Elsevier

The Lancet Neurology

Volume 5, Issue 2, February 2006, Pages 148-157
The Lancet Neurology

Review
Chronic disorders with episodic manifestations: focus on epilepsy and migraine

https://doi.org/10.1016/S1474-4422(06)70348-9Get rights and content

Summary

Epilepsy and migraine are chronic neurological disorders with episodic manifestations that are commonly treated in neurological practice and frequently occur together. In this review we examine similarities and contrasts between these disorders, with focus on epidemiology and classification, temporal coincidence, triggers, and mechanistically based therapeutic overlap. This investigation draws attention to unique aspects of both epilepsy and migraine, while identifying areas of crossover in which each specialty could benefit from the experience of the other.

Introduction

Neurological chronic disorders with episodic manifestations (CDEM) are characterised by recurrent attacks of nervous system dysfunction with a return to baseline between attacks. Among the CDEM treated by neurologists, headaches (including migraine) and epilepsy are the most common, each comprising nearly 20% of outpatient neurological visits.1 Both migraine and epilepsy represent distinct families of neurological disorders with typical constellations of symptoms. Migraine is characterised by recurrent attacks of pain and associated symptoms.2 Epilepsy is characterised by recurrent attacks of positive neurological symptoms, often progressing to altered or lost consciousness, and, at times, convulsive features.3

Many challenges face the physician treating these disorders. The sensory, motor, and cognitive characteristics of migraine and epilepsy often overlap. Both disorders can present with headache. Furthermore, as migraine and epilepsy are highly comorbid, many individuals have both disorders, further complicating accurate diagnosis. Additionally, the therapeutic options for the disorders overlap.

In this review, we will examine migraine and epilepsy side by side, assessing the points of similarity, as well as the differences, between them.

Section snippets

Classification

As CDEM, both epilepsy and migraine are defined by recurrent attacks with particular features. Epilepsy is defined by recurrent unprovoked seizures encompassing both primary and secondary causes of recurrent attacks. In that sense, epilepsy is more akin to the broader category of headache than to migraine.

Both epileptic and headache disorders have established yet evolving classification systems. The International League Against Epilepsy (ILAE) provides three levels of classification. It

Epidemiology

Similar challenges are presented with the study of the epidemiology of migraine and epilepsy. A diagnosis of epilepsy, by current definition, requires at least two seizures. Migraine without aura, by definition, needs at least five attacks. Rules must be established for definition of incidence (is it the time of the first or fifth migraine attack?) and prevalence. Prevalence is usually defined by the occurrence of at least one attack in the previous year.

Treatment

Epilepsy and migraine are fundamentally different disorders, mandating significant differences in approach to treatment. There is a striking underlying mechanistic similarity common to both disorders, neuronal hyperexcitability.62, 63 Many of the treatments for both disorders target this characteristic. This therapeutic overlap allows each specialty to learn lessons from the other, both in terms of specific treatments and therapeutic strategies.

Conclusions

Epilepsy and migraine are CDEM linked by their symptom profiles, comorbidity, and treatment. The presence of one disorder increases the probability that the other is also present. Because of its greater prevalence, migraine is expected in almost a quarter of patients with epilepsy, whereas epilepsy is expected in 1–2% of migraine sufferers.

Much effort has been devoted to descriptive aspects of each disorder, including development of classification schemes, epidemiological investigations, and

Search strategy and selection criteria

Only articles published in English were reviewed. Data were searched during a 4 month period between March and June, 2005, on PubMed with the following keywords: epilepsy, migraine, antiepileptic drugs, classification, incidence, prevalence, neuromodulation, catamenial epilepsy, temporal lobectomy, vagal nerve stimulation, patent foramen ovale, valproate, topirimate. Papers from 1985 onwards were searched. Additionally, many articles were chosen from the extensive files of the authors.

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