The Relationship Between Migraine and Epilepsy

Written by: Kylie Petrarca, RN, BSN

Medically Reviewed by: Andrea D. Murphy, MSN, APRN, ANP-BC, NEA-BC

Edited by: Melissa Calise and Leigh Serth

What is Epilepsy?

Epilepsy is a neurological condition characterized by seizures that occur from abnormal bursts of electrical activity in the brain. 

There are three main classifications of seizures:¹

• General Onset
• Focal Onset
• Unknown Onset

Epilepsy is further classified by the area of the brain it affects (one side or both sides of the brain), associated symptoms and level of awareness during the seizure.¹

General onset: Affects both sides (hemispheres) of the brain.¹

*Common subtypes of general onset seizures include:

1. Tonic-clonic: sudden onset of rigid muscles followed by a loss of consciousness and jerking movements of the extremities
2. Clonic: rhythmic jerking and loss of consciousness
3. Atonic: loss of muscle tone
4. Myoclonic: brief muscle jerks/twitches
5. Epileptic spasms: Arms, legs, head and trunk flex inward or extend outward in brief spasms
6. Absence: staring into space for a brief period of time

*This is not a comprehensive list of general onset seizures. 

Focal onset: Affects one side of the brain. When a person is awake and aware of the seizure it is known as “focal aware” or if awareness is impaired at some point during the seizure it is known as “focal onset impaired awareness.”¹

Unknown onset: Epilepsy is given an “unknown onset” characterization when there is not enough information to determine if the seizure has a general or focal onset. A seizure may be classified as unknown if it was unwitnessed or requires further investigation.¹

Status epilepticus is a complication of a seizure and occurs when a seizure lasts more than 5 minutes or someone experiences more than 1 seizure in 5 minutes without returning to consciousness.²

*It is important to note that not all people with seizures have epilepsy. Seizures may occur as a result of alcohol withdrawal, traumatic brain injury, infection, fever, stroke, etc.*

The Relationship Between Migraine and Epilepsy

The prevalence of migraine in people with epilepsy ranges from 8-24% and the prevalence of epilepsy in people with migraine is 1–17%.³ Epilepsy doesn’t cause migraine but this disorder can cause headaches. Migraine and epilepsy may be misdiagnosed for one another due to similar symptoms but are thought to be comorbid due to overlapping pathophysiology, shared genetic variants and commonalities in treatment options. 

Overlapping Pathophysiology

Although it is unknown why epilepsy and migraine are comorbid, experts have identified some factors that may be involved. People who have migraine and/or epilepsy are thought to have a hyperexcitable brain. 

This could be due to a variety of underlying factors such as:

• Defects in ion channels³
• Impairment of the sodium potassium pump⁹ 
• Glutamate receptor activation³
• Genetic factors³

Aura in migraine and epilepsy

An aura is often a warning sign of an impending migraine attack or seizure. Nearly one third of people with migraine experience an aura⁴ and two thirds of people with generalized epilepsy report experiencing an aura prior to a seizure.⁵ Both migraine aura and epileptic aura are thought to occur because of altered brain activity also known as cortical spreading depression. The aura symptoms in each condition may be similar and can include headache, visual disturbances, phantom smells, numbness, tingling and colored spots but there are typically some key differences.

Differences in migraine and epileptic auras

• Migraine auras may last up to 1 hour whereas epileptic auras usually last less than 5 minutes.⁶
• Migraine auras have a slow, gradual onset compared to epileptic auras which have a sudden onset.⁶
• Visual symptoms in migraine auras tend to start more in the center of the visual field and move towards the periphery whereas epileptic auras tend to start in the periphery.⁷
• A migraine aura is typically followed by a headache, light or sound sensitivity, nausea, vomiting and more. An epileptic aura is followed by a seizure.
• Other symptoms of epileptic auras include: hearing strange sounds or a change in taste, a feeling of déjà vu, sudden surge of emotions and more.⁸

Post-ictal headache

A person may develop a post-ictal headache also known as a “headache after a seizure” that resembles a throbbing, migraine-like headache. A study assessing the prevalence of people with epilepsy with headache found that 60.1% of people reported headaches within the last year.⁹ Most people had postictal headaches (34.2%), followed by interictal 11.7% and lastly preictal 4.5%.⁹ 

Migraine aura-triggered seizure “Migralepsy” 

A seizure may occur as a complication of migraine with aura and may begin during or within 1 hour after an attack. This phenomenon is known as “migralepsy” or migraine aura triggered seizure and this phenomenon is rare. 

Familial Hemiplegic Migraine and Epilepsy

People with hemiplegic migraine are often misdiagnosed as epilepsy due to the muscle weakness and paralysis that can occur on one side of the body. Interestingly, mutations in all three genes linked to familial hemiplegic migraine (CACNA1A, ATP1A2, SCN1A) have also been found in different types of epilepsy.¹⁰

Pediatric Migraine and Epilepsy

Unfortunately, 1 in 10 children live with migraine.¹¹ A study found that migraine in children may be a risk factor for epilepsy. The study found that a history of migraine increased the risk for developing unprovoked seizures by 3.7 fold.¹² Another study of 453 children with epilepsy found that 25% of the children had migraine.¹³ They also found that 49% of children had an onset of migraine after the seizures began compared to 23% before and 19% in the same year.¹³ It should be noted that the study did not specify if the child had migraine with or without aura. 

Due to limited studies, there are fewer migraine treatment options for children. Abortive treatments that can be prescribed in children with migraine include: rizatriptan (aged 6 and older), sumatriptan (12 years and older), and non-invasive neuromodulation devices such as remote electrical neuromodulation and vagus nerve stimulation (12 years and older). In children with frequent migraine attacks, topiramate, a preventive medication, may help decrease the occurrence of both migraine and epilepsy attacks.

Commonalities Between Migraine and Epilepsy

• Olfactory hallucinations (smelling odors that are not there), also known as phantom smells, can occur in people with migraine as well as in people with temporal lobe epilepsy.¹⁴
• Shared genetic mutations
• Visual changes can occur before migraine attacks and seizures
• Comorbidities common to both epilepsy and migraine include suicide, anxiety and depression.
• Triggers for migraine attacks as well as seizures include menstruation, stress and alcohol.
• Head injuries are a risk factor for both conditions.

Treatments for Migraine and Epilepsy

There are more than 30 medications approved to treat epilepsy. A full list of medications can be found here. For people who are not responsive to medication surgery or various types of neuromodulation may be considered.

Some anti-seizure medications that can treat both migraine and epilepsy include topiramate and valproate. Other medications used less often for migraine but may be effective for treating both epilepsy and migraine may be gabapentin, zonisamide and levetiracetam.

The ketogenic diet may also be used to manage migraine and epilepsy. Although found to be more effective for epilepsy, small, short term studies have also found people to have a reduction in migraine attacks using the ketogenic diet but more research is needed.^15,16

Service animals can be helpful for both migraine and epilepsy.¹⁷ Seizure dogs can be trained to respond to someone who is actively having a seizure, notify others and more. Dogs can also be used for migraine and may be able to warn a person about an upcoming attack, provide comfort and items a person may need.

What Type of Clinician Should I See for Migraine and Epilepsy? 

A primary care provider is often involved if a person has migraine disease and/or epilepsy. They may refer to a neurologist for both conditions. However, a clinician with a headache specialty is preferred to best treat migraine and other headache disorders. Similarly, an epileptologist is a neurologist who specializes in treating epilepsy. This type of doctor is preferred if seizures are not controlled in the first year or by trying two or three anti-seizure medications.¹⁸

A Note To Patients and Providers

Healthcare providers should be aware of the relationship between migraine and epilepsy in adults and children. There are many treatment options for epilepsy but topiramate and valproate are two options that can also be used for migraine. It is important to note that the American Headache Society 2021 Consensus Statement recommends that, “A single drug for multiple conditions should be avoided if there is a risk of undertreating any single condition, as optimal treatment may require the use of separate classes of medication.”¹⁹ People with epilepsy should be taught about the signs and symptoms of migraine due to the high prevalence of migraine in people living with epilepsy. In addition, patients should use a migraine and seizure diary to track when either occurs. Detailing triggers such as menstruation, stress, alcohol, dehydration can help identify trends in both migraine and epilepsy. You can find our migraine diary here and the Epilepsy Foundation’s seizure diary here.

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Additional Resources 

1. Epilepsy Foundation
2. Overview of epilepsy
3. Find a doctor for epilepsy
4. Headache and Epilepsy
5. 24/7 Epilepsy Hotline

References

1. https://www.epilepsy.com/what-is-epilepsy/seizure-types
2. https://www.hopkinsmedicine.org/health/conditions-and-diseases/status-epilepticus#:~:text=A%20seizure%20that%20lasts%20longer,permanent%20brain%20damage%20or%20death.
3. Rogawski MA. Migraine and Epilepsy—Shared Mechanisms within the Family of Episodic Disorders. In: Noebels JL, Avoli M, Rogawski MA, et al., editors. Jasper’s Basic Mechanisms of the Epilepsies [Internet]. 4th edition. Bethesda (MD): National Center for Biotechnology Information (US); 2012. Available from: https://www.ncbi.nlm.nih.gov/books/NBK98193/
4. Shankar Kikkeri N, Nagalli S. Migraine with Aura. [Updated 2022 Dec 6]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK554611/
5. Dugan P, Carlson C, Bluvstein J, Chong DJ, Friedman D, Kirsch HE; EPGP Investigators. Auras in generalized epilepsy. Neurology. 2014 Oct 14;83(16):1444-9. doi: 10.1212/WNL.0000000000000877. Epub 2014 Sep 17. PMID: 25230998; PMCID: PMC4206156.
6. Hartl, E., Angel, J., Rémi, J., Schankin, C. J., & Noachtar, S. (2017). Visual Auras in Epilepsy and Migraine – An Analysis of Clinical Characteristics. Headache: The Journal of Head and Face Pain, 57(6), 908–916. doi:10.1111/head.13113 
7. van Dongen RM, Haan J. Symptoms related to the visual system in migraine. F1000Res. 2019 Jul 30;8:F1000 Faculty Rev-1219. doi: 10.12688/f1000research.18768.1. PMID: 31448081; PMCID: PMC6668047.
8. https://www.healthline.com/health/epilepsy/seizure-aura#:~:text=An%20aura%20is%20the%20feeling,focal%20aware%20seizures%20(FAS).
9. Wang, Xq., Lang, Sy., He, Mw. et al. High prevalence of headaches in patients with epilepsy. J Headache Pain 15, 70 (2014). https://doi.org/10.1186/1129-2377-15-70
10. https://www.sciencedirect.com/science/article/abs/pii/S0065266008010031?via%3Dihub
11. https://americanmigrainefoundation.org/resource-library/migraine-children/
12. Ludvigsson, P., Hesdorffer, D., Olafsson, E., Kjartansson, O., & Hauser, W. A. (2005). Migraine with aura is a risk factor for unprovoked seizures in children. Annals of Neurology, 59(1), 210–213. doi:10.1002/ana.20745 
13. Kelley, S. A., Hartman, A. L., & Kossoff, E. H. (2012). Comorbidity of migraine in children presenting with epilepsy to a tertiary care center. Neurology, 79(5), 468–473. doi:10.1212/wnl.0b013e3182617113 
14. https://americanheadachesociety.org/news/whats-that-smell/
15. Di Lorenzo C, Coppola G, Bracaglia M, Di Lenola D, Sirianni G, Rossi P, Di Lorenzo G, Parisi V, Serrao M, Cervenka MC, Pierelli F. A ketogenic diet normalizes interictal cortical but not subcortical responsivity in migraineurs. BMC Neurol. 2019 Jun 22;19(1):136. doi: 10.1186/s12883-019-1351-1. PMID: 31228957; PMCID: PMC6588932.
16. Di Lorenzo C, Pinto A, Ienca R, Coppola G, Sirianni G, Di Lorenzo G, Parisi V, Serrao M, Spagnoli A, Vestri A, Schoenen J, Donini LM, Pierelli F. A Randomized Double-Blind, Cross-Over Trial of very Low-Calorie Diet in Overweight Migraine Patients: A Possible Role for Ketones? Nutrients. 2019 Jul 28;11(8):1742. doi: 10.3390/nu11081742. PMID: 31357685; PMCID: PMC6722531.
17. https://www.epilepsy.com/recognition/seizure-dogs
18. https://www.epilepsy.com/sites/default/files/atoms/files/pg4L_Understanding_09-2018.pdf
19. https://headachejournal.onlinelibrary.wiley.com/doi/10.1111/head.14153

*The contents of this blog are intended for general informational purposes only and do not constitute professional medical advice, diagnosis, or treatment. Always seek the advice of a physician or other qualified health provider with any questions you may have regarding a medical condition. The writer does not recommend or endorse any specific course of treatment, products, procedures, opinions, or other information that may be mentioned. Reliance on any information provided by this content is solely at your own risk.