Acta neurol. scandinav. 54, 204-206, 1976
EEG Department, Section of Neurological Sciences, The London Hospital, London.
A POSSIBLE ASSOCIATION BETWEEN MIGRAINE AND POST-OPERATIVE EPILEPSY IN PATIENTS WITH INTRACRANIAL ANEURYSM
R . J . Cabral and I). F . Scott ABSTHACT There are various overlaps between migraine and epilepsy and another is suggested here in patients who develop seizures following surgery for intracranial aneurysm. Of a group of 37 who had this complication, three with a personal history of migraine and three with a family history of the disorder all developed post-operative seizures.
During a follow-up study of patients with ruptured intracranial aneurysms neurosurgically treated, a n association between migraine and post-operative epilepsy emergcd. Here, these findings will be briefly presented.
Materials and methods One hundred and sixty-eight patients who underwent surgery for ruptured intracranial aneurysm a t the London Hospital from 1945 to 1975 were followed up for, on average, 7 years. There were three female patients, mean age 50 years, with a personal history of migraine. All three had an ipsilateral aneurysm, either on the posterior communicating artery (two patients) o r on the internal carotid artery (one patient). They had had frequent ophthalmoplegic migrainous attacks before surgery. Another three patients had a family history of migraine. Two of them were male and one female, average age 23 years. They had either a middle cerebral artery aneurysm (two patients) o r a n anterior cerebral artery aneurysm (one patient). A11 six patients were treated for ruptured intracranial aneurysm by the direct surgical approach, with clipping o r wrapping of the aneurysm.
Results While the incidence of post-operative epilepsy among the whole group of 168 patients who underwent surgery was 22 per cent (37 patients), all six cases under consideration because of migraine developed post-operative seizures. In the total series, posterior communicating artery o r internal carotid artery aneurysms occurred in 50 instances and eight of these patients developed post-operative epilepsy. Three such patients had both pre-operative migraine and post-operative seizuresa statistically significant association (see Tahle 1). There were, in the whole group, 8 4 patients with middle cerebral, anterior communicating artery or anterior cerebral
Table 1. Coincidence of migraine and post-operative epilepsy in a series of 168 pat ients with intracranial aneurysm. Migraine and postoperative epilepsy by site of aneurysm
No. of patients
1)
Posterior communicating internal carotid arteries (total) a ) With post-operative epilepsy b) Without post-operative epilepsy c ) With migraine and post-operative epilepsy d) With migraine and without post-operative epiIepsy
50 8 42 3 ** 0
2)
Middle cerebral or anterior communicating o r anterior cerebral arteries (total) a) With post-operative epilepsy b ) Without post-operative epilepsy c) With history of migraine and post-operative epilepsy d) With history of migraine and without post-operative epilepsy
84 27 57 3 ' 0
f f
Chi-square = 7.4; P = 0.01 (one-tailed test). Chi-square = 3.2; P = 0.05 (one-tailed test).
artery aneurysms and 27 cases in this group developed post-operative epilepsy. Three of these patients had a family history of migraine, again a statistically significant association (Table 1 ) . Discussion The occurrence of persistently unilateral migraine in patients who are subsequently shown to have intra-cerebral aneurysm, is well known (Meadows 1951, Walton 1956) but the proportion of all migraine sufferers with this coincidence is small. Thus, Lance (1969) bas suggested that it occurs in about 5 per cent of the cases, a figure which is somewhat higher than the incidence of 2 per cent i n the present series. However, the current investigation is mainly concerned with the association of migraine and epilepsy and the findings here are further evidence that there may be some common underlying factors i n both disorders. Other links between epilepsy and migraine have emerged from various studies. Thus, epilepsy is known to occur more commonly i n patients with migraine than would be expected by chance (Slatter 1968, Hockadav & Whiffy 1969). Also EEG abnormalities found in migrainous subjects are similar to those in the inter-ictal EEGs of epileptic patients (Slafter 1968). Recently, Scott et al. (1972) have shown that these preexisting EEG abnormalities were activated by the oral administration of tyramine to patients with both migraine and epilepsy. At a more theoretical level an association between the rate of advance of scotomas across the visual field i n migraine and the progression of the seizure i n certain types of epilepsy have been noted to be similar i n timing to the spreading depression of Lea0 (1944). Therefore, certain similarities in the pathogenesis of these conditions have been suggested by several authors (Milner 1958, Marshall 1959, Basser 1969). The results presented here indicate that patients suffering from migraine and those with a family history of the disorder are significantly more likely to develop epilepsy if they sustain brain trauma as a result of surgical interference. The
reason why epilepsy occurs i s unknown b u t it supports the view t h a t there is a definite overlap between t h e two paroxysmal disorders, migraine and epilepsy.
.4cknowledgements
We wish to t h a n k Mr. T. T. King and Professor E. S. Watkins of t h e neurosurgical department for allowing us to study t h e case notes of their patients. References Basser, L. D. (1969) : The relation of migraine and epilepsy. Brain 92, 285-300.Hocltaday, J. M. & C. W. N. Whitty (1969): Factors determining the electroencephalogram i n migraine: A study of 560 patients, according to clinical type of J. W. (1969) : The Mechanism and Management migraine. Brain 92, 769-788.-Lance, of Headache. Butterworths, London.-Leao, A. A. P. (1944) : Spreading depression of activity in the cerebral cortex. J. Neurophysiol. 7, 359-390.-Marshall, W. H. (1959) : Spreading cortical depression of Leao. Physiol. Rev. 39, 239-279.-Meadows, S. P. (1951): Intracranial aneurysm. Modern Trends i n Neurology, ed. A. Feiling. Butterworth, London.-Milner, P. M. (1958) : A possible correspondence between scotomas of migraine and spreading depression of Leao. Electroenceph. clin. Neurophysiol. 10, 705.-Scott, D. F., A. Moffett & M. Swash (1972): Observations o n the relationship of migraine a n d epilepsy. An electroencephalographic, psychological and clinical study using oral tyramine. Epilepsia 13, 365-375.-Slatter, A. M. (1968) : Some clinical and EEG findings i n patients w i t h migraine. Brain 91, 85-98.-Walton, J. N. (1956) : Subarachnoid Haemorrhage. E. & S. Livingstone, Edinburgh. Received J a n u a r y 5, 1976.
Dr. D. F . Scott, The EEG Department, The London Hospital, Whitechapel, London E.l. 1BB. England.
EEG Department, Section of Neurological Sciences, The London Hospital, London.
A POSSIBLE ASSOCIATION BETWEEN MIGRAINE AND POST-OPERATIVE EPILEPSY IN PATIENTS WITH INTRACRANIAL ANEURYSM
R . J . Cabral and I). F . Scott ABSTHACT There are various overlaps between migraine and epilepsy and another is suggested here in patients who develop seizures following surgery for intracranial aneurysm. Of a group of 37 who had this complication, three with a personal history of migraine and three with a family history of the disorder all developed post-operative seizures.
During a follow-up study of patients with ruptured intracranial aneurysms neurosurgically treated, a n association between migraine and post-operative epilepsy emergcd. Here, these findings will be briefly presented.
Materials and methods One hundred and sixty-eight patients who underwent surgery for ruptured intracranial aneurysm a t the London Hospital from 1945 to 1975 were followed up for, on average, 7 years. There were three female patients, mean age 50 years, with a personal history of migraine. All three had an ipsilateral aneurysm, either on the posterior communicating artery (two patients) o r on the internal carotid artery (one patient). They had had frequent ophthalmoplegic migrainous attacks before surgery. Another three patients had a family history of migraine. Two of them were male and one female, average age 23 years. They had either a middle cerebral artery aneurysm (two patients) o r a n anterior cerebral artery aneurysm (one patient). A11 six patients were treated for ruptured intracranial aneurysm by the direct surgical approach, with clipping o r wrapping of the aneurysm.
Results While the incidence of post-operative epilepsy among the whole group of 168 patients who underwent surgery was 22 per cent (37 patients), all six cases under consideration because of migraine developed post-operative seizures. In the total series, posterior communicating artery o r internal carotid artery aneurysms occurred in 50 instances and eight of these patients developed post-operative epilepsy. Three such patients had both pre-operative migraine and post-operative seizuresa statistically significant association (see Tahle 1). There were, in the whole group, 8 4 patients with middle cerebral, anterior communicating artery or anterior cerebral
Table 1. Coincidence of migraine and post-operative epilepsy in a series of 168 pat ients with intracranial aneurysm. Migraine and postoperative epilepsy by site of aneurysm
No. of patients
1)
Posterior communicating internal carotid arteries (total) a ) With post-operative epilepsy b) Without post-operative epilepsy c ) With migraine and post-operative epilepsy d) With migraine and without post-operative epiIepsy
50 8 42 3 ** 0
2)
Middle cerebral or anterior communicating o r anterior cerebral arteries (total) a) With post-operative epilepsy b ) Without post-operative epilepsy c) With history of migraine and post-operative epilepsy d) With history of migraine and without post-operative epilepsy
84 27 57 3 ' 0
f f
Chi-square = 7.4; P = 0.01 (one-tailed test). Chi-square = 3.2; P = 0.05 (one-tailed test).
artery aneurysms and 27 cases in this group developed post-operative epilepsy. Three of these patients had a family history of migraine, again a statistically significant association (Table 1 ) . Discussion The occurrence of persistently unilateral migraine in patients who are subsequently shown to have intra-cerebral aneurysm, is well known (Meadows 1951, Walton 1956) but the proportion of all migraine sufferers with this coincidence is small. Thus, Lance (1969) bas suggested that it occurs in about 5 per cent of the cases, a figure which is somewhat higher than the incidence of 2 per cent i n the present series. However, the current investigation is mainly concerned with the association of migraine and epilepsy and the findings here are further evidence that there may be some common underlying factors i n both disorders. Other links between epilepsy and migraine have emerged from various studies. Thus, epilepsy is known to occur more commonly i n patients with migraine than would be expected by chance (Slatter 1968, Hockadav & Whiffy 1969). Also EEG abnormalities found in migrainous subjects are similar to those in the inter-ictal EEGs of epileptic patients (Slafter 1968). Recently, Scott et al. (1972) have shown that these preexisting EEG abnormalities were activated by the oral administration of tyramine to patients with both migraine and epilepsy. At a more theoretical level an association between the rate of advance of scotomas across the visual field i n migraine and the progression of the seizure i n certain types of epilepsy have been noted to be similar i n timing to the spreading depression of Lea0 (1944). Therefore, certain similarities in the pathogenesis of these conditions have been suggested by several authors (Milner 1958, Marshall 1959, Basser 1969). The results presented here indicate that patients suffering from migraine and those with a family history of the disorder are significantly more likely to develop epilepsy if they sustain brain trauma as a result of surgical interference. The
reason why epilepsy occurs i s unknown b u t it supports the view t h a t there is a definite overlap between t h e two paroxysmal disorders, migraine and epilepsy.
.4cknowledgements
We wish to t h a n k Mr. T. T. King and Professor E. S. Watkins of t h e neurosurgical department for allowing us to study t h e case notes of their patients. References Basser, L. D. (1969) : The relation of migraine and epilepsy. Brain 92, 285-300.Hocltaday, J. M. & C. W. N. Whitty (1969): Factors determining the electroencephalogram i n migraine: A study of 560 patients, according to clinical type of J. W. (1969) : The Mechanism and Management migraine. Brain 92, 769-788.-Lance, of Headache. Butterworths, London.-Leao, A. A. P. (1944) : Spreading depression of activity in the cerebral cortex. J. Neurophysiol. 7, 359-390.-Marshall, W. H. (1959) : Spreading cortical depression of Leao. Physiol. Rev. 39, 239-279.-Meadows, S. P. (1951): Intracranial aneurysm. Modern Trends i n Neurology, ed. A. Feiling. Butterworth, London.-Milner, P. M. (1958) : A possible correspondence between scotomas of migraine and spreading depression of Leao. Electroenceph. clin. Neurophysiol. 10, 705.-Scott, D. F., A. Moffett & M. Swash (1972): Observations o n the relationship of migraine a n d epilepsy. An electroencephalographic, psychological and clinical study using oral tyramine. Epilepsia 13, 365-375.-Slatter, A. M. (1968) : Some clinical and EEG findings i n patients w i t h migraine. Brain 91, 85-98.-Walton, J. N. (1956) : Subarachnoid Haemorrhage. E. & S. Livingstone, Edinburgh. Received J a n u a r y 5, 1976.
Dr. D. F . Scott, The EEG Department, The London Hospital, Whitechapel, London E.l. 1BB. England.
