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Seizure-related Headache, case & review

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bagaimana hubungan nyeri kepala dengan epilepsi? epilepsi menyebabkan nyeri kepala? nyeri kepala menyebabkan epilepsi? epilepsi yang manifestasinya nyeri kepala? kapan kita curiga suatu nyeri kepala …

bagaimana hubungan nyeri kepala dengan epilepsi? epilepsi menyebabkan nyeri kepala? nyeri kepala menyebabkan epilepsi? epilepsi yang manifestasinya nyeri kepala? kapan kita curiga suatu nyeri kepala merupakan bentuk kejang?

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  • Interictal headache (IIH), and in particular migraine, is considered a relevant co-morbidity in epilepsy; however, available data are ambiguous. Physicians should ask for PIH and offer specific analgesic treatment. To confirm these findings, future studies with a prospective approach implementing a headache and seizure diary should be performed.
  • Although the nature of this association is unclear, several plausible explanations exist: the two disorders coexist by chance; headache is part (or even the sole ictal phenomenon) of seizures or thepost-ictal state; both disorders share a common underlying etiology; and epilepsy mimics the symptoms of migraine.Seizures and headaches as well as their respective primary syndromes (epilepsy and headache/migraine) share several pathophysiological mechanisms. Papetti et al.“Headache and epilepsy”— How are they connected? Epilepsy&Behavior26(2013)386–393
  • [1]Parisi P, et al. The crossover between headache and epilepsy. Expert Rev. Neurother. 13(3), 231–233 (2013)[2]Striano p, et al. ‘‘Comorbidity’’ between epilepsy and headache/migraine: the other side of the same coin!. J Headache Pain (2011) 12:577–578
  • Perempuan > LakiUsiamudaBerdenyut > Nyerikepala lainLobus Temporal
  • Perempuan > LakiUsiamudaBerdenyut > Nyerikepala lainLobus Temporal
  • Perempuan > LakiUsiamudaBerdenyut > Nyerikepala lainLobus Temporal
  • The same patients mightpresent more than one subtype of peri-ictal headache andalso experience interictal headaches. More than a nuisance,they may have diagnostic importance. For example, intemporal lobe epilepsy, headache location is stronglycorrelated with the side of epileptogenic zone, being alateralization sign[13]. Bianchin 2010
  • thefrequencyofepilepsyamongpeoplewithmigraine(range1–17%)ishigherthaninthegeneralpopulation(0.5–1%),justastheprevalenceofmigraineamongpatientswithepilepsyisalsohigher(range8–15%) than that reported in healthyindividuals (Papetti, 2013(
  • thefrequencyofepilepsyamongpeoplewithmigraine(range1–17%)ishigherthaninthegeneralpopulation(0.5–1%),justastheprevalenceofmigraineamongpatientswithepilepsyisalsohigher(range8–15%) than that reported in healthyindividuals (Papetti, 2013(
  • Kenapamunculnya “dalam 1 jam”?
  • ‘‘Ictal epileptic headache’’, used for the first time by Parisi, [1]appears repetitive,since per se ictal signifies ‘‘relating to a seizure’’ (Oxford dictionary), ‘‘relating to a seizure or convulsion ‘‘ (Farlex dictionary), ‘‘relating to or caused by a stroke or seizure’’ (The American Heritage W Medical Dictionary). Moreover, an ‘‘epileptic headache’’ is ‘‘per se’’ ictal.‘‘Ictal headache’’, first used by Piccioli et al., [14] could be confused with headachedue to an ‘‘ictus’’
  • FHM: familial hemiplegic migraine
  • [1] HELP, 2010; Syvertsen et al, 2007, Ito et al, 2004; [2] Wawrzyniak et al, 2009 ; [3] Toldo et al, 2010 ; [4] Ito et al, 2004; Ito & Schachter, 1996 ; [5] Ito et al, 2004; HELP,,2010: Schon & Blau,1987; [6] Leniger et al, 2001; [7] Toldo et al, 2010; Ito et al, 2000 & 2003
  • [1] Wawrzyniak et al, 2009 ; [2]Schon & Blau, 1987; [3] Ito et al, 1999, 2000, 2003, 2004
  • Nyerikepaladapatmunculbersamadengannyerikepala
  • Blanda M, Cluster Headache, Medscape, 18 Oct 2012. 21/9/13 13:11
  • Bianchin et al, 2010
  • Prevent seizureSimple anlagesic

Transcript

  • 1. Seizure-related Headache Review & Case Report Ersifa Fatimah, dr. FK Universitas Airlangga RS Dr Soetomo Surabaya, 2013
  • 2. Introduction • Abundant clinical and epidemiologic data demonstrate that headache/migraine and epilepsy are highly comorbid. • The disorders share overlapping risk factors, brain mechanisms, and treatments. • The clinical presentation of migraine and epilepsy may overlap, creating a challenge in differential diagnosis. Engel & pedley, Epilepsy, A Comprehensive Textbook, 2nd eds, 2008, p 5257 -5273 2
  • 3. Introduction • Periictal headache (PIH) displays a frequent ancillary burden to seizures, but identification of unequivocal predictors is still elusive. PIH is frequent, severe and undertreated. Duchaczeck B et al. Interictal and periictal headache in patients with epilepsy. Eur J Neurol. 2012 Dec 25. 3
  • 4. Introduction • The relationship between headache and seizures is a complicated one, since these two conditions are related in numerous ways. • In order to improve the care for patients with a clinical connection between migraine and epilepsy, it is necessary to try to understand more accurately the exact pathophysiological point of connection between these two conditions. Papetti et al. “Headache and epilepsy”— How are they connected? Epilepsy&Behavior26(2013)386–393 4
  • 5. Introduction • Major discrepancies and conflicting data about comorbidity between headache and epilepsy due to: [1] – the confusion and mixture of epidemiological data between adults and children across studies – the significant underestimation of headache when it is comorbid in populations with epilepsy. • Due to the different methodologies and criteria used, the studies are quite difficult to compare. [2] 5
  • 6. Migralepsy Hemicrania epileptica Epilepgraine Migrainetriggered seizure Post-ictal headache Hybrid crisis 6
  • 7. Kasus Px LK SR PU FM SN Jenis/ Usia Karakteristik nyeri kepala (thn)/ Status/ Pekerjaan P/49/ “Kemeng”, unilateral (kiri) Menikah/ sekitar mata & hidung, Ibu rumah tangga Gejala penyerta Mata kiri merah, kabur, mual. Variabel epilepsi & terapi EEG CT/MRI (Riwayat syncope saat kanak Sharp wave & ISA & pelo mendadak 5 tahun temporal kiri lalu) Normal P/29/ Belum menikah/ Pembantu rumah tangga L/33/ Menikah/ “tukang odongodong” P/16/ Belum menikah/ Pelajar Berdenyut bilateral, 2-3 jam, muncul setelah kejang Kejang fokal umum sekunder tonik klonik, aura: melihat sawah - Berdenyut, unilateral (kiri), muncul setelah kejang. Mual Automatisme sejak 10 tahun Sharp wave & ISA lalu, kejang umum tonik temporal D/S (Interklonik sejak 3 bulan lalu ictal, 2013) Toxo dd Tuberculoma di cerebellum Berdenyut, unilateral  bilateral (mulai kanan), 1 jam, aura (-) Mual, muntah, fotofobia Fokal kiri umum sekunder tonik sejak usia 3 bulan Normal (inter-ictal, 4 tahun lalu) ? P/60/ Menikah/ Penjahit Berat/ditekan bilateral Rasa tidak nyaman di perut, depresi Kejang parsial kompleks 7 tahun lalu, kejang umum tonik-klonik sejak 1 tahun lalu Sharp wave di regio temporal kiri (interictal?, 2012) Normal 7
  • 8. Kasus Px LK SR PU FM SN Jenis/ Usia Karakteristik nyeri kepala (thn)/ Status/ Pekerjaan P/49/ Kemeng, unilateral (kiri) Menikah/ sekitar mata & hidung, Ibu rumah tangga Gejala penyerta Mata kiri merah, kabur, mual. P/29/ Belum menikah/ Pembantu rumah tangga L/33/ Menikah/ “tukang odongodong” P/16/ Belum menikah/ Pelajar Berdenyut bilateral, 2-3 jam, muncul setelah kejang P/60/ Menikah/ Penjahit Berat/ditekan bilateral • • • Berdenyut, unilateral  • bilateral (mulai kanan), 1 Berdenyut, unilateral (kiri), muncul setelah kejang. Variabel epilepsi & terapi EEG CT/MRI (Riwayat syncope saat kanak Sharp wave & ISA & pelo mendadak 5 tahun temporal kiri lalu) Normal Kejang fokal umum sekunder tonik klonik, aura: melihat sawah - Perempuan >sejak 10 tahun Sharp wave & ISA Laki Automatisme lalu, kejang Usia muda >umum tonik temporal D/S (Interklonik sejak 3 bulan lalu ictal, 2013) Berdenyut > Nyeri kepala lain Mual, muntah, Fokal kiri umum sekunder (inter-ictal, 4 Lobus Temporal > Normallalu) fotofobia tonik sejak usia 3 bulan tahun Mual Toxo dd Tuberculoma di cerebellum ? jam, aura (-) Rasa tidak nyaman di perut, depresi Kejang parsial kompleks 7 tahun lalu, kejang umum tonik-klonik sejak 1 tahun lalu Sharp wave di regio temporal kiri (interictal?, 2012) Normal 8
  • 9. Kasus Px LK SR PU FM SN Jenis/ Usia Karakteristik nyeri kepala (thn)/ Status/ Pekerjaan P/49/ Kemeng, unilateral (kiri) Menikah/ sekitar mata & hidung, Ibu rumah tangga Gejala penyerta Mata kiri merah, kabur, mual. P/29/ Belum menikah/ Pembantu rumah tangga L/33/ Menikah/ “tukang odongodong” P/16/ Belum menikah/ Pelajar Berdenyut bilateral, 2-3 jam, muncul setelah kejang P/60/ Menikah/ Penjahit Berat/ditekan bilateral • • • Berdenyut, unilateral  • bilateral (mulai kanan), 1 Berdenyut, unilateral (kiri), muncul setelah kejang. Variabel epilepsi & terapi EEG CT/MRI (Riwayat syncope saat kanak Sharp wave & ISA & pelo mendadak 5 tahun temporal kiri (ictal, lalu) 2013) Normal Kejang fokal umum sekunder tonik klonik, aura: melihat sawah - Perempuan >sejak 10 tahun Sharp wave & ISA Laki Automatisme lalu, kejang Usia muda >umum tonik temporal D/S (Interklonik sejak 3 bulan lalu ictal, 2013) Berdenyut > Nyeri kepala lain Mual, muntah, Fokal kiri umum sekunder (inter-ictal, 4 Lobus Temporal > Normallalu) fotofobia tonik sejak usia 3 bulan tahun Mual Toxo dd Tuberculoma di cerebellum ? jam, aura (-) Rasa tidak nyaman di perut, depresi Kejang parsial kompleks 7 tahun lalu, kejang umum tonik-klonik sejak 1 tahun lalu Sharp wave di regio temporal kiri (interictal?, 2012) Normal 9
  • 10. Association between headache & epileptic seizure according to their temporal occurrence Pre-ictal headache Ictal headache Post-ictal headache Inter-ictal headache Cianchetti C, et al. Epileptic seizures and headache–migraine: A review on types of association and terminology. Seizure: Eur J Epilepsy (2013) 10
  • 11. Prevalence of headache and migraine in epilepsy and its relationship with ictal and interictal period Bianchin MM et al, Migraine and Epilepsy : A Focus on Overlapping Clinical, Pathophysiological, Molecular, and 11 Therapeutic Aspects. Curr Pain Headache Rep (2010)
  • 12. Inter-ictal headache prevalence • Migraine in px wth epilepsy: 14-24% • Epilepsy in px with migraine: 1.1-17% Andermann et al, 1987, Tellez-Zenteno et al, 2005, Leinger et al, 2003 12
  • 13. Inter-ictal headache Tonini et al, 2012 • Research hypothesis: comorbidity among patients with either disorder would be expected to be higher than in the general population • Result: prevalence of comorbidity in patients with epilepsy and in those with headache roughly overlaps that of the general population no association between the two conditions. 13
  • 14. Pre-ictal Headache/Migraine Variants • Migraine with aura followed by an epileptic seizure • ICHD-2: Migraine-triggered seizure (Migralepsy)  prevalence is unknown, associated with basilar-type migraine & menstrual migraines • Migraine without aura followed by an epileptic seizure • Headache followed by an epileptic seizure • Pre-ictal headache • Pre-ictal migraine, migraine-triggered seizure – Migraine attack, fulfilling migraine criteria, +/- aura, – Seizure fulfilling diagnostic criteria for 1 type of epileptic attack – Seizure occurs during/within (conventionally) 1 hour after cessation of the migraine attack • Pre-ictal headache – When criteria for migraine are not met Bianchin, 2010; Cianchetti et al, 2013 19
  • 15. Pre-ictal Headache/Migraine • Migrainous aura is the clinical manifestation of cortical spreading depression(CSD), a potent excitatory electrical neuronal wave followed by neuronal inhibition and glial activation Neuronal activation generated by CSD  decreases the threshold in the epileptic focus  increasing the risk of seizures Bianchin MM et al, Migraine and Epilepsy : A Focus on Overlapping Clinical, Pathophysiological, Molecular, and Therapeutic Aspects. Curr Pain Headache Rep (2010) 20
  • 16. Pre-ictal Headache/Migraine Direct surgical observations & neuroimaging findings: • Increased blood flow that precedes epileptic seizures may trigger trigeminovascular activation & consequent headaches Bianchin MM et al, Migraine and Epilepsy : A Focus on Overlapping Clinical, Pathophysiological, Molecular, and Therapeutic Aspects. Curr Pain Headache Rep (2010) 21
  • 17. Ictal headache Epileptic headache / Ictal epileptic headache • Headache (whether migraine or not) • Onset, and cessation if isolated, coinciding with an EEG pattern of epileptic seizure (rarely EEG alterations may only be detectable using deep electrodes) Cianchetti et al, 2013 Variants • Not followed by other epileptic • Followed by other epileptic manifestations manifestations • Pure/isolated epileptic • Epileptic seizure beginning headache with headache • ICHD-2: Hemicrania epileptica 23
  • 18. Ictal headache Epileptic headache / Ictal epileptic headache Relatively low prevalence of ictal headaches due to: • Cognitive / consciousness impairments provoked by seizures. • Seizures propagate to the thalamus  analgesic status may be rendered (evidence to support this hypothesis is lacking) Bianchin MM et al, Migraine and Epilepsy : A Focus on Overlapping Clinical, Pathophysiological, Molecular, and Therapeutic Aspects. Curr Pain Headache Rep (2010) 24
  • 19. Epileptic headache: Challenge • Probably underdiagnosed – Physician & patient tend to emphasize the other epileptic manifestations • Requiring a diagnostic differentiation from other types of headache – Particularly in pure epileptic headache & no epileptic abnormalities are present in the interictal EEG Cianchetti C, et al. Epileptic seizures and headache–migraine: A review on types of association and terminology. Seizure: Eur J Epilepsy (2013) 25
  • 20. Migraine vs Epilepsy • Share many features: chronic, episodic manifestation, similarities of classification, ictal progression, symptomology • Differentiating is usually accomplished on clinical ground • EEG not routinely indicated in migraine, may be useful Haut S, Differentiating Migraine from Epilepsy. Adv Stud Med. 2005;5(6E):S658-S665 26
  • 21. Migraine vs Epilepsy Migraine Epilepsy Prevalence Lower during earlier childhood, decreasing again in older ages Bimodal pattern, affecting mostly children and the Elderly Sex Female > Male // Consequences Has not been associated with reduced lifespan Stigmatizing disease, being a life-threatening condition Bianchin MM et al, Migraine and Epilepsy : A Focus on Overlapping Clinical, Pathophysiological, Molecular, and Therapeutic Aspects. Curr Pain Headache Rep (2010) 27
  • 22. Migraine vs Epilepsy Ictal Progression Migraine Preaura prodrome/ Premonitory phase Aura Epilepsy Irritability, joy, or sadness Talkactiveness or social withdrawal Appetite change or anorexia Water retention Sleep diturbances Heaviness, depression, irritability GI upset (next table) Ictus Prolonged (4-72 hours) unilateral Brief , self limited (1-2 throbbing headache with associated minute), exception: features status epilepticus Automatism absent Post-ictal Impaired concentration, malaise, or euphoria Common post-ictal state, marked after GTCS Haut S, Differentiating Migraine from Epilepsy. Adv Stud Med. 2005;5(6E):S658-S665 28
  • 23. Migraine vs Epilepsy Aura Migraine Epilepsy Definition Complex of symtoms occuring prior to, at onset, or during migraine Simple partial seizure, no alteration on consciousness Mechanism Cortical spreading depression Synchronous neuronal discharge, limited distribution Functional imaging Wave of decreased CBF Increased cerebral blood flow & metabolism Duration 15-60 minutes, develops slowly Brief (less than 1 minute) Occur in isolation Yes. Acephalgic migraine, aura without headache Yes. Simple partial seizure Common symptoms Visual: most common Sensory: paresthesias Motor: unilateral weakness Limbic: abdominal sensation, fear, deja vu Sensory: paresthesias Motor: twitching Haut S, Differentiating Migraine from Epilepsy. Adv Stud Med. 2005;5(6E):S658-S665 29
  • 24. Keywords • Status migrainosus unresponsive to analgesic therapy  iv administration of lorazepam induced the prompt resolution of the symptoms. Belcastro et al. Ictal epileptic headache mimicking status migrainosus: EEG and DWI-MRI findings. Headache. 2011 Jan;51(1):160-2. • Brief episodes (of a few minutes) of severe frontal headache.. Chiancetti et al. Pure epileptic headache and related manifestations: a video-EEG report and discussion of terminology. Epileptic Disord. 2013 Mar;15(1):84-92. 31
  • 25. EEG in the evaluation of Headache A new list from the American Academy of Neurology (AAN) calls into question 5 clinical practices judged to be of little or no benefit for patients. • Don't perform electroencephalography (EEG) for headaches. – Recurrent headache is the most common pain problem, affecting up to 20% of the general population. – EEG has no advantage over clinical evaluation in diagnosing headache, does not improve outcomes, and increases costs. Jeffrey S. AAN Points to 5 Questionable Practices in Neurology. Medscape, Feb 22, 2013. http://www.medscape.com/viewarticle/779756 32
  • 26. EEG in the evaluation of Headache • A total of 50 patients yielded 50 routine EEGs (headache NOS, n = 32; migraine n = 18). • Overall, there were 37 (74%) normal EEGs and 13 (26%) abnormal. • Routine EEGs are mostly normal in young patients (18-40 years of age) who are referred to our laboratory with a diagnosis of headache NOS or migraine. Senthi NK et al. Diagnostic utility of routine EEG study in identifying seizure as the etiology of the index event in patients referred with a diagnosis of migraine and not otherwise specified headache disorders. Clin EEG Neurosci. 2012 Oct;43(4):323-5. 33
  • 27. EEG in the evaluation of Headache • Contributed greatly to increasing understanding of the pathogenesis of primary headache, but little / no value in the clinical setting. • Interictal EEG is not routinely indicated in the diagnostic evaluation of patients with headache. • Interictal EEG is, however, indicated if the clinical history suggests a possible diagnosis of epilepsy (differential diagnosis). • Ictal EEG could be useful in certain patients suffering from hemiplegic or basilar migraine. Sandrini G et al, Neurophysiological tests and neuroimaging procedures in nonacute headache (2nd edition). Eur J Neurol. 2011 Mar;18(3):373-81. 34
  • 28. EEG in the evaluation of Migraine • Striking EEG patterns have been described in specific subtypes of migraine. • The brain regions most often involved in the published EEG samples in basilar-type migraine include the posterior temporal, parietal, and occipital regions. The posterior electrographic localization may not pertain to other forms of migraine. • Paroxysmal lateralizing epileptiform discharges (PLEDs) or PLED-like activity has been associated with hemiplegic migraine, prolonged migraine aura, or incipient migrainous infarction. Those patients with PLED-like activity did not have any of the usual entities associated with PLEDs, such as stroke, brain abscess, glioblastoma, or viral encephalitis, and their PLEDs usually resolved within 24 hours. Certain migralepsy patients had clinical seizures when PLEDs were present on their EEGs. Schachter SC (ed). Differential diagnosis of migraine and epilepsy. http://professionals.epilepsy.com/page/migraine_eeg.html 35
  • 29. Post-ictal Headache • Features of tension-type headache OR migraine headache (in px with migraine) • Develops within 3 hours after seizure • Diseappears within 72 hours after the seizure • Partial or generalized epileptic seizure ICHD-2, International Headache Society, 2004 Ekstein D, Schachter SC. Postictal headache. Epilepsy & Behavior 19 (2010) 151–155 43
  • 30. Post-ictal headache Risk Factor Age Significantly higher in younger patient [1] Sex Significantly higher in female [2] Male : Female = 1:1.8 (pediatric) [3] Relationship to interictal headache Occurrence of IIH appears to increase the risk of PIH [4], especially with migraine [5] PIH shorter duration than IIH [6] Relationship to family history of headache No association [7] Ekstein & Schachter, 2010 Controversy. Other studies: not statistically significant association 44
  • 31. Post-ictal headache Association with epilepsy-related variables Duration Younger age of onset epilepsy (HELP study, 2010: 22.1 vs 28.8) Longer duration of disease (HELP study, 2010: 9.9 years vs 7.3 years) Severity PIH correlated with AED polytherapy [1] Characteristic of seizure PIH more frequent after GTCS & more severe after prolonged/repetitive seizure [2] Occurred in 96 & 28 % GTCS, 88-62& secondary GTCS, 43% partial seizure, 70-22% CPS GTCS ~ nonmigraineous/ steady CPS ~ throbbing Classification/location of epilepsy No clear association PIH is more frequent in OLE (59-62%) > FLE (40-42%) > TLE (23-41%) [3] Ekstein & Schachter, 2010 45
  • 32. Post-ictal headache Pathophysiology • Headaches may occur as following brainstem activation, with consequent trigeminal activation and vasodilation (as for pre-ictal headaches) Bianchin MM et al, Migraine and Epilepsy : A Focus on Overlapping Clinical, Pathophysiological, Molecular, and Therapeutic Aspects. Curr Pain Headache Rep (2010) 46
  • 33. Patofisiologi Kejang Gangguan permeabilitas membran neuron Ketidakseimbangan inhibisi dan eksitasi Disfungsi sel glia Kejang  “Energy failure” Edema serebri  Nyeri kepala
  • 34. Pathophysiology of Primary Headache Migraine [Suharjanti, 2009 & 2013; Sjahrir, 2008] • • • • • Hyperexcitability neuronal Cortical spreading depression Trigeminal activation: peripheral & central PAG: progressive changes Genetic Tension-type Headache [Suharjanti, 2009; Machfoed, 2008; Basir, 2012] • • • • Muscle contraction Vascular theory Humoral theory Posture Cluster Headache [Suharjanti, 2009; Blanda, 2012] • • • • • Periodicity ~hypothalamus, central disinhibition of nociceptive & autonomic pathways Trigeminal-facial neuronal circuitry alteration due to central sensitization Substance P neurons in V1&2 Vascular dilatation (neurogenic) Histamine? 52
  • 35. • The mechanisms underlying the association of migraine and epilepsy are yet to be elucidated • Several subtypes of migraine disorders & of epilepsy  mechanisms are likely to be diverse • Pathophysiological common aspects do exist 53
  • 36. Migraine & Epilepsy are characterized by lower neuronal threshold in the cortex • Occipital cortex is particularly vulnerable to CSD • Postictal headaches often having migraine-like characteristics occur more in occipital epilepsy • AEDs (eg, valproic acid, topiramate, gabapentin) work for migraine prophylaxis Bianchin et al, 2010 54
  • 37. Migraine & Epilepsy common genetic & molecular aspect Gene/Locus Migraine Epilepsy CACNA1A (19p13) pore-forming α1A-subunit of voltage-dependent P/Q-type calcium channels FHM1 Different forms of epilepsy ATP1A2 (1q23) poreforming α2 subunit of the electrogenic Na+, K+-ATPase FHM2 (occipitotempor al epilepsy) SCN1A voltage-gated Sodium (Na) channel α1-subunit FHM3 Different forms of epilepsy SLC1A3 Excitatory aminoacid transporter1 POLG mitochondrial DNA polymerase & helicase C10orF2 mitochondrial DNA polymerase & helicase Bianchin et al, 2010 55
  • 38. Mutations - Channelopathies  ionic homeostasis - GABAergic/Glutamatergic systems - Mitochondrial functions Spectrum of nervous system diseases with frequent migraine/epilepsy comorbidity Bianchin MM et al, Migraine and Epilepsy : A Focus on Overlapping Clinical, Pathophysiological, Molecular, and Therapeutic Aspects. Curr Pain Headache Rep (2010) 56
  • 39. Therapeutic Aspects • Migraine & epilepsy are associated  clinicians should be aware that individuals with one disorder are more likely to have the other. • Comorbidity should be considered when developing treatment plan: – TCA & neuroleptic drugs for migraine may lower seizure thresholds – Antimigraine anticonvulsants should be considered as a simultaneous treatment for both disorders Bianchin et al, 2010 57
  • 40. Case 58
  • 41. ? Jenis nyeri kepala yang mana? Kaitan nyeri kepala dengan kejang? Penyebab nyeri kepala? Terapi? 59
  • 42. Tn. PU/ L/33/ Menikah/ “tukang odong-odong” • Kejang seluruh tubuh saat sedang tidur, sejak seminggu sebelum berobat ke Poli, kedua lengan & tungkai kaku menghentak-hentak selama 5 menit. Lidah tergigit +. Sebelum kejang tidak ada gejala khusus. Setelah kejang pasien segera sadar dan mengalami nyeri kepala berdenyut sebelah kiri, VAS 5-6, disertai mual, menghilang sendiri dalam beberapa jam atau setelah minum obat dari toko. Kejang berulang 2-3x seminggu, muncul sewaktu-waktu, dengan pola yang sama. Pasien juga mengeluhkan nyeri kepala berdenyut & tegang di bagian depan kepala kadang kumat saat kecapekan sejak 6 bulan ini. (Karakteristik nyeri kepala sama dengan yang setelah kejang). 61
  • 43. • Kejang sejak 10 tahun yang lalu (usia 23 thn), gerakan seperti meniup & menepuk-nepuk tangan, jalan mondar-mandir tanpa ingat arah, pasien tdk ingat saat kejang. • Tx: Valproat 2x250mg, Paracetamol prn • • • • Pemeriksaan fisik: refleks palmomental +/+ EEG: Sharp wave & ISA temporal D/S Lab: IgG Toxo (+), HIV (-) MRI+K: infeksi di serebelum 62
  • 44. Migren? Unilateral Sedang Segera setelah kejang Mual-muntah Infeksi otak Post iktal 1-beberapa jam Berdenyut Interiktal Primer Migren Nyeri kepala Infeksi Post-ictal headache? Migren Focal secondarily generalized Berkembang dalam 3 jam Hilang dalam 72 jam 63
  • 45. Faktor Risiko SR PU Wanita + - Interictal headache - + Onset epilepsi usia muda 26 thn 23 tahun Durasi epilepsi 3 tahun >10 tahun Politerapi - - GTCS secondarily + Muda 64
  • 46. Case Challenge 65
  • 47. Mrs. Lk/ F/49/ Married/ Housewife • Headache, in left periorbital, dull, VAS 8-9, accompanied by nausea, tearing & conjunctival injection of the left eye, begin 4 months ago, occur almost everyday and persist whole day History of syncope in childhood and sudden slurred speech 5 years ago 66
  • 48. • Physical examination: normal • Blood work up: normal • Brain imaging: normal • EEG: Sharp wave & ISA in left temporal lobe • Improved with valproate 250 mg bid ictal cluster headache ??? 67
  • 49. End.