Ictal epileptic headache: Moving forward. Reply to Cianchetti et al.

To the Editor:

We read the reply (1) by Cianchetti et al. to our letter (2) and thank the authors for the facilitated discussion. We also appreciate that this issue raises great interest as showed by the over 20 papers published from 2007 to 2013 by our group addressing this topic (see: Parisi et al. (3–5) and their references). We first stressed in Cephalalgia (6) the need for redefining the diagnostic criteria for headache as the sole manifestation of an ictal epileptiform event (i.e. ictal epileptic headache (IEH)) and recently we proposed the definitive criteria for IEH (7). Regarding the concerns raised by Cianchetti et al. (1), we would like to highlight these points:

Literature data support the view that in IEH (as it happen for autonomic manifestations in Panayiotopoulos syndrome), the ictal EEG anomalies can be focal or generalized, recordable ipsilaterally or contralaterally and associated with the same manifestations (headache) which can be of any types (migraine with or without aura, tension-type headache, etc.). In addition, in IEH cases, electroencephalogram (EEG) abnormalities may only be recorded using depth electrodes (3–5).

“Hemicrania epileptica” (HE) criteria in the second edition of the International Classification of Headache Disorders (ICHD-2), according to the well-documented cases (5), no longer meets our IEH criteria as HE does not exclude other associated motor, sensory and autonomic events (criterion B: “The patient is having a partial epileptic seizure”).

In contrast to what has been stated by Cianchetti et al. (1), our group was the first to stress (3) that an IEH event may not respond to antiepileptic treatment and for this reason the clinical picture of IEH may not be easily recognizable (3).

Finally (as regards the “terminology”), we strongly believe that the word “epileptic” is crucial, as we have stressed many times in several previous articles (Parisi et al. (3–5) and their references), because an “ictal headache” could be of vascular origin, and, in this sense, the term “pure ictal headache” proposed by Cianchetti et al. does not necessarily mean that is of “epileptic” origin. Thus, in our opinion the more appropriate and unambiguous definition to define the clinical picture of headache as only a manifestation of an epileptic seizure is “ictal epileptic headache.”

We hope that going forward we will have the opportunity to confront questions of deep and substantive importance. In the meanwhile, we discourage the use of additional terms, such as “isolated” or “pure” epileptic headache, which could potentially increase confusion surrounding this topic.