Abstracts

Rationale: Migraine may be associated with epilepsy. Pseudoseizure patients may also complain of headache; whether they have migraine more often than expected is not known. This study assessed prevalence of episodic and transformed migraine in patients with epileptic seizures (ES) and pseudoseizures (PS) to see if headache might be used to discriminate between the two patient groups.Methods: Patients aged 14 to 75 years old were assessed after admission to an epilepsy monitoring unit for elective evaluation of uncontrolled seizures. They were excluded if they had a history of brain pathology to eliminate confounding causes of headache or if monitoring was inconclusive. Headache and seizure history was ascertained by a physician using a standardized, structured interview. Seizure and headache diagnoses were determined using inpatient video-EEG monitoring results and International Headache Society (IHS) criteria for migraine, respectively. Parametric and non-parametric statistical analyses were performed.Results: 100 patients were screened and 67 patients qualified for inclusion. 29 patients were determined to have PS and 38 patients were diagnosed with ES. Age, gender, IQ, and medical co-morbidity did not differ in the two groups. Patients with PS had an increased prevalence of psychiatric co-morbidity (p < 0.01) and history of trauma with loss of consciousness (p < 0.01). Migraine prevalence was significantly higher in PS subjects than the ES patients (72% and 45%, respectively, p < 0.05); this was due to the increased prevalence of transformed migraine headaches (34% of PS patients reported transformed migraine vs. 11% of ES patients) (p < 0.02) and unrelated to prevalence of episodic migraine. PS patients tended to have more headache days per month (12/month) compared to ES patients (3/month) (p = 0.08). PS patients more often had aura symptoms of phosphenes (p < 0.05) and scotoma (p < 0.02) than ES patients and more often had migraine associated symptoms of nausea, vomiting, photophobia, phonophobia, and language abnormalities during a headache than ES patients (p < 0.05).Conclusions: PS patients report symptoms of transformed migraines, migraine auras, and migraine associated symptoms more often than ES patients. Eliciting these symptoms should raise suspicion for PS in patients with uncontrolled seizures. Several interpretations of the data are possible: 1) Migraineurs could be more likely than non-migraineurs to have psychopathology, placing them at risk for PS; 2) Migraine may be one of the stressors that leads to PS; or 3) PS patients may not really have increased prevalence of migraine, but may over-report migraine symptoms because of psychopathology and thus be misdiagnosed due to the subjectivity inherent in IHS criteria. If the latter explanation is correct, the IHS migraine diagnostic criteria may not be valid, since they reflect psychopathology as well as headache.