Curr Pain Headache Rep (2014) 18:402 DOI 10.1007/s11916-013-0402-3
CHILDHOOD AND ADOLESCENT HEADACHE (S EVERS, SECTION EDITOR)
Migraine and Epilepsy in the Pediatric Population Christopher B. Oakley & Eric H. Kossoff
Published online: 6 February 2014 # Springer Science+Business Media New York 2014
Abstract Individually, childhood epilepsy and migraine are two of the most common conditions seen in pediatric neurology. What complicates matters is that there can be marked similarities between migraine and epilepsy as well as a variety of underlying conditions that predispose children to both seizures and headache. Thus, separating epilepsy from migraine may not be easy, but can be done with a detailed history as well as timely use of ancillary testing. Once children have been diagnosed with epilepsy, migraine, or both, treatment options become essential in attempts to manage these common, yet often disabling, neurological conditions. Acute interventions tend to be condition specific while preventative options may overlap for migraine and epilepsy. In the following review, we will discuss the epidemiology of childhood epilepsy and headache, the association between them, as well as how to differentiate epilepsy from migraine. Treatment strategies will follow before concluding with a discussion on prognosis. Keywords Migraine . Headache . Pediatric . Adolescents . Seizure . Epilepsy
Introduction Individually, migraine and epilepsy are two of the most common and significant neurological concerns within the pediatric population. They each carry a marked personal as This article is part of the Topical Collection on Childhood and Adolescent Headache
C. B. Oakley (*) : E. H. Kossoff Departments of Neurology and Pediatrics, Johns Hopkins University School of Medicine, 200 North Wolfe Street, Suite 2158, Baltimore, MD 21287, USA e-mail: [email protected]
well as societal impact, especially if not adequately addressed. Furthermore, when either migraine or epilepsy is present in an individual, the other is more likely to be present; this is especially true when looking at migraine prevalence in epilepsy patients [1, 2•, 3•]. This is not surprising given that these two common pediatric neurological conditions often share many characteristics and at times differentiating between them can be difficult. There are, however, clinical and historical aspects for each that may help distinguish between them as well as investigative modalities such as EEG that may be useful in separating the two. Once diagnosed, treatment options for each can be different yet similar. From an acute perspective, the treatments generally differ reflecting the differences in pathophysiology and pharmacological approach to alleviating a migraine or a seizure. However, from a prophylactic perspective, options, both conservative and pharmacological, often overlap. While the prognosis for both childhood epilepsy and migraine is typically favorable, what is different is the specific goal of treatment with complete remission is generally not expected with migraine, whereas with epilepsy, this may be realistic. This is echoed by the fact that a variety of childhood epilepsy may resolve spontaneously, often around puberty, whereas migraines tend to worsen with puberty, especially in adolescent girls [4–6]. In this review, we first discuss the epidemiology of childhood epilepsy and primary headaches. We then review the association, including the genetic link, between epilepsy and migraine. Next, we discuss how to distinguish epilepsy from migraine both historically and with the aid of diagnostic modalities while also discussing predisposing conditions for both epilepsy and migraines. We then review shared treatment strategies for childhood epilepsy and migraine before concluding with a brief discussion on prognosis.
402, Page 2 of 12
Epidemiology of Epilepsy and Headache in Childhood Epilepsy, defined as recurrent unprovoked seizures in a patient separated by at least 24 h, is a relatively common condition in children and adolescents. Epilepsy itself has a recently updated lifetime prevalence of approximately 4 % with about 1 % of adults suffering from epilepsy at a given time [7•]. Conversely, the prevalence rates for pediatric epilepsy are reported to be 0.4 % to 1.0 % [8–10].Interestingly, epilepsy is more common in infancy and toddlerhood as well as in the elderly as compared to school-age children and adolescents [10].Adolescence, however, does seem to play a role in childhood epilepsy as there can be improvement seen around the time of puberty, especially for some epilepsy syndromes such as absence and benign rolandic epilepsy [6]. Gender-specific differences in the prevalence of epilepsy, however, are not typically seen. Most studies do not note a difference in seizure prevalence with regards to gender; when it has been shown, the difference only slightly favors boys with a 0.1 – 0.2 % higher prevalence of epilepsy as compared to girls [10]. Although epilepsy is common, headaches are even more prevalent. School-age children under 10 years of age have an overall headache prevalence reported as high as 56 %. The prevalence continues to increase with age such that, by midadolescence to early adulthood, the prevalence of headache can be as high as 91 % [4, 11–15]. Similar to general headaches, the prevalence of migraines increases with age as follows: children up to 7 years old: 3 % or less; children 11 years old: 11 %; and children passing through adolescence (approximately 13 – 18 years old): as high as 23 – 28 % [16–22]. Unlike epilepsy, there does seem to be a gender-specific difference in pediatric headache and migraine, especially around puberty. Although prior to puberty, boys are marginally favored to have headaches over girls, when all of pediatrics is considered, girls have 53 % higher odds overall [4, 23, 24]. With regard to migraine, prevalence in girls has been reported to be approximately 10 % while only 6 % in boys [4]. Following puberty this difference is exaggerated as post pubescent young women account for nearly 75 % of new migraine patients [5, 25, 26]. From a personal and societal impact, both epilepsy and migraine can have a significant (and perhaps equally negative) influence on quality of life. Migraine is the most common headache disorder leading to medical evaluations. This is often due to the lower quality of life that childhood migraineurs endure with disability scores comparable to those who have childhood cancer and arthritis [27]. Similarly, epilepsy has been linked with a significant decrease in quality of life with disability similar to individuals with arthritis, cancer, diabetes, and heart disease.
Curr Pain Headache Rep (2014) 18:402
Furthermore, children and adolescents with epilepsy have a reported lower self-esteem and thus a greater risk for social concerns and metal health problems [10]. From a financial standpoint, childhood migraine is associated with a substantial burden, with pediatric migraine healthcare costs estimated at over $11 billion per year by the World Health Organization [28]. Epilepsy, too, is associated with fiscal burden with a lifetime cost of incident cases of epilepsy estimated at over $11 billion and a yearly cost of prevalent cases estimated at $12.5 billion [10].
The Association Between Pediatric Epilepsy and Migraine There is often an overlap between epilepsy and migraine, and sometimes it may even be difficult to differentiate between them. Not only is this due to symptom similarities, but also to the fact that many patients have both conditions simultaneously. Specifics of migraine and epilepsy classification are beyond the scope of review but details can be found with regards to migraine in the International Classification of Headache Disorders, 3rd edition (beta version) (ICHD-3 beta) and for epilepsy from the International League Against Epilepsy (ILAE) Commission on Classification and Terminology. Of note, migraine and epilepsy are classified into specific subtypes or syndromes based primarily on history and many have identified or presumed genetic etiologies [29, 30]. Genetic Link Between Migraine and Epilepsy It has been reported that patients with either epilepsy or migraine are more likely to have the other disorder (see Table 1) [1]. In migraine patients, there may be an increase in epilepsy as compared to the general population as noted in one study where 5.9 % of patients with migraine had recurrent seizures (as compared to the recently reported 3.8 % prevalence rate of epilepsy in the overall population) [7•, 31]. A stronger association is seen when considering epilepsy patients and their prevalence of migraine. As compared to the most common headache type (TTH), migraine is reported to be 4.5 times as likely to develop when epilepsy is present [32]. Older reports note that 15 % to 20 % of patients with epilepsy have migraine compared to 12 % of the general population [33–35]. In a recent pediatric study, 25 % of children with epilepsy met criteria for migraine and for those in adolescence (12 – 17 years old) the prevalence rose to 32 % [2•]. Additionally, in 2013 Kanemura et. al. noted that 35 % of epilepsy children they surveyed had headaches overall and 21 % had migraine specifically associated with their seizures, with most occurring post-ictally [36•]. Similarly, in the Epilepsy Phenome Genome Project (EPGP) cohort (12 years old or older), 24 % of those with epilepsy also had migraine (9 % migraine with aura) [3•].
Pro, CS, Multicenter Clin Trial
Retro, Long, Multicenter, Clin Trial as compared to historically reported GP data
Retro, CS, Clin Trial
Pinhas-Hamiel (2008)
Hershey (2009)
Kinik (2010)
Pakalnis (2012)
Retro, CS, Clin Trial as compared to historical GP norms from NHANES
Robberstad (2010) Pro, CS, GP Trial of adolescents in school
Study Design (Database)
Author (year)
Source: Junior High & High Schools in Norway Total: 5588 Source: Ped HA Clinic in Columbus, Ohio Size: 925 Total HA participants (Any Type): 925 Total EM & p-EM: 532 Total TTH & p-TTH: 141 Total CDH: 252
Total HA participants (Any HA Type): 1591 Total Mig: 392 Total TTH: 950
BMI ≥5th 85th % included children as young as 2 years. When re-calculations are done excluding children age 2 – 5 years making the gen pop more representative of study population the percentiles become 17.4 % & 33.8 %, respectively.
NR The OR of recurrent HA were 40 % greater in those whose BMI (13-18) was above the over-wt cutoff (OR 1.4, CI 1.2-1.6, p
CHILDHOOD AND ADOLESCENT HEADACHE (S EVERS, SECTION EDITOR)
Migraine and Epilepsy in the Pediatric Population Christopher B. Oakley & Eric H. Kossoff
Published online: 6 February 2014 # Springer Science+Business Media New York 2014
Abstract Individually, childhood epilepsy and migraine are two of the most common conditions seen in pediatric neurology. What complicates matters is that there can be marked similarities between migraine and epilepsy as well as a variety of underlying conditions that predispose children to both seizures and headache. Thus, separating epilepsy from migraine may not be easy, but can be done with a detailed history as well as timely use of ancillary testing. Once children have been diagnosed with epilepsy, migraine, or both, treatment options become essential in attempts to manage these common, yet often disabling, neurological conditions. Acute interventions tend to be condition specific while preventative options may overlap for migraine and epilepsy. In the following review, we will discuss the epidemiology of childhood epilepsy and headache, the association between them, as well as how to differentiate epilepsy from migraine. Treatment strategies will follow before concluding with a discussion on prognosis. Keywords Migraine . Headache . Pediatric . Adolescents . Seizure . Epilepsy
Introduction Individually, migraine and epilepsy are two of the most common and significant neurological concerns within the pediatric population. They each carry a marked personal as This article is part of the Topical Collection on Childhood and Adolescent Headache
C. B. Oakley (*) : E. H. Kossoff Departments of Neurology and Pediatrics, Johns Hopkins University School of Medicine, 200 North Wolfe Street, Suite 2158, Baltimore, MD 21287, USA e-mail: [email protected]
well as societal impact, especially if not adequately addressed. Furthermore, when either migraine or epilepsy is present in an individual, the other is more likely to be present; this is especially true when looking at migraine prevalence in epilepsy patients [1, 2•, 3•]. This is not surprising given that these two common pediatric neurological conditions often share many characteristics and at times differentiating between them can be difficult. There are, however, clinical and historical aspects for each that may help distinguish between them as well as investigative modalities such as EEG that may be useful in separating the two. Once diagnosed, treatment options for each can be different yet similar. From an acute perspective, the treatments generally differ reflecting the differences in pathophysiology and pharmacological approach to alleviating a migraine or a seizure. However, from a prophylactic perspective, options, both conservative and pharmacological, often overlap. While the prognosis for both childhood epilepsy and migraine is typically favorable, what is different is the specific goal of treatment with complete remission is generally not expected with migraine, whereas with epilepsy, this may be realistic. This is echoed by the fact that a variety of childhood epilepsy may resolve spontaneously, often around puberty, whereas migraines tend to worsen with puberty, especially in adolescent girls [4–6]. In this review, we first discuss the epidemiology of childhood epilepsy and primary headaches. We then review the association, including the genetic link, between epilepsy and migraine. Next, we discuss how to distinguish epilepsy from migraine both historically and with the aid of diagnostic modalities while also discussing predisposing conditions for both epilepsy and migraines. We then review shared treatment strategies for childhood epilepsy and migraine before concluding with a brief discussion on prognosis.
402, Page 2 of 12
Epidemiology of Epilepsy and Headache in Childhood Epilepsy, defined as recurrent unprovoked seizures in a patient separated by at least 24 h, is a relatively common condition in children and adolescents. Epilepsy itself has a recently updated lifetime prevalence of approximately 4 % with about 1 % of adults suffering from epilepsy at a given time [7•]. Conversely, the prevalence rates for pediatric epilepsy are reported to be 0.4 % to 1.0 % [8–10].Interestingly, epilepsy is more common in infancy and toddlerhood as well as in the elderly as compared to school-age children and adolescents [10].Adolescence, however, does seem to play a role in childhood epilepsy as there can be improvement seen around the time of puberty, especially for some epilepsy syndromes such as absence and benign rolandic epilepsy [6]. Gender-specific differences in the prevalence of epilepsy, however, are not typically seen. Most studies do not note a difference in seizure prevalence with regards to gender; when it has been shown, the difference only slightly favors boys with a 0.1 – 0.2 % higher prevalence of epilepsy as compared to girls [10]. Although epilepsy is common, headaches are even more prevalent. School-age children under 10 years of age have an overall headache prevalence reported as high as 56 %. The prevalence continues to increase with age such that, by midadolescence to early adulthood, the prevalence of headache can be as high as 91 % [4, 11–15]. Similar to general headaches, the prevalence of migraines increases with age as follows: children up to 7 years old: 3 % or less; children 11 years old: 11 %; and children passing through adolescence (approximately 13 – 18 years old): as high as 23 – 28 % [16–22]. Unlike epilepsy, there does seem to be a gender-specific difference in pediatric headache and migraine, especially around puberty. Although prior to puberty, boys are marginally favored to have headaches over girls, when all of pediatrics is considered, girls have 53 % higher odds overall [4, 23, 24]. With regard to migraine, prevalence in girls has been reported to be approximately 10 % while only 6 % in boys [4]. Following puberty this difference is exaggerated as post pubescent young women account for nearly 75 % of new migraine patients [5, 25, 26]. From a personal and societal impact, both epilepsy and migraine can have a significant (and perhaps equally negative) influence on quality of life. Migraine is the most common headache disorder leading to medical evaluations. This is often due to the lower quality of life that childhood migraineurs endure with disability scores comparable to those who have childhood cancer and arthritis [27]. Similarly, epilepsy has been linked with a significant decrease in quality of life with disability similar to individuals with arthritis, cancer, diabetes, and heart disease.
Curr Pain Headache Rep (2014) 18:402
Furthermore, children and adolescents with epilepsy have a reported lower self-esteem and thus a greater risk for social concerns and metal health problems [10]. From a financial standpoint, childhood migraine is associated with a substantial burden, with pediatric migraine healthcare costs estimated at over $11 billion per year by the World Health Organization [28]. Epilepsy, too, is associated with fiscal burden with a lifetime cost of incident cases of epilepsy estimated at over $11 billion and a yearly cost of prevalent cases estimated at $12.5 billion [10].
The Association Between Pediatric Epilepsy and Migraine There is often an overlap between epilepsy and migraine, and sometimes it may even be difficult to differentiate between them. Not only is this due to symptom similarities, but also to the fact that many patients have both conditions simultaneously. Specifics of migraine and epilepsy classification are beyond the scope of review but details can be found with regards to migraine in the International Classification of Headache Disorders, 3rd edition (beta version) (ICHD-3 beta) and for epilepsy from the International League Against Epilepsy (ILAE) Commission on Classification and Terminology. Of note, migraine and epilepsy are classified into specific subtypes or syndromes based primarily on history and many have identified or presumed genetic etiologies [29, 30]. Genetic Link Between Migraine and Epilepsy It has been reported that patients with either epilepsy or migraine are more likely to have the other disorder (see Table 1) [1]. In migraine patients, there may be an increase in epilepsy as compared to the general population as noted in one study where 5.9 % of patients with migraine had recurrent seizures (as compared to the recently reported 3.8 % prevalence rate of epilepsy in the overall population) [7•, 31]. A stronger association is seen when considering epilepsy patients and their prevalence of migraine. As compared to the most common headache type (TTH), migraine is reported to be 4.5 times as likely to develop when epilepsy is present [32]. Older reports note that 15 % to 20 % of patients with epilepsy have migraine compared to 12 % of the general population [33–35]. In a recent pediatric study, 25 % of children with epilepsy met criteria for migraine and for those in adolescence (12 – 17 years old) the prevalence rose to 32 % [2•]. Additionally, in 2013 Kanemura et. al. noted that 35 % of epilepsy children they surveyed had headaches overall and 21 % had migraine specifically associated with their seizures, with most occurring post-ictally [36•]. Similarly, in the Epilepsy Phenome Genome Project (EPGP) cohort (12 years old or older), 24 % of those with epilepsy also had migraine (9 % migraine with aura) [3•].
Pro, CS, Multicenter Clin Trial
Retro, Long, Multicenter, Clin Trial as compared to historically reported GP data
Retro, CS, Clin Trial
Pinhas-Hamiel (2008)
Hershey (2009)
Kinik (2010)
Pakalnis (2012)
Retro, CS, Clin Trial as compared to historical GP norms from NHANES
Robberstad (2010) Pro, CS, GP Trial of adolescents in school
Study Design (Database)
Author (year)
Source: Junior High & High Schools in Norway Total: 5588 Source: Ped HA Clinic in Columbus, Ohio Size: 925 Total HA participants (Any Type): 925 Total EM & p-EM: 532 Total TTH & p-TTH: 141 Total CDH: 252
Total HA participants (Any HA Type): 1591 Total Mig: 392 Total TTH: 950
BMI ≥5th 85th % included children as young as 2 years. When re-calculations are done excluding children age 2 – 5 years making the gen pop more representative of study population the percentiles become 17.4 % & 33.8 %, respectively.
NR The OR of recurrent HA were 40 % greater in those whose BMI (13-18) was above the over-wt cutoff (OR 1.4, CI 1.2-1.6, p
![[Migraine and epilepsy].](/assets/img/hold.png)
