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To the Editor,
It was with considerable interest that I read the recent case report by
Avraham SB et al. published online in “Pediatrics” on March 8, 2010, (1)
which demonstrated that an antiepileptic drug (in that case, valproic
acid) is able to fully recover the clinical picture in children affected
by “Acute Confusional Migraine” (ACM).
ACM is a rare type of “migraine variant” described as acute
ACM is a rare type of “migraine variant” described as acute
confusional states, lasting 4 to 24 hours, associated with agitation and
aphasia commonly seen in juvenile migraineurs.
Since 2007, I have been trying (2-7) to focus the attention of
international experts involved in the epilepsy and headache fields about
the lack of diagnostic criteria filling an “headache attack” as possible,
although rare, (3) sole ictal epileptic manifestation. I have also tried
to explain, from an etiopathogenetical point of view, why this event is so
rare (4,5) and why we should revise the diagnostic criteria both in ILAE
and IHS classifications. (7)
In this regard, we suggested that this new condition be included in
the international classifications with the new term ‘‘ictal epileptic
In writing this commentary, I would like to stress that the stigma
attached to epilepsy can stand back the understanding of the relationship
between headache and epilepsy. In fact, we must bear in mind that the
stigma attached to epilepsy goes back a long way in time and has permeated
numberless cultures. Once, epilepsy was even believed to originate from
malignant causes and to be associated with sin or demonic possession.
Thus, I personally believe that this stigma may explain a general
reluctance (5) (not only in the general public, but even among physicians)
to recognise the few documented cases (2,6) in which migraine/headache has
been demonstrated as sole ictal manifestation of epilepsy.
I feel that may be worth sharing with a larger paediatric readership,
such as that of "Pediatrics”, these reflections, and the case report
recently published in your Journal 1 highly contributes to open the
discussion which this hot topic certainly deserve.
For example, is so interesting to discuss about the efficacy of
intravenous diazepam in our case previously described in whom a good
clinical and EEG response was observed (2) whereas the case reported in
your Journal (1) showed a clinical remission only after intravenous
valproate administration. Particularly, in the patient described by
Avraham SB et al (1) an electroencephalogram (EEG), performed 2 hours
after confusion onset, showed diffused slowing in the form of high-
amplitude delta activity, and the possibility of an epileptic event
(complex partial seizure) was also rouled out by inefficacy of intravenous
midazolam (4 mg) administration.
I agree with the Authors up to a point . We need to be careful !
That’s why in many cases of long-lasting epileptic events intravenous
benzodiazepines may sometimes fail, as occurred, for example, in a
previous our published (8) prolonged refractory “status epilepticus” in
whom even intravenous valproate failed. In addition, neither the presence
of delta activity it is enough to roule out an epileptic origin of an
event. (5) In fact, while unequivocal epileptiform abnormalities usually
point to a diagnosis of epilepsy, it should be borne in mind that the lack
of a clear epileptic spike wave activity is frequent in other ictal
autonomic manifestations such as in Panayiotopoulos syndrome, (9) as well
as in patients with a deep epileptic focus arising, for example, from the
orbito-mesial frontal zone. (5) In such cases, ictal epileptic EEG
activity might be recorded either from the scalp or by stereo-EEG
recording as a ‘‘theta’’ or even ‘‘delta’’ shape without any spike
activity. (5) The neurobiological reasons for these EEG features are, in
my opinion, closely related to the anatomo-neurophysiological variables
(fiber size, myelination and extent of polysynaptic interconnections).
In conclusions, I believe tat we need to go so much in deep in order
to clarify the complex relationships which link headache/migraine and
epilepsy. The case published in your Journal (1) gives us further
opportunities to discuss about them.
1. Avraham SB, Har-Gil M, Watemberg N. Acute Confusional Migraine in
an Adolescent: Response to Intravenous valproate. Pediatrics. 2010;
125;e956-e959; (published online Mar 8, 2010) DOI: 10.1542/peds.2009-2717.
2. Parisi P, Kasteleijn-Nolst Trenit_ DG, Piccioli M, Pelliccia A,
Luchetti A, Buttinelli C, Villa MP. A case with atypical childhood occipi-
tal epilepsy ‘‘Gastaut type’’: an ictal migraine manifestation with a good
response to intravenous diazepam. Epilepsia. 2007; 48:2181–2186.
3. Parisi P, Piccioli M, de Sneeuw S, de Kovel C, van Nieuwenhuizen
O, Buttinelli C, Villa MP, Kasteleijn-Nolst Trenité DGA. Redefining
headache diagnostic criteria as epileptic manifestation? Cephalalgia.
2008; 28:408–409. Author reply 409.
4. Parisi P.Why is migraine rarely, and not usually, the sole ictal
epileptic manifestation? Seizure. 2009; 18:309–312.
5. Parisi P.Who’s still afraid of the link between headache and
epilepsy? Some reactions to and reflections on the article by Marte Helene
Bjørk and co-workers. J Headache Pain. 2009; 10:327–329.
6. Piccioli M, Parisi P, Tisei P, Villa MP, Buttinelli C, Kasteleijn-
Nolst Trenité DGA. Ictal headache and visual sensitivity. Cephalalgia.
7. Parisi P, Kasteleijn-Nolst Trenité DGA. Commentary on
“Migralepsy”: a call for revision of the definition. Epilepsia. 2010;
Forthcoming (May issue).
8. Iannetti P, Spalice A, Parisi P. Calcium-channel Blocker
Verapamil Administration in Prolonged
and Refractory Status Epilepticus. Epilepsia. 2005; 46:967–969.
9. Parisi P, Ferri R, Pagani J, Cecili M, Montemitro E, Villa
MP.Ictal Video-Polisomnography and EEG Spectral Analysis in a Child with
Severe Panayiotopoulos Syndrome. Epileptic Disorders. 2005; 7: 333-339.
Thank you for your interest in spreading the word on Pediatrics.
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