Abstracts

Rationale: We present a case of a transgender individual hospitalized for migraine with aura (MWA) whose hospital course was complicated by psychogenic non-epileptic seizures (PNES).

Methods: We present a case and discuss considerations in balancing antiseizure medications (ASM) with gender-affirming hormonal therapy.

Results: An 18-year-old transgender person (pronouns they/them/their) with a history of Major Depressive Disorder and Postural Orthostatic Tachycardia Syndrome presented with worsening migraines, characterized by headaches associated with photophobia and episodic confusion. Outpatient medications were aripiprazole 10 mg daily, benztropine 0.5 mg daily, escitalopram 15 mg daily, hydroxyzine 50 mg daily, and lithium 300 mg BID. Other medications were cholecalciferol, fexofenadine, ivabradine, and midodrine. The hospital course was complicated by seizure-like episodes. Video-EEG monitoring showed no electrographic correlate for episodes of head turning and arm jerking, which were not clinically stereotyped, leading to a diagnosis of PNES. The patient was treated for migraine with aura with topiramate. At this time, the patient identified as non-binary and was still exploring treatment options regarding hormonal therapy.

Approximately 0.3% to 0.9% of the world’s population identifies as transgender, and these numbers have been increasing over the last decade [1, 2]. One key intervention for this population is gender-affirming therapy with supplemental hormonal treatment. Transgender individuals may require treatment with ASMs for both neurological and psychiatric conditions. Some ASMs are inducers of the CYP-450 pathway and interact with estrogen and testosterone. Relevant to this patient, topiramate decreases ethinyl estradiol levels and can lead to erectile dysfunction and anorgasmia [1, 3]. Unfortunately, there is a paucity of data regarding use of ASMs in transgender patients, many of whom are actively seeking gender-affirming therapy. This poses a therapeutic dilemma as treating a patient’s neurologic condition with ASMs may interfere with the efficacy of gender-affirming hormonal therapy [Table 1].

References:
1. Johnson, E.L. and P.W. Kaplan, Caring for transgender patients with epilepsy. Epilepsia, 2017. 58(10): p. 1667-1672.
2. Meerwijk, E.L. and J.M. Sevelius, Transgender population size in the United States: a meta-regression of population-based probability samples. American journal of public health, 2017. 107(2): p. e1-e8.
3. Svalheim, S., et al., Interactions between antiepileptic drugs and hormones. Seizure, 2015. 28: p. 12-17.
4. Reimers, A., E. Brodtkorb, and A. Sabers, Interactions between hormonal contraception and antiepileptic drugs: clinical and mechanistic considerations. Seizure, 2015. 28: p. 66-70.

Conclusions: Unfortunately, there is a paucity of data to guide clinicians about balancing the risk of interactions between ASMs and hormonal treatment with anti-seizure benefits. A multidisciplinary approach is warranted prior to starting medications that may interfere with gender-affirming treatments.

Funding: Please list any funding that was received in support of this abstract.: None.