Clinical characteristics of headache related to epilepsy: experience from a tertiary epilepsy center

Abstract

Background: Headache is one of the most common diseases in epilepsy, with affected patients experiencing various types of headaches. This study aimed to investigate differences in headache types across epilepsy types, comparing pain levels among epilepsy patients with multiple headache types, and exploring associations between headache characteristics and epilepsy prognosis.

Methods: We retrospectively analyzed consecutive adult epilepsy patients with headache, collecting comprehensive sociodemographic, epilepsy-related, and headache-related data, as well as data on headache-attributed lost time and quality of life. The overall prevalence of headache in epilepsy patients was determined, and we compared clinical characteristics, quality of life, and headache-attributed lost time across different epilepsy types. Based on the temporal relationship between headache and seizures, headache related to epilepsy were classified into inter-ictal headache (Inter-IH), ictal headache, pre-ictal headache (Pre-IH), and post-ictal headache (Post-IH) for subgroup analysis to explore differences in clinical characteristics by headache type. We conducted multiple logistic regression and receiver operating characteristic (ROC) analyses to calculate the area under the curve (AUC), assessing correlations between headache characteristics and epilepsy prognosis and the predictive accuracy for drug-resistant epilepsy (DRE).

Results: A total of 539 epilepsy patients were included, comprising 233 with Inter-IH (43.22%), 38 with Pre-IH (7.05%), and 423 with Post-IH (78.48%); no patients had ictal headache. Among those with Inter-IH, 58 (10.76%) met the diagnostic criteria for migraine, and 87 (16.14%) met the criteria for tension-type headache. In our cohort, 7 patients (1.30%) experienced both Inter-IH and Pre-IH, 112 (22.08%) had both Inter-IH and Post-IH, 7 (1.30%) experienced Inter-IH, Pre-IH, and Post-IH, and 18 (3.34%) had both Pre-IH and Post-IH. The study included 382 patients with focal epilepsy (70.87%), 40 with generalized epilepsy (7.42%), and 117 with epilepsy of unknown origin (21.71%), with temporal lobe epilepsy being the most common focal type, representing 46.07% of cases. Patients with focal epilepsy reported lower quality of life than those with epilepsy of unknown origin (QOLIE-10, p < 0.05) and had a lower proportion of bilateral Post-IH than those with epilepsy of unknown origin (p < 0.05). The proportion of patients with level 1 Headache-Attributed Lost Time-90 Days (HALT-90) was higher in generalized epilepsy than in focal (87.50% vs. 66.23%, p < 0.05) and unknown origin (87.50% vs. 64.96%, p < 0.05). With migraine and HALT-90 were associated with DRE (p < 0.05), although predictive accuracy was low (AUC = 0.539; AUC = 0.566, respectively).

Conclusion: The most common type of epilepsy with headache was focal epilepsy, with patients experiencing poorer quality of life than those with epilepsy of unknown origin. Clinical characteristics of headache related epilepsy did not vary significantly by epilepsy type, but patients of generalized epilepsy with headache had the least time lost. Post-IH was the most common type of headache in epilepsy patients. With migraine and HALT-90 were associated with DRE, but the predictive accuracy for DRE was insufficient.

Keywords: Epilepsy type; Headache; Inter-ictal headache; Post-ictal headache; Pre-ictal headache.

Fig. 1

Details of ASM use in epilepsy patients with headache. Abbreviation: ASM = anti-seizure medicine

Fig. 2

Venn diagram of Inter-IH, Pre-IH, and Post-IH overlap in the total population. Abbreviations: Inter-IH = inter-ictal headache, Pre-IH = pre-ictal headache, Post-IH = post-ictal headache

Fig. 3

Comparison of pain levels between the Inter-IH and Pre-IH groups. The proportion of patients experiencing an equal degree of pain between Inter-IH and Pre-IH was the highest at 42.86%. In 35.71% of patients, the pain level of Inter-IH was lighter than that of Pre-IH, while in 21.43% of patients, the pain level of Inter-IH was heavier than that of Pre-IH. Abbreviations: Inter-IH = inter-ictal headache, Pre-IH = pre-ictal headache

Fig. 4

Comparison of pain levels between the Inter-IH and Post-IH groups. The pain severity of Post-IH was greater than that of Inter-IH in 63.87% of patients. In 20.17% of patients, the pain severity of Post-IH was equal to that of Inter-IH, while in 15.97% of patients, the pain severity of Post-IH was less than that of Inter-IH. Abbreviations: Inter-IH = inter-ictal headache, Post-IH = post-ictal headache

Fig. 5

Comparison of pain levels between the Pre-IH and Post-IH groups. The severity of Post-IH was greater than that of Pre-IH in 48.00% of patients. In 28.00% of patients, the severity of Pre-IH and Post-IH was equal, while in 24.00% of patients, the severity of Post-IH was less than that of Pre-IH. Abbreviations: Pre-IH = pre-ictal headache, Post-IH: post-ictal headache

Fig. 6

The types of epilepsy in patients with headache

Fig. 7

Details on the type of focal epilepsy in patients with headache

Fig. 8

Characteristics of headache compared according to the types of epilepsy. Abbreviations: Inter-IH = inter-ictal headache, Post-IH = post-ictal headache