Functional neurological seizures and migraine: A systematic review and case series

Laura Duque; Ivan Garza; Gregory D Cascino; Jeffrey P Staab

doi:10.1016/j.yebeh.2023.109437

Functional neurological seizures and migraine: A systematic review and case series

Epilepsy Behav. 2023 Oct:147:109437. doi: 10.1016/j.yebeh.2023.109437. Epub 2023 Sep 15.

Authors

Laura Duque¹, Ivan Garza², Gregory D Cascino³, Jeffrey P Staab⁴

Affiliations

¹ Department of Psychiatry & Psychology, Mayo Clinic, Rochester, MN, USA; Department of Psychiatry, Brigham and Women's Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA.
² Department of Neurology (Headache Division), Mayo Clinic, Rochester, MN, USA.
³ Department of Neurology (Epilepsy Division), Mayo Clinic, Rochester, MN, USA.
⁴ Department of Psychiatry & Psychology, Mayo Clinic, Rochester, MN, USA; Department of Otorhinolaryngology - Head and Neck Surgery, Mayo Clinic, Rochester, MN. Electronic address: staab.jeffrey@mayo.edu.

PMID: 37717461
DOI: 10.1016/j.yebeh.2023.109437

Abstract

Background: The seizure subtype of functional neurological disorder (FND-seizures) is a common neuropsychiatric condition manifesting with episodic epilepsy-like events. Despite the common belief that FND-seizures are precipitated by psychological stressors, neurological disorders may also be triggers. In 1890, Babinski described four cases of FND symptoms associated with migraine attacks. Despite the passing of more than 130 years since this first clinical observation, the relationship between FND-seizures and migraine is not fully elucidated.

Objectives: (1) To complete a systematic review of the literature that investigated potential associations between FND-seizures and migraine and the response of FND seizures to treatment with migraine prophylactic medications (2). To undertake a retrospective study of patients with FND-seizures and migraine, including response to migraine prophylaxis.

Methods: (1) Using PRISMA methods, we completed a systematic review of EMBASE and Scopus databases from inception to March 31, 2021, for literature on FND-seizures and migraine. (2) Our multi-disciplinary team, including subspecialists in psychosomatic medicine, epilepsy, and headache disorders, reviewed consecutive patients diagnosed with FND-seizures and migraine to assess potential causal associations and responses to standard migraine prophylactic medications.

Results: (1) The search yielded seven studies from 126 screened manuscripts (N = 1,186 patients with FND-seizures; mean age 38.7 years; 72.6% female). They varied substantially in design, population, diagnostic measures, and outcomes. Nevertheless, all studies found associations between FND-seizures and migraine, which were stronger than those between epileptic seizures and migraine in comparative investigations, but provided limited information on treatment response. (2) In our case series, investigators reached unanimous consensus that migraine attacks triggered FND-seizures in 28/43 (65.1%) patients reviewed (mean age, 38.8 years; 74% female). In 19/26 (73%) patients with adequate follow-up data, treatment with migraine prophylactic medications alone (no behavioral interventions) concomitantly reduced FND-seizure and headache frequency by >50%.

Conclusion: Our systematic review and case series indicate that migraine attacks may trigger FND-seizures, perhaps more often that currently understood, and suggest that migraine prophylaxis may reduce FND-seizure frequency in such cases. To validate these observations, fully powered prospective investigations are required.

Keywords: Conversion disorder; Functional neurologic disorder; Functional seizures; Migraine; Migraine prophylaxis; Non-epiletic seizures.