Abstract
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 (‘hemi-crania’) 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 inter-ictal 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).