Maria Giuseppina Ledda

Pure epileptic headache and related manifestations: a video-EEG report and discussion of terminology

We present the first video-EEG recording of episodes of “epileptic headache”. The case reported is that of a 9-year-old girl with brief episodes (of a few minutes) of severe frontal headache, which corresponded to the presence of concurrent spikes and slowwaves, starting in the right temporal area. A dysplastic lesion of the right temporal lobe was observed by MRI and the patient received surgery, with subsequent disappearance of headaches. This case highlights ictal EEG as the main diagnostic tool for epileptic headache. We discuss the terminology regarding this type of manifestation and believe that cases without subsequent epileptic manifestations, as in the present case, should be more appropriately referred to as “pure ictal epileptic headache” or simply “pure epileptic headache”.

Effectiveness and safety of antipsychotics in early onset psychoses: A long-term comparison

The effectiveness and safety of various antipsychotics was evaluated in a long-term study on 47 patients, 29 with schizophrenia and 18 with schizoaffective disorder, aged 10 to 17 years (mean 15.5) at onset. Follow-up ranged from 3 years (all 47 patients) to 11 years (19 patients). Data were collected on the following antipsychotics: haloperidol, risperidone, olanzapine, quetiapine, aripiprazole and clozapine. Cases with positive response were significantly more frequent with clozapine as compared to haloperidol, risperidone and olanzapine. Risperidone was significantly better than haloperidol at the 3-year follow-up. A comparison of the degree of clinical improvement evaluated with PANSS and CGI in patients treated with drugs in subsequent periods showed clozapine led to significantly greater improvement as compared to haloperidol, risperidone and olanzapine, and risperidone as compared to haloperidol. Data on long-term functioning significantly favored clozapine as compared to all the other drugs. Discontinuation due to side effects involved 20% patients with clozapine, lower percentage with the other drugs. The results of this study on early-onset schizophrenic and schizoaffective disorders confirm that even in the long-term, clozapine is more effective than haloperidol, risperidone and olanzapine. Despite a relevant incidence of adverse effects, clozapine seems to have unique effectiveness in treating children and adolescents with early-onset schizophrenic disorders.

Headache, migraine and epileptic seizures. A comment on the types of association and on terminology.

Dear Sir, We read with interest the letter by Parisi et al. (1) on the ‘‘Ictal Epileptic Headache’’ (IEH) and we believe that it stimulates a further discussion on the topic, implying suggestions for the new classifications of both headache and epilepsy. As stated by Parisi et al. (1), ‘‘ictal epileptic headache’’ (which could also be called simply ‘‘epileptic headache’’) is a real although rare condition, in which headache is the sole or largely predominant symptom, and regarding which not more than 11 well-documented cases have been published (2). We agree with the proposal by Parisi et al. (1) of an inclusion of this situation in a classification of headache linked to seizures. We suggest, however, some modifications to their proposal. The first one concerns the criterion C: The necessity of a seizure pattern on the electroencephalography (EEG) concomitant with headache is inherent in the concept of ‘‘epileptic headache.’’ However, at least two cases have been reported (3,4) in which the scalp EEG was silent and epileptic abnormalities were detected only with deep electrode (case two (3)) or deep/stereo-EEG (case one (4)). Therefore we suggest modifying the text to ‘‘. . .discharges on scalp or deep EEG concomitantly with headache.’’ Moreover, we do not think criteria B and D are necessary. Concerning D, we think the response to treatment cannot be a criterion, since a seizure could not respond to antiepileptic treatment. Concerning B, Parisi et al. (1) probably added this definition to differentiate it from the ‘‘Hemicrania epileptica’’ (7.6.1 of the International Classification of Headache Disorders-II (ICHD-2) classification). ‘‘Hemicrania epileptica,’’ however, is a condition that we think needs further discussion. In the literature we found that only Isler et al. (5) reported this condition. No further reports have been published in about 25 years, raising some suspicion as to its existence. Moreover, if we simply eliminate from the definition of ‘‘Hemicrania epileptica’’ the term ‘‘partial’’ inserted in the criterion B (‘‘. . .partial epileptic seizure’’) and ‘‘ipsilateral’’ inserted in the criterion C (‘‘. . .it is ipsilateral to the ictal discharge’’), we obtain a definition that fits perfectly with that of ‘‘epileptic headache’’ or ‘‘ictal epileptic headache.’’ Therefore, we suggest that ‘‘Hemicrania epileptica’’ be substituted by ‘‘Epileptic headache’’ or ‘‘Ictal epileptic headache’’ (the term ‘‘ictal’’ is not strictly necessary since an epileptic phenomenon is per se ictal). IEH or epileptic headache is therefore a condition of head pain lasting seconds or minutes or hours (‘‘status epilepticus’’), with various locations and without other manifestations, with EEG (scalp or deep) abnormalities of various type, strictly contemporary to pain (onset and cessation contemporary to head pain). Lesions causing this can be located in different brain areas (2), or there may be no visible lesion. We could also differentiate the cases of IEH that may be followed by other epileptic manifestations (motor/sensory/autonomic) from ‘‘pure’’ IEH, characterized by only head pain, possibly with minor manifestations (2). In the same patient, in the course of the disorder, episodes of ‘‘pure’’ IEH may alternate with episodes followed by other epileptic manifestations.

Pressure-painful scalp arteries in children and adolescents suffering from migraine.

Objective: This study aimed to evaluate the presence of pressure-painful scalp arteries in children and adolescents with migraine. Materials and methods: Pressure-painful points on scalp arteries were searched in 130 consecutive children (6–12 years old) and adolescents (>13 years old) affected with migraine, 89 females and 41 males, and in 40 age-matched controls. Results: In the absence of a migraine episode, we examined 76 patients: 54 (71.1%) reported one or more pressure-painful arteries and 22 reported none. Of the 40 controls, pressure-painful arteries were present in 11, with a highly significant difference (p < 0.0001). During a migraine attack, of the 54 patients examined, 43 (79.6 %) reported one or more pressure-painful arteries and 11 reported none. The arteries most frequently painful were the frontal branch and the superficial temporal artery. Conclusions: Scalp arteries are frequently painful on pressure in children and adolescents with migraine, both in the absence of and during a migraine attack. Painful arteries suggest hypersensitivity of periarterial nociceptive afferents.

Compression of Superficial Temporal Arteries by a Handmade Device: A Simple Way to Block or Attenuate Migraine Attacks in Children and Adolescents

Because a prolonged compression of the major scalp arteries blocks migraine attacks in a substantial number of patients, we studied the effect of the use of a simple handmade device in blocking an incoming headache attack in children and adolescents. Thirty-seven consecutive ambulatory patients were instructed to apply, at the onset of each migraine attack, a handmade device firmly compressing both temporal arteries. Thirteen patients interrupted treatment because of intolerance of the local pain provoked by compression of the device. Of the remaining 24 patients, 17 reported benefit from using the device and 7 no effect. In these 17 patients, the percentage of attacks aborted or attenuated by early use of the device was 90.5% in the first month and 95.7% in the second month; the consumption of antipain drugs dropped from the mean 4.4 ± 2.6 in the pre-device month to 1.3 ± 1.6 in the first and 0.6 ± 0.9 in the second month.

Definitions need to be consistent with the facts. Reply to Parisi et al.

Dear Editor, We have read the letter written by Parisi et al. (1) in reply to our letter (2), and we cannot agree with several of their assertions. First, we will discuss some points of their proposed classification, shown in table 1 of their first letter (3). In the present letter (1) they reaffirm as of ‘considerable importance’ their criterion B (‘Headache that is ipsilateral or contralateral to lateralized ictal epileptiform EEG discharges [if EEG discharges are lateralized]’). As they surely know, there are cases of epileptic headache with not lateralized pain and lateralized EEG discharges (see table in (4)), therefore their criterion cannot be valid, as it will exclude some patients, also a few included in table 1 of their recent article (5). In our letter (2), we were trying to justify Parisi’s erroneous criterion (3), assuming that they were referring to the condition called ‘hemicrania epileptica’. In any case, we discussed this definition (2). Now Parisi et al. ((1), paragraph 2) sustain the validity of the term ‘hemicrania epileptica’ to be ‘reserved for all cases in which a IEH (ictal epileptic headache) is present and is associated synchronously or sequentially with other ictal sensory-motor events’. They should take in account that the distinctive criterion for ‘hemicrania epileptica’ is the ipsilaterality of the unilateral head-pain (‘hemicrania’) and the epileptic discharge, and not the manifestations following the headache. Motor/sensory/ autonomic epileptic events following an ‘epileptic headache’ constitute a variant of its expression, to be differentiated from the ‘pure’ (or ‘isolated’) form (2,4). In this variant, the headache represents an ‘aura’ preceding the other epileptic manifestations. Taking this opportunity, we would like to underline that only the episodes of ‘pure’ epileptic headache have a clinical relevance, requiring a diagnostic differentiation from other types of headache, particularly in patients not presenting other types of seizures and epileptic abnormalities in the interictal EEG (4). We are pleased that Parisi et al. (1), using our motivation that a seizure may not respond to antiepileptic treatment (2), implicitly agree with our suggestion to eliminate the classification criterion D (‘Headache resolves immediately after i.v. antiepileptic medication’), which they propose as compulsory (‘must all be fulfilled’) in table 1 of their first letter (3). We confirm to Parisi et al. (1), that we do not support the term ‘ictal headache’, as they can verify reading our letter. Instead, we think that the term ‘ictal epileptic headache’, is redundant, as 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 Medical Dictionary). As we said in our letter (2), we think that the term ‘epileptic headache’ is exhaustive, also because an epileptic headache is necessarily and obviously ictal (post-ictal, pre-ictal and interictal headaches are not epileptic headaches). Finally, we assure Parisi et al. (1) that in no way did we indicate as ‘mandatory’ the use of EEG recording by cerebral deep electrodes. We only suggested, on the basis of some cases reported in the literature in which the scalp EEG was normal, to also introduce the deep EEG in the diagnostic criteria, with this formulation: ‘. . . discharges on scalp or deep EEG concomitantly with headache’ (paragraph 4 of our letter, last line). Additional data on the subject are available (6).

Child and Adolescent Behavior Inventory (CABI): A New Instrument for Epidemiological Studies and Pre-Clinical Evaluation

Background: Some questionnaires have already been elaborated to collect information from parents of children and adolescents, both as preparation for clinical evaluation and for screening and epidemiological studies. Here a new questionnaire, the CABI, is proposed, and it is validated in a population of 8-10 year-old children. Compared to existing questionnaires, the CABI has been organized so as to be of medium length, with items concerning the most significant symptoms indicated by the DSM-IV-TR for the pertinent disorders, and covering a wider range than existing instruments. There is no charge for its use. Methods: The answers of the parents of 302 children in the last 3 years of primary school provided the normative data. A discriminant validation was done for internalizing and externalizing disorders and as a comparison with self-administered anxiety and depression scales. Exploratory factor analysis and internal consistency were also performed. Results: Distribution of scores on the main scales in the normal population shows positive skewness, with the most frequent score being zero. A highly discriminant capability was found in regard to the sample of children with internalizing and externalizing disorders, with high correlation with the self-administered anxiety and depression scales. Conclusion: The CABI appears to be capable, at least for 8-10 year-old children, of effectively discriminating those with pathological symptoms from those without. Compared with the widely- used CBCL, it has the advantages of a lower number of items, which should facilitate parental collaboration especially in epidemiological studies, and of being free of charge.

Child and Adolescent Behavior Inventory (CABI): Standardization for Age 6-17 Years and First Clinical Application

Background: The Child and Adolescent Behavior Inventory (CABI) is a questionnaire designed to collect information from the parents of children and adolescents, both for the preparation of screening and epidemiological studies and for clinical evaluation. It has been published in CPEMH in 2013, with the first data on 8-10 years old school children. Here we report an extended standardization on a school population 6-17 years old and the first results of the application in a clinical sample. Methods: Parents, after giving their informed consent, answered to the questionnaire. Complete and reliable data were obtained from the parents of 659 school children and adolescents 6-17 y.o., with a balanced distribution of gender. Moreover, in a population of 84 patients, the results with the CABI were compared with the clinical evaluation and the CBCL. Results: In the school population, scores were different in relation to gender and age. The values of externalizing disorders were higher in males, with the highest values for ADHD in the 6-10 y.o. children. On the contrary, the scores of internalizing disorders and of eating disorders tended to be slightly higher in females. In the clinical population, scores at the CABI were in agreement with the clinical evaluation in 84% cases for depressive symptoms (compared to CBCL 66%), 53% for anxiety symptoms (CBCL 42%) and 87% for ODD (CBCL 69%), differences, however; without statistical significance (chi square). Conclusion: The study obtained normative data for the CABI and gave information of the behavioral differences in relation to age and gender of the school population as evaluated by parents/caregivers. Clinically, the CABI provided useful information for the clinical evaluation of the patient, sometimes with better agreement with the final diagnosis compared to the CBCL.

Terminology should be as simple as possible and should express the concepts clearly

We read with interest the letter by Parisi et al. as comment to our review. They discuss our proposal of a preferential use of the term ‘‘Epileptic headache’’ instead of ‘‘Ictal epileptic headache (IEH)’’. In our review it was pointed out, even with references to dictionaries, that the term ‘‘ictal’’ is redundant with respect to the term ‘‘epileptic’’. Moreover, an epileptic headache is necessarily ictal and there are not ‘‘non-ictal’’ epileptic headaches: the ‘‘nonictal’’ are epilepsy-associated headaches, but not epileptic headaches. Therefore ‘‘ictal’’ it is not necessary to differentiate it from ‘‘non-ictal’’, since ‘‘non-ictal’’ is not epileptic. Parisi et al. write: ‘‘We believe that IEH is the term more appropriate and easy to use in order to summarize and define the clinical picture of an event in which headache/migraine is the sole ictal epileptic event not associated with other ictal epileptic signs/ symptoms’’. It is not clear how the term IEH unambiguously can indicate the exclusion of epileptic headaches followed by other clinical manifestations typical of epilepsy. The only way to distinguish the two different conditions in the terminology is to call ‘‘pure’’ or ‘‘isolated epileptic headache’’ when not followed by other typically epileptic manifestations. These are the only epileptic headaches that may pose a diagnostic problem with other types of headache, while the others are clearly identifiable as part of an epileptic event. This distinction was not well considered by Parisi et al., e.g. in their article where they report in Table 1 under the term IEH also cases in which the form is followed by other events, that is 4 out of the 6 cases of ‘‘hemicrania epileptica’’ by Isler and the case of Walker et al. This is in disagreement with the definition they give of IEH. It must be emphasized that, when we speak of ‘‘epileptic headache’’ we mean a condition of a headache (whether migraine or not) with onset coinciding with epileptiform EEG abnormalities (with an epileptic pattern different from the interictal one) corresponding to the duration of the headache, or of the whole seizure when followed by other epileptic manifestations.