Migraine & Epilepsy: Best Friends - Lucas Orellana, Jonas Salk Medical Center, Argentina
Adult neurologist and epileptologist Lucas Orellana shares the intriguing connection between migraine and epilepsy! These seemingly distinct neurological conditions share common pathogenic mechanisms, genetics, and treatments and while they are often experienced together there may be challenges in distinguishing between them. Lucas emphasises the importance of personalised treatment plans and the role of lifestyle factors and stress as common triggers. Tanscription and links are below! 👇🏻
Reported by Torie Robinson | Edited and produced by Carrot Cruncher Media.
Podcast
-
00:00 Lucas Orellana
“The lifetime prevalence of migraine in people with epilepsy is 52% higher than in people without epilepsy.”
0:09 Torie Robinson
Could that migraine that you’ve had actually be an epileptic seizure? Or, vice versa, might the epileptic seizure you’ve had actually be a migraine? The thought of such confusion - or even potential misdiagnoses can sound a bit scary! But, today we hear more about the similarities between migraine and the epilepsies - including the pathophysiological and clinical overlaps, and treatments with our fabulous, return guest, epileptologist and neurologist Lucas Orellana!
If you’re new and you haven’t done so already, please do like and comment on this episode and subscribe to our channel, so that we can get way more people learning about and developing a factual understanding of the epilepsies!
00:51 Lucas Orellana
I'm an adult neurologist and epileptologist based in Buenos Aires and I'm currently working in the epilepsy section of the Jonas Salk Institute and Luis Pasteur Institute in Buenos Aires.
01:03 Torie Robinson
One of the reasons we can keep chatting all the time is because we talk about things that often people don't necessarily associate with the epilepsies. So, today we're going to be talking about migraine and epilepsy. Could you give us a bit of info about that, please?
01:16 Lucas Orellana
At first glance, migraine and epilepsy seem to be two neurological distinct conditions, but research evidence suggests that they have many things in common, such as their pathogenic mechanisms, their pathophysiology, their genetics, and also their treatments. So, many, many features that are in common between these two entities. We can talk a little bit about the epidemiology first, because it's really important to know that before talking about that because around 1% of the population might have migraine. But the interesting thing here is to say that the lifetime prevalence of migraine in people with epilepsy is 52% higher than in people without epilepsy. So, that is significant. Especially in women, but usually women have much more prevalence of migraine globally than men, but that percentage is also seen in people with epilepsy. Probably the clinical features of migraine in people with epilepsy may vary - it is very heterogeneous. They could be temporally unrelated to the epileptic seizures, but sometimes, and interestingly, they are related to the seizures and they could be classified as pre-ictal, ictal, and post-ictal headache seizures - depending if they occur before, during, or, after an epileptic seizure. So, there is a strong relationship - even though not only talking about the prevalence, the incidence of migraine in people with epilepsy and vice versa (because there is a higher prevalence of epilepsy in people who suffer from migraine as well).
03:23 Torie Robinson
Great!
03:24 Lucas Orellana
So, there's a huge connection between these two entities. And the clinical features are a little bit more… have a lot of variations, but we're always talking about the same thing. There's a big overlap (epidemiological overlap) between these two entities.
03:44 Torie Robinson
So, are we thinking that they could potentially have the same genetic causes or triggers? I've heard that sometimes, clinicians might not be sure if a migraine aura is in fact an aura or epileptic focal seizure, is that right?
04:01 Lucas Orellana
Sometimes it's really difficult to distinguish them clinically because there are features: motor symptoms, visual symptoms, sensitive symptoms… [they] are practically the same!
04:16 Torie Robinson
Huh!
04:16 Lucas Orellana
There might be some slight differences that could help the clinician with a good eye and to distinguish them but, for instance; one of the biggest difficulties is to distinguish between a visual migraine aura (which is probably the most common aura in people with migraine - it's up to 20% of people with migraine could suffer from visual auras) and distinguish that from a visual epileptic focal seizure. Sometimes, the duration of these 2 events, the speed of progression of the symptoms, and the regression of the symptoms… [there] could be some clinical features, different clinical features, that could help us distinguish between one from the other. But sometimes, video EEG is sometimes the only way that we can firmly distinguish that. But I think that the clinical sense is the most important in the context, of course.
05:27 Torie Robinson
Yeah, context is huge. But that must be even harder, I think, to distinguish if a person does have an epilepsy and experiences migraines! And sometimes, I mean, I would think “Gosh, am I experiencing a seizure right now? Or is this ‘just’ the most awful, awful migraine?” Maybe you don't know. And maybe the clinician doesn't know. Then, sometimes, I imagine… I mean, I'm just putting it out there... but what if a person experienced migraines and you might have a clinician who said “That's a type of focal seizure.” and it's not - it's migraines alone! It must get very confusing, I think.
06:00 Lucas Orellana
An exhaustive medical history, I think, it's the most important thing in this, and to listen to the patient and listening to what the patient feels about these symptoms, the frequency, all the characteristics that the patient - in their own words - really could help us to help us distinguish between them, of course.
06:27 Torie Robinson
We're talking about the clinical overlap; could you just go into a little bit of detail about the cause of that hyperexcitability, if it's to do with anything like, I don't know, glutamate or all that cool stuff.
06:40 Lucas Orellana
The pathophysiological aspects in migraine and epilepsy have a very strong overlap due to a pathophysiological background that has many, many things in common. I think that I would say that the neuronal hyper-excitability may be the principal feature in these two entities, both migraine and epilepsy.
07:04 Torie Robinson
Ah.
07:05 Lucas Orellana
That could be due to an imbalance, an ion imbalance, an imbalance of neurotransmitters -we have the glutamate (that is the positive hyper-excitability neurotransmitter) and GABA (which is the most inhibitory or the principal inhibitory neurotransmitters). So, always we have to have a balance to make things go well, but when there is…
07:33 Torie Robinson
Ideally!
07:34 Lucas Orellana
…yes!... when there's a disorder of that balance, well, we start to have some kind of troubles and attacks probably due to this imbalance because that leads to a lot of metabolic disorders such as problems with calcium, sodium, among others, ok.
07:55 Torie Robinson
And again, which can be related to the epilepsy as well as migraine!
07:59 Lucas Orellana
Mmm-hmm.
07:59 Torie Robinson
And then, also, the treatments for epilepsy and migraine can be really similar too?
08:03 Lucas Orellana
Due to these pathophysiological similarities, many people who suffer from epilepsy and migraine should be given medication that (in case they need it) that could help us to prevent migraine attacks and also epileptic seizures. And Topiramate and Valproate are both approved by FDA as preventive treatments for both migraine and of course they are anti-seizure medications. So, the good thing about it is that if you are treating a patient who suffers from migraine and has epilepsy, okay, let's make a rational therapy to avoid polytherapy, okay?
08:58 Torie Robinson
Mmm.
08:58 Lucas Orellana
So, a good idea is to use medications that could be helpful for both conditions. And in this case, Topiramate and Valproate might be the most recommended for that purpose.
09:12 Torie Robinson
At least initially, I suppose.
09:14 Lucas Orellana
Totally, they are at least the first approved for that. But, that would depend on the characteristics of the patient and many other comorbidities that the patient would have.
09:28 Torie Robinson
And then the side effects as well, right, of these drugs.
09:30 Lucas Orellana
Totally. Totally. Because it's also good to remark that some anti-seizure medications could lead the patient into headaches.
09:41 Torie Robinson
Great! How ironic! Haha!
09:41 Lucas Orellana
So, it's an adverse effect. Yes. Yes, so, it's really important that we can see all these adverse effects that the use of drugs should be really personalised to the patient history, to the patient comorbidities, and of course to the preferences of the patient, of course, as well.
10:07 Torie Robinson
Looking at overall quality of life, I guess, at the end of the day.
10:09 Lucas Orellana
As you mentioned, the quality of life and as you always mentioned that it's really important I want to focus this to emphasise that we have to look beyond the seizures. So, migraine is one of the most common complaints of people with epilepsy. We have to listen to the patient, listen to ask the patient if that patient has migraine, okay, because it's sometimes….
10:40 Torie Robinson
Underreported? Well yeah, both, yeah.
10:41 Lucas Orellana
Under-reported exactly, probably because clinicians don't ask properly this question.
10:50 Torie Robinson
What are our conclusions here then? What is, have you got any takeaway messages for our listeners at all? Whether they be a person with epilepsy, a mum, or dad, or a clinician or researcher. Do we need more research into this?
11:03 Lucas Orellana
Totally, because many, many, many things are still not completely understood. We have some background ideas, but this is like the basis for many, many follow-up studies because we have to completely understand. There is undoubtedly an overlap and relationship between these 2 entities. They are not exactly the same, but at… they are not totally different. So, this is a clinical genetic overlap between these 2 syndromes. I think that the key points are listening closely to the patient, ask the patient if that patient suffers from headaches, and try to do a complete medical history of that to listen really carefully to the characteristics of their headache complaint, try to choose medications that could help us for both conditions, and be rational with the use of medications. Not only say “I'm controlling the seizures, I'm controlling the headache.”, but also “Is the patient accordingly tolerating this medication?” because everything counts at the hour of having a good quality of life in the patient.
12:33 Torie Robinson
And I say also, I imagine, look for correlations, right? Between seizure activity and migraine, and then see, you know, when you look at their lifestyle, does it correlate to when they don't get enough sleep or they're too stressed out at work, or all these different things? It's looking beyond the initial symptoms, right?
12:51 Lucas Orellana
Triggers are really… share many similarities (at least what patients with migraine and epilepsy report). Sleep disturbances and stress are the most important triggers for both conditions.
13:07 Torie Robinson
And sometimes menstruation as well, actually. That's another one, isn't it.
13:09 Lucas Orellana
Hormonal aspects are well, as another trigger totally. Catamenial, epilepsies, catamenial, migraines are extremely common. So, the good thing is that if we make good health improvements in the daily life, because this is like daily life habits are things that we do daily, if we improve those factors, those aspects, probably we are hoping to have an improvement both for the epilepsy and migraine. So, the good thing is that effort that the patient does every day of their lives is not only good for their general quality of life, but also for the control of seizures and migraine attacks.
14:01 Torie Robinson
This was a really cool topic - thank you so much to Lucas! Migraines and seizures can each be debilitating and so, a far improved understanding of each and their links between one another is definitely required.
Learn more about Lucas and his work on the website torierobinson.com (where you can access this entire podcast, including the video, and the transcription of the episode) all in one place. And if you’re new and you haven’t done so already, please do like and comment on this episode, and subscribe to our channel so that we can get way more people learning about and having a better and indeed factual understanding of the epilepsies, around the world! See you next week!
-
Lucas Orellana is an adult epileptologist from Buenos Aires, Argentina.
Lucas is a member of the Argentinean Neurology Society (SNA), the Argentinean League Against Epilepsy (LACE), and the YES (Young Epilepsy Section) Latin America of the ILAE (International League Against Epilepsy).
He is currently a staff member and organiser of the Epilepsy section of Jonas Salk Medical Center. He is also working in the Neurology department of FLENI Institute.
Lucas’ main areas of interest are currently electroencephalography and the pharmacological aspect of seizure treatment.
Lucas enjoys teaching, and believes in the importance of continuous medical education.
-
-