EEG-BM & Headache

Sub-bag Neurofisiologi/Poli Elektromedik FK- UGM/RS Sardjito

THE ELECTROENCEPHALOGRAM IN THE EVALUATION OF HEADACHE The American Academy of Neurology 1994

Headache disorders are clinical syndromes defined by historical criteria. The EEG is not included in the diagnostic criteria of the International Headache Society for migraine or other major headache categories. The majority of headache sufferers do not have an identifiable structural lesion that explains their pain.

therefore
An EEG could be considered useful in the evaluation of headache if abnormalities were observed that :
(1) separate persons with and without headache, potentially shedding light on the underlying pathophysiology of headaches; (2) define subgroups associated with different natural histories or responses to therapy; or (3) effectively identify patients with a definable structural etiology.

THE EVIDENCES

Electroencephalographic mapping in migraine during the critical and intercritical periods Rev Electroencephalogr Neurophysiol Clin. 1987 Sep;17(3):289-99.

Twenty-nine migraineurs underwent spectral analysis and topographic EEG mapping.

Migraine with a complex aura, posterior-anterior spreading of slow activities and depression of alpha activity contralateral to the neurological signs were the prominent findings. Migraine with a visual aura had unilateral reduction of alpha and theta activity. Common migraine the only abnormality was markedly reduced alpha activity over one occipital region and reduction of theta activity in the same location.
Note: In all patients, except one, restudied at least 7 days after an attack, EEG asymmetries had disappeared

Cont.
Unilateral EEG changes can thus be detected during attacks of both classic and common migraine. The posterior-anterior spreading of slow activities during an induced attack of classic migraine has temporal and spatial similarities with the "spreading oligemia. This suggests that common, as classic, migraine is associated with unilateral disturbances of cortical electrogenesis, which might reflect an underlying metabolic abnormality.

Brain mapping in migraine. Hughes JR, Robbins LD. Clin Electroencephalogr. 1990 Jan;21(1):14-24.

The topographic maps of 100 various types of headache >< 38 normal :

Patients with classic migraine showed 11 markers, but especially three of high amplitude theta on 0(1) and alpha on 0(1) and T6, Patients with other types of headaches in general did not show useful markers.

EEG in migraine: a review of the literature. Sand T.Funct Neurol. 1991 Jan-Mar;6(1):7-22.

Results demonstrate that there are no significant differences between the control group and the tension-type headache group. Neither were differences found in migraine without aura group but in migraine with aura there was an increase of the theta/alpha ratio in the temporal posterior and occipital zones. This ratio could be used as a neurophysiological indicator in the evolution of the migraine with aura pathology.

Alpha rhythm power and the effect of photic stimulation in migraine with brain mapping. Tsounis S, Varfis G. Clin Electroencephalogr. 1992 Jan;23(1):1-6.

The topographic maps of 50 patients suffering from migraine with or without aura were compared to the brain maps of 20 normal controls and 20 patients with tension-type headaches. Only the migraine group showed a significant decrement of alpha rhythm power, during rest with eyes closed, at the posterior areas of the brain, and a significant increment of alpha power at the same regions during IPS at 20 c/sec.

Clinical neurophysiology studies in headache: a review of data and pathophysiological hints. Schoenen J. Funct Neurol. 1992 May-Jun;7(3):191-204.

In migraine between attacks EMG studies are normal. Temporalis exteroceptive silent period is useful in the differential diagnosis of headaches and sheds some light on the pathophysiology of tension-type headache.

THE ELECTROENCEPHALOGRAM IN THE EVALUATION OF HEADACHE The American Academy of Neurology 1994

Prominent photic driving at high flash frequencies (H-response) in migraine patients is the most consistently reported difference between headache patients and controls.

Quantitative EEG in children with headache. Valdizan JR, Andreu C, Almarcegui C, Olivito A. Headache. 1994 Jan;34(1):53-5.

Results demonstrate that there are no significant differences between the control group and the tension-type headache group. Neither were differences found in migraine without aura group but in migraine with aura there was an increase of the theta/alpha ratio in the temporal posterior and occipital zones. This ratio could be used as a neurophysiological indicator in the evolution of the migraine with aura pathology.

Neurophysiological tests and neuroimaging procedures in non-acute headache: guidelines and recommendations European Journal of Neurology 2004, 11: 217224

Interictal electroencephalography (EEG) is not routinely indicated in the diagnostic evaluation of headache patients. Interictal EEG is, however, indicated if the clinical history suggests a possible diagnosis of epilepsy (differential diagnosis). Ictal EEG could be useful in certain patients suffering from hemiplegic and basilar migraine.

Cerebral mapping in subjects suffering from migraine with aura Dante et al. Cephalalgia Volume 10 Issue 6 Page 279 - December 1990

Cerebralmapping of the spontaneous electroencephalographic activity was performed in 31 subjects suffering from migraine with aura and the results were compared with those of a matched control group. All the patients were examined during the interictal period. Traditional visual interpretation of EEG records was negative in all exept five cases (16.1%) Spectral analysis showed an asymmetry in alpha total power over the posterior regions in 13 cases (41.9%) and an asymmetry in alpha band peak frequency in 17 (54.8%). By means of cerebral mapping and statistical significance probability demonstrate a significant increase in alpha total power in 13 cases (41.9%) and a regional increase in delta and theta total power in 20 cases (64.5%). In comparison with the control group, the migraine patients showed a widespread increase in slow activity (theta and delta) mostly over the temporal regions.

Review

In a few controlled and blinded studies, however, slight excess of various EEG rhythms has been found in migraine patients. Similar prevalences of interictal EEG abnormalities have generally been found in patients with classic and common migraine, but the diagnostic classification may not have been precise enough in some studies. During visual aura, either slow waves, depression of background activity amplitude or normal EEG have been reported. The most definitely abnormal EEGs with unilateral or bilateral delta activity have been recorded during attacks of hemiplegic migraine, and during attacks of migraine with disturbed consciousness. The relationship between migraine and epilepsy has still not been adequately clarified. The connection seems to exist in several small entities (e.g. migraine-like headache as an epileptic manifestation, epileptic seizures triggered by epileptic attacks, and possibly in epilepsies with occipital spike waves), but it is seemingly not "fundamental". Newer methods, i.e. EEG frequency analysis and topographic brain mapping, are promising tools in this field. So far, mostly small studies have been published with somewhat inconsistent results. A pattern of increased alpha rhythm variability (and/or asymmetry) in the headache-free phase seems to emerge, however.

Evidence 1987

Migraine Posterior-anterior spreading of slow activities Depression of alpha activity contralateral Reduction of alpha and theta activity. High amplitude theta on 0(1) and alpha on 0(1) and T6 Increase in alpha total power Regional increase in delta and theta total power Widespread increase in slow activity (theta and delta) mostly over the temporal regions. Increase of the theta/alpha ratio in the temporal posterior and occipital zones. Decrement of alpha rhythm power, during rest Increment of alpha power at during IPS EMG studies are normal. Prominent photic driving at high flash frequencies (H-response) Theta/alpha ratio in the temporal posterior and occipital zones -

TTH

1990

No marker

1991 1992 1992 1994 1994 children

No marker No marker Temporalis exteroceptive silent period No abnormality No abnormality

Review

Slight excess of various EEG rhythms slow waves. Depression of background activity amplitude Unilateral or bilateral delta activity Normal EEG

Increased alpha rhythm variability (and/or asymmetry) in the headache-free phase

THE RECOMMENDATIONS

 The EEG is not useful in the routine evaluation of patients with headache. This does not exclude the use of EEG to evaluate headache patients with associated symptoms suggesting a seizure disorder, such as atypical migrainous aura or episodic loss of consciousness. Assuming head-imaging capabilities are readily available, EEG is not recommended to exclude a structural cause for headache (option).

CONCLUSION

 Current QEEG methods are not routinely indicated in the diagnostic evaluation of headache patients. Quantitative frequency analysis of EEG must always be recorded with raw EEG data and interpreted by a skilled physician in order to avoid misinterpretation of technical artifacts, normal state fluctuations and various physiological rhythms.