Migraine triggered seizures and epilepsy triggered headache and migraine attacks: a need for re-assessment

In this issue of the Journal, Belcastro and associates review terminology and classification issues for migralepsy, hemicrania epileptica, post-ictal and ictal headache [1]. They raise key points such as ictal headache and visual seizures are often misdiagnosed as migraine, “migralepsy” is unlikely to exist and an “epilepsy-migraine sequence” is much more common and well documented than the dominant view of a “migraine-epilepsy sequence”. Their relevant proposals need appropriate attention by the committee of the international classification of headache disorders (ICHD) as well as the physicians in their clinical practice because of the consequences that misdiagnosis may have on patients. Misdiagnosis between epilepsy and migraine is considerable though their differentiation should not be difficult on clinical grounds [2]. The problem is that emphasis is unduly placed on individual symptoms, rather than on a comprehensive synthetic analysis of their quality, chronological sequence and other clustering features. There are many examples of such errors where visual seizures are unquestionably diagnosed as acephalgic migraine and more often migraine with aura (if seizures are followed by post-ictal headache) or basilar migraine with occipital paroxysms (which does not exist, because this is a syndrome of idiopathic childhood occipital epilepsy). Elementary visual hallucinations of occipital seizures develop rapidly within seconds, are brief in duration (2–3 min), are usually coloured and circular. These are fundamentally different from the visual aura of migraine, which develops slowly in minutes, is longer lasting (≥5 min) and mainly achromatic with linear patterns [3].