Abstract
Sir,
We read with considerable interest the comments made by Cianchetti et al. (1) on the ‘ictal epileptic headache’ (IEH) criteria (2) and we agree that this rare, intriguing phenomenon deserves to be discussed extensively by experts in the field. However, we do not agree with their proposed use of the term ‘ictal headache’ (IH), which was supported by Dainese et al. (discussed in Striano et al. (3)), rather than IEH for two main reasons: 1. when the headache is the sole ictal event, it is important to highlight its epileptic origin; 2. as an ictal paroxysmal condition may be non-epileptic (e.g. vascular), the use of the term ‘ictal’ on its own would be somewhat misleading.
In addition, our proposal for the IEH criteria (2) includes the rare condition in which headache is the only ictal epileptic manifestation (2,4). We also disagree with Cianchetti et al.’s proposal (1) to eliminate the definition of ‘hemicrania epileptica’ from the forthcoming ICHD-III classification, believing instead that this term should be reserved for all cases in which an IEH is present and is associated synchronously or sequentially with other ictal sensory-motor events.
Lastly, with regard to Cianchetti et al.’s concerns (1), we have previously pointed out (4) that the scalp electroencephalogram (EEG) may be normal in IEH and that it may be possible to detect epileptic abnormalities exclusively by means of deep electrodes. Although this limitation will inevitably result in the IEH phenomenon being underestimated, it does not mean the use of EEG recording by cerebral deep electrodes is mandatory in such cases.
Moreover, in view of the afore-mentioned considerations, we believe that our criteria B and D (2) are of considerable importance, as a seizure may not respond to antiepileptic treatment, just as it does not respond in numerous other seizure types (4).