabilityHyperexcitability
Spreading
depression
Neuronal
hypersynchrony
Non-synaptic
Synaptic
MIGRAINEMIGRAINE
EPILEPSYEPILEPSY
TriggersTriggers
TriggersTriggers
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HyperexcitabilityHyperexcitability
Spreading
depression
Neuronal
hypersynchrony
Non-s
ynap
tic
volu
metra
nsm
ission
Synaptictransm
ission
MIGRAINEMIGRAINE
EPILEPSYEPILEPSY
SLOWSLOW
BRIEFBRIEF
Propagation
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Epilepsy & Migraine
• Pathophysiology
• Symptomatology
• Epidemiology
• Pharmacology
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The What and Where pathways
Both cortical pathways are crucial for the visual function
• the ventral pathway for object vision
• the dorsal pathway for spatial vision
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Visual aura
• EpilepsyRound, coloured patterns
Complex pseudohallucinations,
sometimes related to past events
• MigraineIllusions
Monochromatic mosaics
Positive and negative symptoms
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Visual aura
• EpilepsyRound, coloured patterns
Complex pseudohallucinations,
sometimes related to past events
• MigraineIllusions
Positive and negative elements
Monochromatic mosaics
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Epilepsy & Migraine:
Migraine aura
• Duration: 20-30 min (<1h), but may develop within 5 min
• Mix of excitatory and inhibitory phenoma symptoms
• typically
visual and/or sensory and/or speech symptoms
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Migraine aura
Complex disturbances of visual perception:
• Metamorphopsia,
• Macro-, Micropsia (Lilliput hallucinations)
• Zoom vision
• Mosaic vison
• Alice in Wonderland syndrome
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Alice’s Adventures in Wonderland
By
Lewis Carroll
Oxford 1862
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“Curiouser and curiouser!” cried
Alice (she was so much surprised,
that for the moment she quite forgot
how to speak good English).
“Now I’m opening up like the largest
telescope that ever was! Goodby
feet” (for when she looked down at
her feet, they seemed to be almost
out of sight, they were getting so far
off).
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PicassoLa femme qui pleure
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Epileptic vs. migraine aura
• EpilepsySynaptic transmission
Rapid onset and briefFrequent attacks, clustering
Often evolving to temporal lobe symptoms
• MigraineVolume transmission (by diffusion)Gradual development >5 min.Duration 5-60 min
From occipital to parietal cortex
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HyperexcitabilityHyperexcitability
Spreading
depression
Neuronal
hypersynchrony
Non-synaptic
Synaptic
MIGRAINEMIGRAINE
EPILEPSYEPILEPSY
MigralepsyMigralepsy
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Migralepsy
(migraine-triggered seizure)
An epileptic attack occurring
during or within one hour after
migraine aura
ICHD, 2nd edition, 2004
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Postictal headache
• Common after GTCs
• Often with migraine-like features
• Related to occipital lobe epilepsy
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Postictal headache
• Develops within 3 h following the seizure
• Resolves within 72 h after the seizure
ICHD, 2nd edition, 2004
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Syvertsen M, Helde G, Stovner LJ, Brodtkorb E
Headaches add to the burden of epilepsy
Postictal headaches in 109 patients with active epilepsy 44 %
Migraine-like postictal headaches 17 %
Interictal migraine in patients
with postictal migraine-like headaches 74 %
J Headache Pain 2007;8:224-30
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HyperexcitabilityHyperexcitability
Spreading
depression
Neuronal
hypersynchrony
Non-synaptic
Synaptic
MIGRAINEMIGRAINE
EPILEPSYEPILEPSY
PostictalPostictal
migrainemigraine
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HyperexcitabilityHyperexcitability
Spreading
depression
Neuronal
hypersynchrony
Non-synaptic
Synaptic
MIGRAINEMIGRAINE
EPILEPSYEPILEPSY
Childhood
occipital
epilepsies
++
Hemiplegic
migraine
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Childhood occipital epilepsies
• Early onset (Panayiotopoulos syndrome)
Autonomic symptoms with vomiting
Deviation of eyes
Impaired consciousness
non-convulsive status
• Late onset (Gastaut type)
Brief visual seizures
Postictal headache
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Hemiplegic migraine
-one-sided motor weakness during the aura phase
• Sporadic
• Familial
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Hemiplegic migraine
-one-sided motor weakness during the aura phase
• Sporadic
• Familial
CACNA1A
ATP1A2
SCN1A
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HyperexcitabilityHyperexcitability
Spreading
depression
Neuronal
hypersynchrony
HEMIPLEGICHEMIPLEGIC
MIGRAINEMIGRAINE
EPILEPSYEPILEPSY
CACNA1A
ATP1A2
SCN1A
++MutationsMutations
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Epilepsy & Migraine
• Background and definitions
• Pathophysiology
• Symptomatology
• Epidemiology
• Pharmacology
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Ottman R, Lipton RB
Comorbidity of migraine and epilepsy
Telephone interviews with 1.948 adult probands with
epilepsy and 1.411 of their siblings and parents.
Cumulative incidence of migraine was
•24 % in probands with epilepsy
•23 % in relatives with epilepsy
•12 % in relatives without epilepsy
Neurology 1994;44:2105-10
Conclusion: Risk of migraine is 2.4 higher in
persons with epilepsy than without:
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Epilepsy Migraine
Gene A
Gene CGene BSeparate
genetic
influences
Shared
genetic
influences
?
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Ottman R, Lipton RB
Is the comorbidity of epilepsy and
migraine due to a shared genetic susceptibility?
•Equal risk of migraine in genetic vs. non-genetic epilepsy
•Risk of epilepsy in relatives was not associated
with proband’s history of migraine
Conclusion: The overall comorbidity is not explained by
genes predisposing to both disorders.
Neurology 1996;47:918-24
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The Vågå Study of Headache Epidemiology(Ottar Sjaastad)
Structured headache interview of 1838
inhabitants aged 18-65
(89% of target population was accessed)
• Have you ever had convulsions, epileptic fits
or other epileptic symptoms?
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VVååggåå
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EylertEylert BrodtkorbBrodtkorb
Dept. for Neurology and Clinical NeurophysiologyDept. for Neurology and Clinical Neurophysiology
TrondheimUniversityTrondheimUniversity HospitalHospital
Epilepsy & Migraine:Epilepsy & Migraine:
Clinical and Epidemiological AspectsClinical and Epidemiological Aspects
The VThe Vååggåå mountainsmountains -- JotunheimenJotunheimen
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The Vågå Study
Prevalence rates
•Migraine without aura 23%
•Migraine with aura 9.7%
•Epilepsy 1.2%
(cases under treatment)
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Brodtkorb E, Bakken IJ, Sjaastad O
Comorbidity of migraine and epilepsy in a Norwegian
community
Active epilepsy (seizures within last 5 years)
In migraine (5/524) 1.0 %
In migraine with aura (3/168) 1.8 %
Without migraine (6/1132) 0.5 %
Migraine
In active epilepsy (5/11) 45%
In epilepsy in remission (4/28) 14 % (p =0.09)
Seizure 2008;15:1421-3
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Epilepsy Migraine
Does epilepsy render the
brain susceptible to migraine?
Does migraine cause epilepsy?- by reducing seizure threshold?
- by vascular factors?
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Ludvigsson P et al.
Migraine with aura is a risk factor for unprovoked
seizures in children
METHODS: Migraine symptoms were evaluated in all
incident epilepsy and in matched controls .
RESULTS: Migraine with aura was associated with a
fourfold increased risk for developing epilepsy
Ann Neurol 2006;59:210-3
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Velioğlu SK, Boz C, Ozmenoğlu M.
.
The impact of migraine on epilepsy: a prospective
prognosis study
METHOD: 59 patients were diagnosed with both
epilepsy and migraine and were compared with controls
with epilepsy only during 10 years follow-up.
CONCLUSION: Comorbid migraine had a negative
effect on the prognosis of epilepsy
Cephalalgia 2005;25:528-35
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HyperexcitabilityHyperexcitability
Spreading
depression
Neuronal
hypersynchrony
Non-synaptic
Synaptic
MIGRAINEMIGRAINE
EPILEPSYEPILEPSY
Special Special
syndromessyndromes
GenesGenes
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Epilepsy & Migraine
• Background and definitions
• Pathophysiology
• Symptomatology
• Epidemiology
• Pharmacology
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Mulleners WM, Chronicle EP
Anticonvulsants in migraine prophylaxis:
a Cochrane review
Valproate and topiramate were better than
pacebo, whereas acetazolamide, clonazepam,
lamotrigine and vigabatrin were not;
gabapentin, in particular, needs further
evaluation.
Cephalalgia 2008;28:585-97
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Conclusion
♦ Migraine is common in active epilepsy
♦ The association may be bidirectional
♦ Headaches may add to the burden of seizures
♦ Comorbidity may influence the drug choice
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Epilepsy & Migraine: Epidemiology
General population
General population
People with epilepsy
People with migraine
Prevalence
of migraine
Prevalence
of epilepsy
Leniger T, Diener HC, Hufnagel A
Nervenarzt 2003;74:869-74
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Therapeutic activity of AEDs in pain
Phenytoin
Carbamazepine
Oxcarbazepine
Lamotrigine
Zonisamide
Valproate
Topiramate
Gabapentin
Levetiracetam
Tiagabine
Neuropathic
pain
Tigeminal
neuralgia
Migraine
prophylaxis
controlled trial/
general acceptance
less extensive
evidenceFrom Rogawski & Loscher,
Nat Med 2004;10:685-92
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Therapeutic activity of AEDs in pain
Phenytoin
Carbamazepine
Oxcarbazepine
Lamotrigine
Zonisamide
Valproate
Topiramate
Gabapentin
Levetiracetam
Tiagabine
Neuropathic
pain
Trigeminal
neuralgia
Migraine
prophylaxis
controlled trial/
general acceptance
less extensive
evidenceFrom Rogawski & Löscher,
Nat Med 2004;10:685-92
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Therapeutic activity of AEDs in pain
Phenytoin
Carbamazepine
Oxcarbazepine
Lamotrigine
Zonisamide
Valproate
Topiramate
Gabapentin
Levetiracetam
Tiagabine
Neuropathic
pain
Trigeminal
neuralgia
Migraine
prophylaxis
controlled trial/
general acceptance
less extensive
evidenceFrom Rogawski & Löscher,
Nat Med 2004;10:685-92
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Epilepsy Migraine
Does epilepsy render the
brain susceptible to migraine?
Does migraine cause epilepsy?- by vascular factors?
- by reducing seizure threshold?
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Migraine & Epilepsy Prevalence
Migraine EpilepsyNord-Trøndelag 1997 Iceland 1993
0
5
10
15
20
25
20-29 30-39 40-49 50-59 60-69 70-79 80-
Women
Men
%%0
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Hauser. In: Epilepsy: A Comprehensive Textbook 1997:47-57
Incid
ence/1
00,0
00
250
200
150
100
50
0
0 20 40 60 80 100
Age (years)
Incidence of EpilepsyHighest in the young and the elderly
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Montagna P, Gallassi R, Medori R et al
MELAS Syndrome: characteristic migrainous
and epileptic features and maternal transmission
Severe prolonged migrainous symptoms and prolonged
partial status epilepticus are characteristic features of the
MELAS syndrome (mitochondrial encephalomyopathy,
lactic acidosis, and stroke-like episodes).
Maternal transmission, previously found in MERRF, is
suggested in this disorder as well.
Neurology 1988;38:751-4
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Some patients with cerebral AVMs suffer
migrainous attacks which meet criteria for migraine
Correlation for
•side of unilateral headache
•lateralized auras Haas DC
Headache 1991;31:509-13
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The Vågå Study of Headache Epidemiology
Classic migraine in epilepsy:
In all with Epilepsy Hx: 5 / 40 = 12.5 %
In those still treated: 4 / 21 = 19.0 %
In active epilepsy: 2 / 11 = 18.2 %
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The Vågå Study of Headache Epidemiology
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Migraine & Epilepsyare linked by
♦ symptom profiles
♦ cortical hyperexcitability
♦ comorbidity
♦ the efficacy of “antimigraine antiepileptics”
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EylertEylert BrodtkorbBrodtkorb
Dept. for Neurology and Clinical NeurophysiologyDept. for Neurology and Clinical Neurophysiology
St. OlavSt. Olav’’s Hospitals Hospital
TrondheimUniversityTrondheimUniversity HospitalHospital
Epilepsy & Migraine:Epilepsy & Migraine:
Clinical and Epidemiological AspectsClinical and Epidemiological Aspects
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Epileptic vs. migraine postdrome phase
• EpilepsySomnolence, sleep
Headache, nauseaFocal neurological deficits
• MigraineTired, irritable, impaired concentration
Some: refreshed, euphoric
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The epileptic aura:Simple partial seizure
The ictal symptoms are
determined by the function
of the seizure-generating
cortical area
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The Detailed History of the Ictal Event
1 Precipitating factor / situation
2 What did the patient experience?
3 What did eye witnesses observe?
onset - progression - end
4 Duration
5 Postictal/ Postdromal phase
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PathophysiologyPathophysiology of Migraineof MigraineConcept of neuronal hyperexcitability
Triggers Neuroelectric event
(spreading depression)
Brain stem pathways/
Trigeminovascular systemGenes
Ion channels
Vascular changes
CGRP
?
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Epilepsy & Migraine:
Pathophysiology
Propagation of the attack
• Epilepsy
Synaptic transmission
• Migraine
Volume transmission via diffusion
(“spreading depression”)
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HyperexcitabilityHyperexcitability
Spreading
depression
Neuronal
hypersynchrony
Non-synaptic
Synaptic
MIGRAINEMIGRAINE
EPILEPSYEPILEPSY
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44 (3.9%)19 (3.6%)5 (8.9%)4 (3.6%)10 (2.8%)All
14 (1.2%)10 (1.9%)3 (5.4%)1 (0.9%)6 (1.7%)Single or situation-
related seizures
16 (1.4%)3 (0.6%)01 (0.9%)2 (0.6%)Epilepsy in remission
without treatment
8 (0.7%)1 (0.2%)01 (0.9%)0Epilepsy in remission
with treatment
6 (0.5%)5 (1.0%)2 (3.6%)1 (0.9%)2 (0.6%)Active epilepsy
n=1132 n=524n=56n=112n=356
Migraine
total
Combined
MwA /
MwoAMwAMwoA
Controls
Migraine
Seizure disorders
Association between migraine and seizure disorders
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PicassoPortrait de Dora Maar
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VVååggåå
Vågå mountains
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tttt ProdromeProdromeProdromeProdrome
AuraAuraAuraAura
IctusIctusIctusIctus
The The The The ictalictalictalictal eventeventeventevent
PostictalPostictalPostictalPostictalphasephasephasephase
InterictalInterictalInterictalInterictalperiodperiodperiodperiod
InterictalInterictalInterictalInterictalperiodperiodperiodperiod
EpilepsyEpilepsyEpilepsyEpilepsy