Symptomatic Occipital Epilepsy Misdiagnosed as Migraine
Two young patients with symptomatic occipital lobe epilepsy due to discrete lesions of cysticercosis were misdiagnosed and treated for 2 years as migraine with visual aura. The patients suffered from frequent visual seizures often followed by migraine-like headache. Seizures manifested with colored and mainly circular elementary visual hallucinations of up to 1 minute duration. Headache, often severe and of long duration, was frequently associated with nausea, photophobia, and phonophobia. Both patients became seizure-free with appropriate treatment of the underlying disease and epileptic seizures.
Episodic elementary visual hallucinations followed by headache are common and with the same sequence in migraine with aura and visual occipital lobe seizures. However, elementary visual hallucinations of visual seizures are markedly different in quality, location, and chronological development in comparison with the visual aura of migraine.
Elementary visual hallucinations of occipital seizures are brief for seconds to 3 minutes, develop fast within seconds and are predominantly colored and circular. They usually start in the periphery of a hemifield and often march to other seizure symptoms or convulsions. Conversely, visual aura of migraine consists mainly of achromatic zigzag linear patterns, starts in the center of the visual field, it gradually progresses over >4 min usually lasting <30 min toward the periphery of one hemifield and often leaves a scotoma. Postictal headache, often indistinguishable for migraine as defined by the International Classification of Headache Disorders (ICHD-2), occurs in more than half of patients with visual seizures.
Misdiagnosis of visual occipital seizures as migraine appears to be common with significant repercussion on management issues.
We report 2 patients with symptomatic occipital epilepsy who were misdiagnosed as migraine with aura though ictal clinical symptoms were typical of visual epileptic seizures despite severe postictal migraine like headache.
Two young patients with symptomatic occipital lobe epilepsy due to discrete lesions of cysticercosis were misdiagnosed and treated for 2 years as migraine with visual aura. The patients suffered from frequent visual seizures often followed by migraine-like headache. Seizures manifested with colored and mainly circular elementary visual hallucinations of up to 1 minute duration. Headache, often severe and of long duration, was frequently associated with nausea, photophobia, and phonophobia. Both patients became seizure-free with appropriate treatment of the underlying disease and epileptic seizures.
Episodic elementary visual hallucinations followed by headache are common and with the same sequence in migraine with aura and visual occipital lobe seizures. However, elementary visual hallucinations of visual seizures are markedly different in quality, location, and chronological development in comparison with the visual aura of migraine.
Elementary visual hallucinations of occipital seizures are brief for seconds to 3 minutes, develop fast within seconds and are predominantly colored and circular. They usually start in the periphery of a hemifield and often march to other seizure symptoms or convulsions. Conversely, visual aura of migraine consists mainly of achromatic zigzag linear patterns, starts in the center of the visual field, it gradually progresses over >4 min usually lasting <30 min toward the periphery of one hemifield and often leaves a scotoma. Postictal headache, often indistinguishable for migraine as defined by the International Classification of Headache Disorders (ICHD-2), occurs in more than half of patients with visual seizures.
Misdiagnosis of visual occipital seizures as migraine appears to be common with significant repercussion on management issues.
We report 2 patients with symptomatic occipital epilepsy who were misdiagnosed as migraine with aura though ictal clinical symptoms were typical of visual epileptic seizures despite severe postictal migraine like headache.