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Evaluation of EEG abnormalities in children with migraine

Ocena nieprawidłowości EEG u dzieci z migreną

Leszek Boćkowski, Joanna Śmigielska Kuzia, Wojciech Sobaniec, Krzysztof Sendrowski

Department of Pediatric Neurology and Rehabilitation, Medical University of Białystok

ABSTRACT

Although EEG is not recommended for the clinical diagnosis of recurrent headache in children, but provides a vast potential for exploring the pathophysiology of migraine. The aim of the paper was the evaluation of EEG in children with migraine with and without aura. Material and method. Our study group con-sisted of 128 children and adolescents aged 7 - 18 years: 35 with migraine with aura, 45 with migraine without aura and 48 subjects with episodic tension-type headache. Patients with epilepsy or seizures history were excluded. EEG was performed interictally at least 24 hours after the last headache attack. Results. EEG was interpreted as abnormal in 62.9% subjects with migraine with aura, 64.4% patients with migraine without aura and in 54.2% children with tension-type headaches. Epi-leptiform discharges were detected in about 50% of records in each group with recurrent headache. In migraine with aura vs. without aura there was a higher incidence of attenuation of EEG activity and focal slow activity, lower incidence of generalized epileptic activity and generalized slow activity. There was an obvious trend towards a higher incidence of epileptic activity in response to photic stimulation in migraine vs. tension-type headache, particularly in migraine without aura. There were no significant differences in distribution of alpha, beta, theta and delta rhythms of background EEG activity in patients with recur-rent headaches. Conclusions. The results of our study based on children without seizure history seems to suggest that the increased incidence of EEG abnormalities in childhood migraine did not necessarily point to an epileptic origin. Some differences between interictal EEG patterns could confirm central neuronal hyperexcitability in migraine.

Keywords: migraine, children, electroencephalography

STRESZCZENIE

Chociaż EEG nie jest zalecane jako badanie diagnostyczne napa-dowych bólów głowy u dzieci, ale może być przydatnym narzę-dziem w badaniach nad patofizjologią migreny. Celem pracy była ocena EEG u dzieci z migreną z aurą i bez aury. Materiał i metoda. Naszym badaniem objęliśmy grupę 128 dzieci w wieku 7 – 18 lat: 35 z migreną z aurą, 45 z migreną bez aury i 48 z bólami głowy typu napięciowego. Wykluczono pacjentów z padaczką i napadami padaczkowymi w wywiadzie. EEG wyko-nywano w okresie bezbólowym, co najmniej 24 godziny po ostatnim ataku. Wyniki. Nieprawidłowy zapis EEG stwierdzono u 62,9% dzieci z migreną z aurą, 64,4% z migreną bez aury i 54,2% dzieci z bólami głowy typu napięciowego. Wyładowania padaczkowe znaleziono w około 50% zapisów EEG w każdej z podgrup napadowych bólów głowy. W grupie dzieci z migreną z aurą w porównaniu z migreną bez aury stwierdzono częst-sze występowanie zapisów niskonapięciowych i ogniskowej czynności wolnej, natomiast rzadziej występowały uogólnione zmiany napadowe i uogólniona czynność wolna. Zaobserwo-wano tendencje do częstszego występowania aktywności napa-dowej jako reakcji na fotostymulację u pacjentów z migreną w porównaniu z bólami głowy typu napięciowego, szczególnie w migrenie bez aury. Nie było istotnych różnic rozkładu fal alfa, beta, hetta i delta w ilościowej ocenie EEG u pacjentów z róż-nymi typami napadowych bólów głowy. Wnioski. Uzyskane przez nas wyniki mogą sugerować, iż duży odsetek nieprawid-łowości EEG w migrenie dziecięcej niekoniecznie odzwierciedla pochodzenie padaczkowe. Pewne różnice zapisów EEG w okre-sie między atakami bólowymi mogą potwierdzać nadpobudli-wość neuronalną charakterystyczną dla migreny.

Słowa kluczowe: migrena, dzieci, elektroencefalografia

The �o�-acu�e headache d�ag�os�s �� ch�ldre� �s based esse���ally o� a de�a�led repor�s o� �he pa��e��s h�s�ory a�d symp�oms a�d o� careful cl���cal exam��a��o�. The role of elec�roe�cephalography �EEG� a�d �he co��rovers�es sur-rou�d��g ��s a��e�da�� use �� �he evalua��o� of headaches �s be��g deba�ed. Al�hough early EEG s�ud�es of m�gra��e emphas��ed �he freque�� ab�ormal record��gs, co��emporary rev�ewers have cr���c��ed mos� of �hem for var�ous me�ho-dolog�cal om�ss�o�s a�d flaws [1-4]. The o�ly s�g��f�ca�� ab�ormal��y repor�ed was �he prom��e�� dr�v��g �� respo�se �o pho��c s��mula��o� �H respo�se� �� m�gra��eurs [1]. O�her EEG ab�ormal���es �� m�gra��e pa��e��s observed dur��g �he

���er�c�al phase were: ���erhem�spher�c asymme�ry of alpha rhy�hm, d�ffuse or focal slow��g a�d ��crease of fas� ac��v��y [5]. Al�hough �h�s �s ���eres���g, �� �s �o� �ecessary for �he cl���cal d�ag�os�s of m�gra��e [6]. Accord��gly, �� gu�del�-�es of Amer�ca� Academy of Neurology a�d Comm���ee of Ch�ld Neurology �oc�e�y [7] a�d recomme�da��o�s of EFN� Task Force [8], record��g of EEG �s �o� rou���ely ��d�ca�ed for �he d�ag�os�s of �o�-acu�e headache �� ch�ldre�. Howe-ver, �� ma�y cases, par��cularly �� ch�ldre� w��h shor� h�s�ory of headaches or w��h �he a�yp�cal headaches, ma�y phys�-c�a�s f��d �� �ecessary �o suppleme�� �he cl���cal work up of headache pa��e��s w��h several �europhys�olog�cal �es�s.

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Accord��g �o �he rece�� publ�shed ques��o��a�re da�a from I�aly, 25 headache spec�al�s�s, 75% �eurolog�s�s a�d 60% of ge�eral prac����o�ers recomme�ded EEG exam��a��o� �o some m�gra��e pa��e��s see� �� �he prev�ous 3 mo��hs [9].

Al�hough mos� �europhys�olog�cal �es�s have l�m��ed value for headache d�ag�os�s bu� �hey have a vas� po�e�-��al for explor��g �he pa�hophys�ology a�d �he effec�s of pharmacolog�cal �rea�me�� [8,10-12]. The curre�� co�cep�s of m�gra��e pa�hoge�es�s e�compasses a �eurovascular hypo�hes�s w��h ce��rally ge�era�ed d�srup��o� of �r�gem�-�al se�sory process��g. �everal s�ud�es have show� �ha� �he �euro�al s�ruc�ures ��volved are �he bra��s�em, �he cerebral cor�ex, per�pheral a�d ce��ral compo�e��s of �r�gem��o-vascular sys�em [11]. The seque�ce of ac��va��o� a�d �he rela��ve roles of �hese s�ruc�ures are s��ll be��g deba�ed. Elec�rophys�olog�cal �ech��ques allow �he s�udy of some of �he s�ruc�ures �� v�vo a�d e�large our k�owledge o� co�-�rovers�al aspec�s of m�gra��e pa�hopys�ology such as cor-��cal exc��ab�l��y or ce��ral se�s����a��o� [12]. Our prev�ous s�ud�es have bee� focused o� cor��cal evoked po�e���als �� ch�ldre� w��h m�gra��e a�d seems �o co�f�rm a� ���er�c-�al dysfu�c��o� �� cor��cal se�sory ��forma��o� process��g [13,14].

Da�a from �he s�ud�es o� �he use of �he EEG �� �he evalua��o� of recurre�� headaches �� ch�ldre� �s very d�f-f�cul� �o ���erpre�. Me�hodolog�cal problems ra�ge from �he pa��e�� popula��o� hav��g m�xed �ypes of headaches, �ll-def��ed d�ag�os��c cr��er�a, mul��ple age groups, lack of co��rol subjec�s a�d u�clear def�����o�s of EEG ab�or-mal���es [3,4,7]. Qua����a��ve freque�cy a�alys�s of EEG �QEEG� w��h or w��hou� �opograph�c mapp��g �s a more objec��ve me�hod �ha� co�ve���o�al EEG ���erpre�a��o�. Th�s �ech��que has bee� used prev�ously �� m�gra��e bu� w��h co��rad�c�ory resul�s [1,15].

There are �o s�ud�es �ha� clearly compare �he ��c�de�ce of EEG ab�ormal���es �� m�gra��e vs. �o� m�gra��e ped�a-�r�c headache pa��e��s [7]. Therefore, �� �h�s s�udy we focu-sed o� �he rou���e EEG a�d qua����a��ve EEG a�alys�s �� ch�ldre� a�d adolesce��s w��h �he m�gra��e w��h aura a�d w��hou� aura �� compar�so� w��h ep�sod�c �e�s�o�-�ype headaches. The a�m of our s�udy was �he evalua��o� a�d compar�so� of charac�er�s��c elec�rophys�olog�c fea�ures of EEG �� ch�ldre� w��h recurre�� headaches w��hou� pas� se��ure h�s�ory.

MATERIAL AND METHODS

The s�udy pro�ocol was approved by �he local e�h�cs com-m���ee of Med�cal U��vers��y �� ��ałys�ok a�d fully ��for-med consent was obtained from the parents of all subject s�ud�ed. The s�udy group co�s�s�ed of 128 of ch�ldre� a�d adolesce��s aged be�wee� 7-18 years, all of �he pa��e��s of �he Depar�me�� of �ed�a�r�c Neurology a�d Reha-b�l��a��o�, Med�cal U��vers��y of ��ałys�ok w��h recurre�� headaches. Th�r�y f�ve of �hem suffered from m�gra��e w��h aura �MA�, 45 of �hem suffered from m�gra��e w��-hou� aura �MO� a�d 48 subjec�s have ep�sod�c �e�s�o�-�ype headache �TTH�. M�gra��e a�d �e�s�o�-�e�s�o�-�ype headaches were d�ag�osed based o� �he cr��er�a of �he seco�d ed���o� of I��er�a��o�al Headache Class�f�ca��o� [16]. A �eurolog�s�

w��h exper�e�ce �� headache ques��o�ed �he pa��e��s abou� �he�r cl���cal fea�ures a�d surveyed cl���cal �eurolog�cal co�d���o�s, ��me of o�se�, freque�cy of a��acks, s�de of pa��, pa�� ���e�s��y a�d �o�headache symp�oms. �ubjec�s were devo�d of a�y o�her pa�hology of ce��ral �ervous sys�em, a�d/or sys�em�c d�sease. �a��e��s w��h ep�lepsy or se��u-res h�s�ory were excluded. No�e of �he pa��e��s rece�ved prophylac��c a���-m�gra��e �herapy.

Record��g sess�o� was performed ���er�c�ally a� leas� 24 hours af�er �he las� headache a��ack, w��hou� assum��g a�y a�alges�c or a�y o�her symp�oma��c �rea�me��. EEG was performed always a� �he same ��me of �he day: 9.00 - 12.00 a.m. MEDELEC DG COM�ACT 32 appara�us was used for EEG record��gs. Elec�rodes were pos���o�ed o� F�1, F�2, F7, F3, FZ, F4, F8, T3, C3, CZ, C4, T4, T5, �3 �4, T6, O1, O2 der�va��o�s, �� accorda�ce w��h �he 10-20 sys�em. The f�l�ers were se� a� 0.3 – 70 H�. Each record��g las�ed a� leas� 20 m�� of EEG spo��a�eous ac��v��y for each subject and included the intermittent photic stimulation ��ra�� dura��o� 5sec w��h ���erval be�wee� �ra��s 2sec, flash ra�e from 2/sec up �o 24/sec.� a�d hyperve���la��o� for 3 m��u�es. We ���erpre�ed �he EEGs v�sually a�d qual�f�ed as �ormal or ab�ormal accord��g �o w�dely accep�ed cr��er�a [17]. EEG ab�ormal���es ��cluded: a. slow ac��v��y �ge�e-ral��ed or focal�, b. a��e�ua��o�/suppres�o� of backgrou�d EEG �decreased ampl��ude of o�e �ype of ac��v��y or of all ac��v��y� c. focal a�d ge�eral��ed ��crease �� EEG ac��v��y, d. assymme�ry �� EEG ac��v��y, e. ep�lep��form d�scharges �focal sp�kes, sharp waves, sp�ke-a�d wave d�scharges, polysp�ke complexes, polysp�ke-a�d-slow-wave comple-xes, mul��ple-sharp-wave complecomple-xes, mul��ple-sharp-a�d-slow-wave complexes, hypsarrhy�m�a� .

For qua����a��ve EEG s�udy ar��fac� free epochs were selec�ed. �egme��s w��h eye moveme��s, hyperve���la-��o�, pho��c s��mula��o� a�d o�her ar�efac�s were excluded. Twe��y 2-seco�ds, segme��s from fro��opar�e�al �F3-��� a�d par�e�oocc�p��al ��3-O1� reg�o�s were a�aly�ed. D�s�r�bu��o� of backgrou�d ac��v��y of alpha, �he�a, del�a a�d be�a rhy�hms was calcula�ed.

��a��s��cal �es�s were do�e us��g �TATI�TICA 6.0. The values of parame�ers w��h�� d�ffere�� headache groups were compared by Ma��-Wh���ey U �es� a�d ��ude�� t test for u�pa�red samples �af�er check��g by ANOVA Kruskal – Wall�s a�alys�s�. ��a��s��cal s�g��f�ca�ce was def��ed as p<0.05. EEG ab�ormal���es were rela�ed �o age, ge�der, dura��o� of �ll�ess, freque�cy of headaches, prese�ce of aura, a�d u��la�eral loca��o� of pa�� by regress�o� a�alys�s ��pearma� ra�k coeff�c�e���.

RESULTS

The mea� age of pa��e��s whe� EEG record��g was do�e was 13.06 ± 2.09 years. Female-�o-male ra��o was 1.3: 1. The demograph�c a�d cl���cal da�a �s prese��ed �� �able 1. A pos���ve fam�ly h�s�ory of m�gra��e was fou�d �� 40% ch�l-dre� w��h m�gra��e, more freque�� �� m�gra��e w��hou� aura. U��la�eral pa�� demo�s�ra�ed abou� half of m�gra��eurs.

The d�s�r�bu��o� of EEG ab�ormal���es �s descr�bed �� �able 2. EEG was ���erpre�ed as ab�ormal �� 62.9% sub-jec�s w��h m�gra��e w��h aura, 64.4% pa��e��s w��h

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m�gra-��e w��hou� aura a�d �� 54.2% ch�ldre� w��h �e�s�o�-�ype headaches. There were �o s�g��f�ca�� d�ffere�ces �� �he d�s�r�bu��o� of EEG ab�ormal pa��er�s accord��g �o all m�gra��eurs a�d �e�s�o�-�ype headaches. I� compar�so� of m�gra��e subgroups, �he ��c�de�ce of a��e�ua��o� of EEG was s�g��f�ca��ly h�gher �� m�gra��e w��h aura vs. w��hou� aura �11.4% vs. 0%; �<0.05�. There was a� obv�ous �re�d, al�hough �o� s�a��s��cally s�g��f�ca��, �owards a h�gher ��c�-de�ce of focal slow ac��v��y �� m�gra��e w��h aura �20% vs. 8.8%� a�d a h�gher ��c�de�ce of ge�eral��ed slow ac��v��y �� m�gra��e w��hou� aura �22.2% vs. 8.6%�. No�e of �he pa��e��s demo�s�ra�ed a�y fas� ac��v��y or ��crease �� EEG ac��v��y. O� �he o�her ha�d, ep�lep��form d�scharges were de�ec�ed �� abou� 50% of records �� each group w��h recur-rent headache.

The d�s�r�bu��o� of ep�lep��form d�scharges accord��g �o �he d�ffere�� headache �ypes �s prese��ed �� �able 3. The mos� freque��ly observed ep�lep��form d�scharges co�s�-s�ed of o�e of �he follow��g: focal sp�kes a�d sharp waves or ge�eral��ed ep�lep��c ac��v��y. The ��c�de�ce of focal d�scharges was s�m�lar �� all groups: m�gra��e w��h aura, w��hou� aura a�d �e�s�o� �ype headaches. However, �he ��c�de�ce of ge�eral��ed ep�lep��c ac��v��y was s�g��f�ca�-�ly lower �� m�gra��e w��h aura vs. m�gra��e w��hou� aura

�8.6% vs. 26.7%; �<0.05�. O�her ep�lep��form d�scharges were rare or not found.

Ep�lep��c ac��v��y �� respo�se �o ac��va��o� me�hods shows f�g 1. There was a� obv�ous �re�d, al�hough �o� s�a-��s��cally s�g��f�ca��, �owards a h�gher ��c�de�ce of ep�lep-��c ac��v��y �� respo�se �o phoep�lep-��c s��mula��o� �� m�gra��e vs �e�s�o�-�ype headache �8.8% vs. 2.1%�, par��cularly �� m�gra��e w��hou� aura �11.1%�. The ��c�de�ce of ep�lep-��c ac��v��y �� respo�se �o h�perve���la��o� was s�m�lar �� m�gra��eurs w��hou� aura a�d �e�s�o�-�ype headache suffe-rers �40% a�d 37.5% respec��vely� a�d lower �� m�gra��e w��h aura �25.7%�.

Table 4 prese��s da�a of qua����a��ve EEG a�alys�s. There were �o s�g��f�ca�� d�ffere�ces �� d�s�r�bu��o� of alpha, be�a, �he�a a�d del�a rhy�hms �� pa��e��s w��h recur-rent headaches.

We a�aly�ed also �he correla��o� be�wee� cl���cal da�a a�d EEG f��d��gs. There were �he �ega��ve correla��o� be�wee� EEG ab�ormal���es ��c�de�ce a�d �he age of pa��e�� �R= - 0.359; �<0.001�. We fou�d �o s�g��f�ca�� correla��o� be�wee� �he EEG pa��er�s a�d �he ge�der of pa��e��s, aura, d�sease dura��o�, freque�cy of a��acks, pos���ve h�s�ory of m�gra��e �� fam�ly, u��la�eral loca��o� of pa��.

Table I. Demographic and clinical data of the patients

Migraine with

aura (MA) Migraine without aura (MO) Migraine(M) Episodic tension – type headache (TTH)

Number of subjects (n) 35 45 80 48

Age of patients, years (mean ± SD) 14.46 ± 1.93 11.42 ± 2.58 12.67 ± 2.70 13.32 ± 2.86

Gender (female/male) 17f/18m 20f/25m 37f/43m 35f /13m

Duration of illness in months: mean ± SD 21.77 ± 30.04 24.75 ± 22.21 22.90 ± 28.04 15.34 ± 13.63 Unilateral headache location: n (%) 24 (68.6%) 19 (42.2%) 43 (53.8%) 0 (0%) History of migraine in family: n (%) 10 (28.6%) 22 (48.9%) 32 (40%) 2 (4%)

Table II. Distribution of EEG abnormalities in children with recurrent headaches

EEG findings Migraine with aura (n=35) Migraine without aura (n=45) MigraineN=80) Episodic tension – type headache (n=48)

Normal (%) 13 (37.1%) 16 (35.6%) 29 (36.3%) 22 (45.8%)

Abnormal (%) 22 (62.9%) 29 (64.4%) 51 (63.7%) 26 (54.2%)

Generalized slow activity (%) 3 (8.6%) 10 (22.2%) 13 (16.3%) 8 (16.7%)

Focal slow activity (%) 7 (20%) 4 (8.8%) 11 (13.8%) 3 (6.3%)

Attenuation (%) 4 (11.4%)* 0 4 (5%) 1 (2.1%)

Fast activity (%) 0 0 0 0

Increase in EEG Activity (%) 0 0 0 0

Interhemispheric

Assymetry of alpha rhytm (%) 1 (2.9%) 0 1 (1.3%) 0

Epileptiform discharges (%) 17 (48.6%) 23 (51.1%) 40 (50%) 24 (50%) * P<0.05 vs. migraine without aura (ANOVA Kruskal – Wallis analysis)

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Table III. Distribution of epileptiform discharges in EEG of children with recurrent headaches

EEG findings Migraine with aura (n=35) Migraine without aura (n=45) MigraineN=80) Episodic tension – type headache (n=48)

Focal spikes 0 0 0 0

Focal sharp waves (%) 17 (48.6%) 23 (51.1%) 40 (50%) 23 (47.9%)

Spike-and-wave complexes (%) 0 1 (2.2%) 1 (1.3%) 0

Sharp-and-slow-wave complexes 0 0 0 0

Polyspike complexes 0 0 0 0

Multiple-sharp-wave compexes 0 0 0 0

Generalized epileptic activity (%) 3 (8.6%)* 12 (26.7%) 15 (18.8%) 11 (22.9%) * P<0.05 vs. migraine without aura (ANOVA Kruskal – Wallis analysis)

Fig. 1. Epileptic activity during photic stimulation and hyperventilation in children with recurrent headaches (%) Table IV. Distribution of the background EEG activity in F3-Pz and P3-O1 derivative in children with headaches

Migraine with aura

(n=35) Migraine without aura (n=45) Episodic tension – type headache (n=48) Alpha rhythm (%) in F3-Pz 32.07 ± 13.72 34.13 ± 11.21 34.57 ± 16.25

Alpha rhythm (%) in P3-O1 33.97 ± 12.60 34.063 ± 9.23 37.42 ± 13.76

Theta rhythm (%) in F3-Pz 33.39 ± 8.19 29.53 ± 7.97 20.08 ± 10.99

Theta rhythm (%) in P3-O1 31.75 ± 7.59 30.59 ± 10.24 32.02 ± 7.57

Delta rhythm (%) in F3-Pz 56.44 ± 14.39 57.77 ± 11.47 57.59 ± 11.63 Delta rhythm (%) in P3-O1 52.86 ± 14.11 56.02 ± 14.64 51.75 ± 13.27

Beta rhythm (%) in F3-Pz 8.14 ± 2.69 6.92 ± 1.75 7.09 ± 3.81

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DISCUSSION

Mos� of �he publ�shed s�ud�es repor�ed rou���e EEG da�a o� ch�ldre� w��h „all �ypes” of recurre�� headaches, ��cluded �e�s�o� �ype-�ype headaches, m�gra��e, „s��us” headache a�d so o� [3, 18, 19]. A 1960 s�udy of 500 ch�ldre� w��h recurre�� headache repor�ed �ha� 44% of EEGs were ab�or-mal [20]. The perce��age of pa��e��s w��h ab�orab�or-mal EEG �� o�her s�ud�es var�ed from 20.6% [3] �o 40.8% [19]. D�ffere�� �o� spec�f�c EEG pa��er�s were recorded: sp�ke d�scharges, paroxysmal slow wave ac��v��y, ge�eral��ed slow��g, a�d fas� ac��v��y. Da�a for �he headache subgroups was pooled so �ha� ex�rac��o� of EEG �� pa��e��s w��h m�gra��e vs. all o�her groups could �o� be do�e [7]. �rev�ous s�ud�es focused o� ch�ldre� w��h m�gra��e have sugges�ed �ha� �he EEG �� m�gra��eurs �s more l�kely �o be ab�ormal �ha� �� o�her �ypes of headaches [21,22, 23,24]. The perce��age of ch�ldre� w��h a� ab�ormal EEG was h�gher a�d var�ed from 11% [22] �o 51.9%[23], 73.4% [24] a�d 75% [21]. Nevo e� al. a�aly�ed �he EEGs of 257 ch�ldre� w��h headache a�d fou�d ���er�c-�al ep�lep��c ab�ormal���es prese�� �� 12% cases [25]. They also �de���f�ed a subgroup of ch�ldre� suffer��g from m�gra-��e w��h �he freque�cy of spec�f�c ab�ormal�m�gra-��es ra�s��g �o 26.7%. These da�a correla�e card��ally w��h our resul�s. EEG was ���erpre�ed as ab�ormal �� 62.9% subjec�s w��h m�gra-��e w��h aura, 64.4% pam�gra-��e��s w��h m�gram�gra-��e w��hou� aura a�d �� 54.2% ch�ldre� w��h �e�s�o�-�ype headaches. Of �hese 80 ch�ldre�, 16.3% had ge�eral��ed slow ac��v��y, 13.3% had focal slow ac��v��y, 5% had a��e�ua��o� a�d 50% had ep�-lep��form d�scharges. Da�a from l��era�ure also demo�s�ra-�es �o�spec�f�c EEG ab�ormal��demo�s�ra-�es �� m�gra��eurs. I� �he re�rospec��ve s�udy [24], 64 ch�ldre� w��h m�gra��e had a� EEG w��h �he follow��g fea�ures: d�ffuse slow��g �38%�, paroxysmal ac��v��y �27%� a�d focal ab�ormal���es �13%�. Ep�lep��form d�scharges �� our pa��e��s w��h m�gra��e were represe��ed mos� freque�� by focal sharp waves a�d sp�kes �50%� or ge�eral��ed ep�lep��c ac��v��y �22.9%�. O�her au�-hors also fou�d h�gh ��c�de�ce of sp�ke a�d sharp waves from 10% [22] �o 46.9% [24] a�d slow��g of ac��v��y from 0% [23] �o 27% [24].

The d�screpa�c�es be�wee� var�ous ��ves��ga��o�s are probably caused by several fac�ors. Vary��g d�ag�os��c cr��er�a for m�gra��e were used a�d �o�e of c��ed s�ud�es [21-24] used �he curre��ly accep�ed IH� cr��er�a. �ome au�hors recog���ed „se��ure headaches” [18] or „se��ure-rela�ed headaches” [3,26]. Vary��g cr��er�a of EEG ab�or-mal���es were used. For example, spec�f�c EEG pa��er� 14 a�d 6 cycles per seco�d ���erpre�ed as ab�ormal �� 46.4% m�gra��eurs [21] �s �ow co�s�dered as a be��g� var�a��. �ome��mes s�ud�es do �o� def��e �he „�yp�cal EEG fea�u-res” or „�yp�cal ep�lep��form d�scharge” [18]. Moreover, �he au�hors do �o� s�a�e whe� �he EEG was performed �� rela��o� �o �he epoch of headache al�hough �c�al a�d pre-�c�al EEG cha�ges have bee� repor�ed by some resear-chers [27]. Impor�a�� fac�or �s selec��o� of subjec�s �o EEG ��ves��ga��o� because of rela��o�sh�p be�wee� m�gra��e a�d ep�lepsy. Ma�y s�ud�es have suppor�ed hypo�hes�s of al�era��o� of cor��cal hyperexc��ab�l��y as a poss�ble pa�ho-log�cal mecha��sm u�derly��g �he o�se� of m�gra��e a�d ep�lep��c a��acks [11,12,15,28]. Of �he 17 pa��e��s w��h

paroxysmal EEG, 7 had h�s�ory of se��ures a�d 4 had a fam�ly h�s�ory of se��ures [24]. Therefore we excluded pa��e��s w��h h�s�ory of ep�lep��c se��ures. However, �� our s�udy �he ��c�de�ce of ep�lep��form d�scharges �� m�gra��e was ra�s��g �o 50%.

We d�d �o� f��d a�y s�g��f�ca�� d�ffere�ces �� d�s�r�-bu��o� of EEG ab�ormal pa��er�s accord��g �o all m�gra-��eurs. However, �here was a� obv�ous �re�d �owards a h�gher ��c�de�ce of ep�lep��c ac��v��y �� respo�se �o pho��c s��mula��o� �� m�gra��e vs �e�s�o�-�ype headache. �ome au�hors repor�ed s�g��f�ca��ly h�gher ��c�de�ce of slo-w��g �ha� �he group w��h o�her �ypes of headaches [3], bu� rev�ew of ava�lable da�a from l��era�ure also do �o� co�f�rm d�ffere�ces be�wee� ch�ldre� w��h m�gra��e as compared �o �hose w��h o�her recurre�� headache �ypes [7].

We observed some d�ffere�ces be�wee� EEG pa��er�s �� m�gra��e w��h aura a�d w��hou� aura. The h�gher ��c�-de�ce of a��e�ua��o� of EEG ac��v��y, lower ��c���c�-de�ce of ge�eral��ed ep�lep��c ac��v��y, �re�ds �owards a h�gher ��c�-de�ce of focal slow ac��v��y a�d lower ��c���c�-de�ce of ge�e-ral��ed slow ac��v��y a�d were fou�d �� m�gra��eurs w��h aura. ��cc��ell� e� al. a�aly�ed �he EEGs of 137 ch�ldre� and adolescents with recurrent headache and found speci-f�c ���er�c�al ab�ormal���es �� 11.7% of �he whole sample [28]. The d�s�r�bu��o� of ab�ormal���es across subgroups of pa��e��s w��h headaches �� a c��ed s�udy was s�g��f�ca��ly d�ffere��: 5.9% �� �e�s�o�-�ype headaches, 5.4% �� m�gra-��e w��hou� aura a�d 43.5% �� m�gram�gra-��e w��h aura. The au�hors sugges� �he hypo�hes�s of a poss�ble cl���cal co���-�uum be�wee� some �ypes of m�gra��e w��h aura a�d ep�-lep��c sy�dromes due �o al�ered �euro�al exc��ab�l��y w��h s�m�lar ge�e��c subs�ra�es [28]. Cha��elopa�h�es of vol�age-ga�ed Na a�d K cha��els m�gh� be a l��k be�wee� m�gra-��e w��h aura a�d ep�lepsy [11]. Th�s co�clus�o� �s also suppor�ed by �he ev�de�ce of prove� eff�cacy of m�gra��e prophylac��c drugs, such as calc�um cha��el blockers a�d a���co�vulsa��s [28].

I��r�gu��g da�a �� our s�udy �s represe��ed by �he h�gh propor��o� of ep�lep��c ac��v��y �� respo�se �o pho��c s��mu-la��o� a�d hyperve���s��mu-la��o� �� pa��e��s w��h m�gra��e w��-hou� aura �11.1%, 5 of 45 a�d 40%, 18 of 45 respec��vely� vs. m�gra��e w��h aura �5.7%, 2 of 35 a�d 25.7%, 9 of 35 respec��vely�. A�o�her s�udy prese��ed co��rary resul�s – h�gh propor��o� of pho�ose�s���v��y �� pa��e��s w��h m�gra-��e w��h aura �30.4%�, wh�le �� was �o� a �r�gger��g fac�or �� ch�ldre� w��h o�her �ypes of headache [28]. �ome au�-hors co�s�der �he prese�ce of pho�oparoxysms �� m�gra��e as a �ega��ve prog�os��c fac�or of ep�lepsy o�se� [29].

Qua����a��ve freque�cy a�alys�s of EEG �QEEG� has bee� used prev�ously �� m�gra��e bu� w��h co��rad�c�ory resul�s. I�creased or decreased alpha power, ��creased power, ��creasedpower, ��creased asymme�ry, ��creased del�a a�d �he�a power have bee� repor�ed ���er�c�ally �� m�gra��e [30,31] Moreover, QEEG power a�d asymme�ry ��crease 36 hours before �he �ex� m�gra��e a��ack compared w��h �he ���er�c�al per�od [27]. The ma�� spo��a�eous ab�ormal���es �� EEG spec�ral a�al-ys�s fou�d dur��g �he cr���cal phase of m�gra��e a��ack were �he slow��g a�d asymme�ry of �he dom��a�� freque�cy �� �he alpha ra�ge [32]. I� our s�udy �here were �o� a�y

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s�g-��f�ca�� d�ffere�ces �� d�s�r�bu��o� of alpha, be�a, �he�a a�d del�a rhy�hms �� a��ack-free per�ods �� pa��e��s w��h m�gra��e w��h aura, w��hou� aura a�d �e�s�o�-�ype head-aches. O�ly few s�ud�es �� l��era�ure co��a��ed da�a �ha� compared QEEG �� ch�ldre� w��h m�gra��e w��h aura a�d w��hou� aura [31,33,34,35]. Vald��a� e� al fou�d ��creased �he�a/alpha ra��o �� m�gra��e w��h aura, �ormal �� �e�-s�o�-�ype headaches [35], o�her au�hors d�d �o� repor� a�y s�g��f�ca�� d�ffere�ces be�wee� ���er�c�al EEG �� ch�ldre� w��h m�gra��e w��h aura a�d w��hou� aura[31,33,34]. How-ever, �� �s �o� easy �o compare �he resul�s from d�ffere�� QEEG s�ud�es because d�ffere�� me�hodolog�cal pro�ocols have bee� appl�ed [15].

CONCLUSIONS

I� co�clus�o�, al�hough EEG �s �o� recomme�ded �o exclude a s�ruc�ural cause for recurre�� headache �� ch�ldre�, bu� pre-se��s a vas� po�e���al for explor��g �he pa�hophys�ology of m�gra��e. I� our op���o�, �he resul�s of our s�udy, based o� ch�ldre� w��hou� se��ures h�s�ory, a�d da�a from l��era�ure, sugges� �ha� �he ��creased ��c�de�ce of EEG ab�ormal���es �� ch�ldhood m�gra��e d�d �o� �ecessar�ly po��� �o a� ep�lep��c or�g��. However, �he hypo�hes�s of �he l��k be�wee� ep�lepsy a�d m�gra��e, par��cularly w��h aura, could �o� be excluded. �ome d�ffere�ces be�wee� ���er�c�al EEG pa��er�s �� m�gra-��e w��h aura, m�gram�gra-��e w��hou� aura a�d �e�s�o�-�ype hea-daches could sugges� ce��ral �euro�al hyperexc��ab�l��y �� m�gra��e pred�spos��g �o �he headache a��acks.

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Correspondence:

Leszek Boćkowski, Department of Pediatric Neurology and Rehabilitation, Medical University of Białystok, 17 Waszyngtona Str., 15-274 Białystok, Poland

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