This is my 56th powerpoint..it deals with HEMICRANIA EPILEPTICA, one of the rarest clinical conditions. A condition, that results in ipisilateral headache/migraine, owing to seizure discharge. Relevant details have been provided. Do go through this.

1. PRESENTED BY:
VISHNU.R.NAIR,
5TH YEAR PHARM.D,
NATIONAL COLLEGE OF PHARMACY(NCP).

2. PATIENT DETAILS:
PATIENT NAME: Mrs. X
AGE: 65 years
SEX: Female
WEIGHT: 50 kgs
HEIGHT: 150 cm
BMI: 22.2
I.P NO.: 218224/17
DEPARTMENT: NEUROLOGY
DOA: 23/08/2017
DOD: 26/08/2017
DURATION OF HOSPITAL STAY: 4 days.

3. REASON FOR ADMISSION:
- Headache, with LOC > 15 minutes(for 1 year)
- 25 episodes of such occurrence
PATIENT MEDICAL HISTORY:
K/C/O HTN (On T. Nicardia, 10 mg)
SOCIAL HABITS: Non-smoker, non-alcoholic.
KNOWN ALLERGIES: Nil.
FOOD HABITS: Non-vegetarian.

4. VITALS CHART:
DATE 23/08/2017 24/08/2017 25/08/2017 26/08/2017
TEMPERATURE(i
n degree
Fahrenheit)
N N N N
B.P(in mm Hg) 110/80 100/70 100/70 110/90
PULSE(in
beats/min)
75 69 68 71
SPO2(in %) 98

5. GENERAL EXAMINATION:
1. SKIN: Normal
2. BUILT/NOURISHMENT: Moderate
3. CVS: S1S2(+)
4. RS : B/L NVBS
5. GIT: WNL
6. CNS: No focal deficits

6. OTHER INVESTIGATIONS:
1. EEG:
- Taken on 24/08/2017
- Awake & sleep EEG was taken
- Showed INTERMITTENT SHARP WAVES in LEFT TEMPORAL REGION
- Features suggest potentially EPILEPTIFORM DYSFUNCTION
2. CT-SCAN(HEAD):
- Taken on 24/08/2017
- Observation: No significant abnormality seen in brain parenchyma.

7. DIAGNOSIS: “HEMICRANIA
EPILEPTICA”

8. HEMICRANIA EPILEPTICA: A
BRIEF INSIGHT

9. MIGRAINE & EPILEPSY:
INTERCHANGING TERMS &
CONTROVERSY UNDERNEATH:
- MIGRAINE & EPILEPSY are the most common brain diseases
- Although the co-morbidity of above conditions are well-known  ONLY FEW
REPORTS OF “MIGRALEPSY” & “HEMICRANIA EPILEPTICA” have been
published
- According to ICHD-II criteria  the following terminologies were proposed:
A. MIGRALEPSY:
- “Rare event, in which a SEIZURE HAPPENS during MIGRANOUS AURA”
- Complication of migraine
B. HEMICRANIA EPILEPTICA, POST-ICTAL HEADACHE:

10.  To date  neither the INTERNATIONAL HEADACHE SOCIETY not the ILAE
have proper documentation that HEADACHE/MIGRAINE may be the SOLE
ICTAL EPILEPTIC MANIFESTATION
 Thus, there is a newer terminology “ICTAL EPILEPTIC HEADACHE”, as the
cases, in which MIGRAINE IS THE SOLE ICTAL EPILEPTIC
MANIFESTATION!!

11. HEMICRANIA EPILEPTICA: WHAT IS
IT?
- Defined as “IPSILATERAL HEADACHE, with MIGRANIOUS FEATURES, that
occur as an ICTAL MANIFESTATION, attributing to SEIZURE DISCHARGE”
- According to a case-report published by ISLER H et al  the following features
were observed with hemicranial pain attacks:
a. Pain  coincided with seizure activity
b. Lasted for SECONDS-MINUTES
c. Headache  lasted for hours
d. According to a case report  headache lasted for most of the 20 minutes of a
recorded seizure!

12. According to ICHD-II criteria  fulfilment of any of the following criteria makes a
patient positive for HEMICRANIA EPILEPTICA(HE):
1. Headache lasting for seconds-minutes, with features of migraine
2. Patient has a partial epileptic seizure
3. Headache develops SYNCHRONOUSLY WITH THE SEIZURE, & is
IPSILATERAL to the ICTAL DISCHARGE
4. Headache resolves IMMEDIATELY AFTER THE SEIZURE

13. DIAGNOSIS:
- Diagnosis  requires SIMULTANEOUS ONSET OF HEADACHE WITH EEG-
DEMONSTRATED DISCHARGE
BACKGROUND HISTORY(CONFLICTS WITH ICHD
CRITERIA):
- First case of HE appeared in 1988
- In total, ONLY 5 PATIENTS HAVE BEEN REPORTED TO BE DIAGNOSED
WITH HEMICRANIA EPILEPTICA(ALL OVER THE WORLD)!!!!!!!
- In all the above patients  the following features were found:
a. Migraine/headache lasted longer than “seconds-minutes”
b. Migraine/headache  appeared to be the sole manifestation of a NON-
CONVULSIVE SE!

14. - When EEG of the above 5 patients were recorded  the following features were
found:
a. 4 patients  showed PARTIAL SE in the OCCIPITAL LOBES
b. Bilateral continuous spike & slow-wave discharges were reported in one
patient  indicates NCSE(Non-convulsive status epilepticus)!
- Above observations CONTRADICT with ICHD-II criteria in the following ways:
a. Headache/migraine  could be the sole manifestation of NOT ONLY OF A
PARTIAL SEIZURE, but ALSO OF A GENERALIZED NON-CONVULSIVE SE!
b. Headache could be IPSI/CONTRA-LATERAL to the ICTAL EPILEPTIFORM
DISCHARGE!!

15. BRAIN-MRI, that shows the following findings:
(A): Thickening of cortex in right-occipital lobe
(B): Restricted diffusion in right occipital cortex
(C): EEG, that shows seizure from right occipital & parietal cortex.

16. ONLY 5 CASES OF HEMICRANIA EPILEPTICA HAVE
BEEN REPORTED IN ALL
Makes this condition an extremely rare case!!!!

17. SUMMARIZED FINDINGS OF 5 CASES OF
HEMICRANIA EPILEPTICA

18. PATHOPHYSIOLOGICAL
MECHANISMS(HYPOTHESIS SUGGESTED):
- Migraine/headache  can originate at either SUBCORTICAL/CORTICAL
LEVEL
- EPILEPTIC FOCUS  usually arises CORTICALLY  can only be modulated at
SUBCORTICAL LEVEL
- Sub-clinical epileptic discharge  activates TRIGEMINOVASCULAR SYSTEM
 results in MIGRAINE/HEADACHE, without any other associated cortical
epileptic sign/symptom
- Threshold required for ONSET OF CSD(Cortical Spreading Depression)  is
LOWER than that required for an EPILEPTIC SEIZURE
- To be precise  there are higher chances of occurrence of CSD due to EPILEPTIC
DISCHARGE, RATHER THAN VICE-VERSA!!!

19.  ROLE OF CSD in MIGRAINE(CSD THEORY):
- CSD is a “wave of neuronal excitation in the CORTICAL GRAY MATTER”
- Spreads from its site of origin
- CELLULAR DEPOLARIZATION in gray matter  causes “AURA PHASE” 
activates TRIGEMINAL FIBERS  causes HEADACHE!

20. TREATMENT STRATEGIES:
- Treatment approach to this condition is controversial
- Treatments that can be used(according to case-reports) include:
1. Levetiracetam
2. Topiramate
3. Intravenous diazepam (Parisi P et al, Ghofrani et al, Belcastro V et al)
4. Phenytoin(Perucca P et al).

21. DIFFERENCES BETWEEN HE & POSTICTAL HEADACHE(ICHD-II
CRITERIA):

23. ASSESSMENT OF CURRENT THERAPY +
PROGRESS REPORTS:
1. 23/08/2017:
- Patient was referred from NOPD
- C/O headache with LOC > 15 minutes
- Treatment given includes:
A. INJ. LEVIPIL(LEVETIRACETAM):
- Dual benefits of anti-epileptic & migraine prophylaxis exploited here
- CALCIUM CHANNELOPATHY  can cause NEURONAL
HYPEREXCITABILITY  leads to headache/migraine
- Drug  inhibits NEURONAL-TYPE CALCIUM CHANNELS  exhibits
migraine prophylactic property! (Homa Sadeghian et al, Annals of Indian
Academy of Neurology)

24. 2. 24/08/2017:
- Patient was conscious & oriented
- EEG & CT(head) was done
- Levetiracetam was continued
- The following drug was added:
A. T. CLOBA 5(CLOBAZAM):
- Novel 1,5-benzodiazepine, approved by the US-FDA for the treatment of LGS in
2011
- Confers less sedative properties compared to other benzodiazepines(Marius
Pernea, Alastair G.Sutcliffe. “Clobazam and its use in Epilepsy”).

25. 3. 25/08/2017:
- Patient was conscious & oriented
- No fresh complaints recorded
- Along with continuation of Inj. Levetiracetam & T. Clobazam , the following
medication was also added:
A. T. TOPIROL(TOPIRAMATE):
- Dual advantages of anti-epileptic & anti-migraine properties exploited here
- Benefits of topiramate in seizures & migraine prevention include:
i. Drug  blocks VOLTAGE-GATED sodium & calcium channels(Zona C et al)
ii. Drug  inhibits excitatory glutamate pathway(White HS et al)
iii. Drug  enhances inhibitory activity of GABA(Qian J et al)
iv. Drug  INHIBITS CARBONIC ANHYDRASE ACTIVITY(Shank RP et al)

26. 4. 26/08/2017:
- No fresh complaints
- Same medications were continued(as of 25/08/2017)
- Patient was conscious & oriented
- Patient felt symptomatically better, & was discharged appropriately.

27. TREATMENT CHART:
T.NAME GENERIC
NAME
DOSE ROUTE
OF
ADMINIS
TRATION
DURATIO
N
DAY 1 DAY 2 DAY 3 DAY 4
INJ.
LEVIPIL
LEVETIR
ACETAM
500 mg i.v Q6H Y Y Y Y
T. CLOBA
5
CLOBAZ
AM
5 mg P/O 0-0-1 Y Y Y
T.
TOPIROL
TOPIRA
MATE
50 mg P/O HS Y Y

28. DISCHARGE SUMMARY:
- A 65 year old female patient was admitted, with H/O headache associated with
LOC, lasting for more than 15 minutes
- Such episodes occurred since 1 year
- No focal neurological deficits noted
- Clinical evaluation showed “Epileptiform dysfunction”
- She was treated with i.v Levetiracetam, during the period of hospitalization
- No fresh complaints were noted
- By the time of discharge she is symptom-free.

29. DISCHARGE ADVICE:
- T. TOPIROL (50 mg) HS
- Review after 3 weeks in Neurology OPD.

30. POINTS TO PHYSICIAN:
A. WITH RESPECT TO TREATMENT CHART:
1. NO ANTIHYPERTENSIVE PROVIDED:
- Although patient was hypertensive  no antihypertensive was administered
during the treatment course
- Patient was on T. Nicardia (10 mg), which is Nifedipine
- Most common side effects of NIFEDIPINE include headache, flushing,
constipation, swollen ankles etc., which usually resolve after a few days of
treatment.
- If above symptoms do not resolve(since patient is hypertensive & had HE) 
either taper the dose gradually & then shift over to METOPROLOL
- Another better option is using CANDESARTAN(Have good side-effect profiles, &
can be used in patients with mild HTN)!

31. 2. NO NEUROPROTECTIVES PROVIDED:
- According to EEG & discharge summary summarization  “EPILEPTIFORM
DYSFUNCTION” was observed
- 3 anti-epileptics were administered to the patient
- Yet, no neuroprotectives were provided!
- Suggestions include: Methylcobalamin, pyridoxine
- Also, since patient was on Inj. Levetiracetam  there is high risk of
neuropsychiatric issues attributed to the drug activity  in this condition,
pyridoxine is mandatory!

32. 3. DRUG INTERACTION, THAT HAS TO BE MONITORED
CLOSELY:
- Concomitant administration of TOPIRAMATE &
CLOBAZAM  increased risk of CNS effects  monitor for
increased sedation, respiratory depression!

33. B. WITH RESPECT TO DISCHARGE ADVICE:
- Absence of antihypertensive
- Absence of neuroprotectives!

34. DRUG-BASED COUNSELLING:
1. T.TOPIROL(TOPIRAMATE):
- Report to physician if there is change in visual field(visual field defects)!

35. DISEASE-BASED COUNSELLING:
1. EPSOM SALT:
- EPSOM SALT  Contains magnesium sulphate  changes psychochemical cell
relationships in the brain  reduces frequency of seizures and convulsions
- Use in the form of:
a. Epsom salt bath (2-3 times/ week)
b. Add half tsp of salt to orange juice / water  drink every morning
2. LIME:
- Popular Ayurvedic remedy
- Lime  helps improve blood circulation to brain
- Also normalizes excess calcium that may hamper brain functionality
- Use in the form of:
a. (2 tsp. lime juice + half tsp. baking soda + water)  drink daily before going to bed
b. Apply lime juice on head  massage thoroughly for a few mins.  do daily before
taking a shower

36. 3. GET ENOUGH SLEEP, AS SLEEP DEPRIVATION TRIGGERS SEIZURES
4. MANAGE STRESS AND AVOID STRESSFUL SITUATIONS
5. GINGER:
- Ginger  contains anti-inflammatory & pain relieving compounds that halt
migraine/headaches!
- Mix 1/3rd tsp. of powdered ginger into a glass of water  drink it
6. Avoid food triggers that can exacerbate/aggravate headaches
7. Keep a regular sleep pattern.

39. THANK YOU!!!!!