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OCCIPITAL LOBE EPILEPSY OR MIGRAINE HEADACHE 227 Is, for Example, Primarily of Epileptic and Not of Migra- CONCLUSIONS Ine Etiology (6, 11)

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OCCIPITAL LOBE EPILEPSY OR MIGRAINE HEADACHE 227 Is, for Example, Primarily of Epileptic and Not of Migra- CONCLUSIONS Ine Etiology (6, 11) DOI: 10.5937/sanamed1603225S UDK: 616.853-079.4; 616.857-079.4 2016; 11(3): 225–228 ID: 227795212 ISSN-1452-662X Case report OCCIPITALLOBE EPILEPSY OR MIGRAINE HEADACHE Skrijelj E. Fadil, Mulic Mersudin State University of Novi Pazar, Novi Pazar, Serbia Primljen/Received 17. 07. 2016. god. Prihva}en /Accepted 25. 08. 2016. god. Abstract: Introduction: Occipital lobe epilepsies symptomatic, cryptogenic occurring in all ages, and idi- are rarely met in clinical practice, but when they occur, opathic that as a rule occur in childhood (1). Seizures are they can be misdiagnosed as migraine-like headache. the most often simple partial, while the occurrence of Their prevalence ranges from 5% to 10% of all epilepsi- complex seizures is frequently the sign of extra-occipi- es. Seizures can occur at any age; etiologically speaking tal propagation discharges (temporal, parietal or frontal they can be symptomatic, cryptogenic and idiopathic lobe). A short duration of seizures lasting from a few se- (most often onsetis in childhood). Clinical symptomato- conds to one minute and sometimes even three minutes logy is manifested by partial epileptic seizures in the is characteristic, but very rarely longer. Seizures occur sense of visual elementary and/or complex manifestati- frequently, sometimes every day. Clinical semiology of ons, palinopsia, amaurosis, tonic head deviation, bul- seizures involves visual and oculomotor symptoms. Vi- bus, nistagmus and headache. Propagation discharge to sual symptomatology is predominated by elementary, neighbour areas (temporal, parietal and frontal) is a fre- rarely complex visual hallucinations, illusions, palinop- quent occurrence appearing with complex partial seizu- sia and amaurosis. Visual hallucinations often appear in res frequently finishing with secondary generalized to- the form of small colorful circles that move within the nic-clonic (GTC) seizures. Case report: We are presen- visual field or are rarely shining and of twinkling pulsat- ting a17-year-old male patient who has suffered from at- ing lights (2). Elementary visual hallucinations are often tacks of visual problems with headache since 10 years of followed by oculomotor symptoms with a contralateral age. All the time it is treated as a migraine headache. tonic deviation of the eyes and head, and epileptic nis- During the last attack of headache the patient also had a tagmus with pulsating movements. Headache is often loss of consciousness, EEG that was performed for the associated with seizures deriving from the occipital area first time evidenced epileptic discharges of the occipital that can be ictal or postictal and often has migraine char- area.The therapy also included treatment with antiepi- acteristics. Visual hallucinations are the key symptom leptic drug pregabalin resulting in seizure withdrawal. that suggests the occipital focus. If the visual symptoms Conclusion: The appearance of visual symptoms follo- are not expressed, semiology of seizures and standard wed by headache is most frequently qualified as migrai- EEG can be often the cause of misdiagnosed type of epi- ne triggered headache. However, when antimigraine lepsy, because they express more the propagation dis- therapy does not give favorable results epileptic headac- charge and less initial locality (3). The occurrence of ic- he should be suspected, with obligatory performance of tal discharge propagation to neighbor areas is very fre- EEG recording. Occipital lobe epilepsy often presents quent in symptomatic etiology, but very rare in idiopat- diagnostic dilemmas due to clinical manifestations that hic etiology (3). Spreading of seizures can lead to the oc- are similar to that of non-migraine headache. currence of complex partial seizures (temporal and fron- Key words: headache, migraine, epilepsy, occipi- tal lobes), hemiclonic and GTC seizures. Epileptic sei- tal epilepsy, dilemma, diagnosis, EEG recording. zures of the occipital lobe occur more frequently in the awake than in the sleeping state, the interictal EEG INTRODUCTION shows occipital spikes and/or the spike-and-wave com- plex in 57% of cases, unilaterally or bilaterally (4). Bi- Epilepsies with seizures generated from the occipi- occipital discharges of the spike-and-wave complex oc- tal lobe (occipital epilepsies) represent a rare clinical cur both in symptomatic and idiopathic etiology. In manifestation. Their prevalence rates from 5%-10% of symptomatic epilepsies of the occipital lobe various all epilepsies (1). Etiologically speaking they can be samples predominate, beginning from congenital mal- 226 Skrijelj E. Fadil, Mulic Mersudin formations, vascular lesions (infarction, periventricular DISCUSSION leukomalacia, porencephaly, hemorrhagic types) syste- mic diseases, metabolic disorders, infections and neo- Epilepsies of the occipital lobe are a typical repre- plasms (4). Prognosis is favorable in the idiopathic and sentation of focal epilepsies that are characterized by unfavorable in the symptomatic epilepsy where it essen- ictal aura (subjective ictal phenomenon) with predomi- tially depends on the type and size of lesion cause. Phar- nant visual symptomatology associated with headache. macoresistance is seen in most symptomatic cases with The specificity of occipital epilepsies is elementary vi- a disorder of cortical development or occipital lobe tu- sual hallucinations in the form of small multicolor mo- mor where surgical treatment is the method of choice. ving circles that increase and multiply, their rapid oc- As the consequence of focal affection of any occipital lo- currence and short duration from a few seconds to 3-4 be, visual elementary hallucinations with associated hea- minutes (1, 5). Beside the short-lasting visual aura at- dache can occur that often results in diagnostic dilemma, tacks, occipital epilepsies are characterized by ictal or regardless if it is the case of occipital lobe epilepsy or mi- postictal migraine triggered headache (unilateral or bi- graine (5, 6). Migraine (hemicrania) is a vascular, unilate- lateral, pulsating, nausea) that is various in duration, ral, gradual, most often throbbing and pulsating headache lasting from several minutes to several hours or longer. followed by vomiting, photophobia and phonophobia, Identical clinical symptomatology can be also seen in and which is of various duration ranging from 4-72 hours. migraines with aura, with the migraine aura develop- Migraine is most frequently a neurological disease with ing slowly, lasting longer (³ 5 minutes) and is mostly the prevalence of 6%-16%. Two major clinical types are followed by colorless visual symptoms in the sense of migraine without aura (80%) and migraine with aura black-and-white zig-zag lines or scotoma. Migraine (20%) (7, 8). The migraine aura is most often expressed headache follows the migraine aura mostly lasting by twinkling lights, scotomes, including black-and-white 4-72 hours (7, 8). Migraine and occipital epilepsies ha- zig-zag lines or amaurosis in duration of 15-60 minutes ve a paroxysmal beginning and a great number of com- that is followed by headache. Migraine, and particularly a mon symptoms that often creates a problem of their di- migraine with aura, is frequently difficult to differentiate agnostic differentiation. Therefore, in practice it is qui- from the epilepsy of the occipital lobe due to their similar te frequent that epilepsy of the occipital lobe is to be clinical symptomatology (9, 10). proclaimed as a migraine with aura, and more rarely the opposite. These diagnostics mistakes are not rare CASE REPORT and can be found in numerous reports by many authors (5, 6). Although the visual aura and headache have the- We present a 17-year male patient born at term ir specificities both in the speed of their development and with normal early psychomotor development, wit- and the time of duration, they cannot be often signifi- hout data on hereditary epilepsy, and who had attacks cant parametric differentiating factors between epi- of short-lasting visual problems (shiny color spots, po- lepsy and migraine (8). The thing, that can clearly dif- or vision or complete loss of vision followed by unilat- ferentiate occipital epilepsies from migraine is the ma- eral back head headache. Seizures occurred 2-3 times nifestation of ictal oculomotor symptomatology in the per week with associated headache of various duration, sense of the deviation of the head, eyes, nistagmus or 1/2-4 hours, and sometimes longer. Standard biochem- hemiconvulsions, GTC seizures and EEG epileptic ical and biohumoral laboratory analyses of blood and discharges (5). EEG is the main and irreplaceable diag- urine were performed, as well as neurological and nostic test for disorders which in occipital epilepsies ophthalmological examination, CT and MRI that were interictally often register unilateral and/or bilateral oc- within the range of normal referent values. Having all cipital epileptic discharges in the appearance of spike this in mind, the diagnosis of migraine with aura was and/or spike-and-waves. Therefore, it is necessary to made. All the time the patient was treated with stan- perform EEG in all atypical, persistent headaches, mi- dard antimigraine medications (sumatripan, pizotip- graine that does not react to standard analgesics and hen, propanolol, naproxen, aspirin) but without signifi- antimigraine medications. In migraines EEG most of- cant therapeutic effects. It was at this point of time, ten shows unspecific, non-epileptiform changes, how- when during headache loss of
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