Prevalence of benign epileptiform variants from an EEG laboratory in India and frequency of their misinterpretation.

OBJECTIVE: To prospectively study the prevalence of benign epileptiform variants (BEVs) and their impact on epilepsy misdiagnosis. METHODS: Consecutive patients, older than one year, who underwent EEG from January 2016 to December 2019 were prospectively studied for the presence of BEVs. We used descriptions of Klass and Westmoreland (1985) to categorize the BEVs. We reviewed old EEG reports and records in patients with BEV to determine whether they were interpreted as abnormal. RESULTS: Of the 1862 subjects included, 1474 (79 %) patients had epilepsy while 388 (21 %) had other diagnoses. The mean age of the subjects was 23.1 ± 15.3 years and 1111 (60 %) were males. BEVs were noted in 223 (12 %) subjects undergoing EEG. The most common BEVs were wicket waves (n = 127, 6.8 %) and small sharp spikes (n = 69, 3.7 %) while 6 Hz spike-wave discharges (0.9 %), 14 and 6 Hz positive spikes (0.6 %), rhythmic mid-temporal theta burst of drowsiness (0.4 %) and subclinical rhythmic epileptiform discharges in adults (0.2 %) were less common. Patients with BEVs were older and were more likely to have normal EEG (68.2 % vs. 55.8 %; p < 0.001). BEVs were not mentioned in any of the 282 previous EEG reports. BEVS were considered to be over-interpreted as epileptiform abnormalities in 31 of 101 (30 %) records available for review. CONCLUSION: BEVs are present in 12 % of subjects undergoing EEG. BEVS are largely unrecognized and are misdiagnosed as epileptiform discharges in one third of the patients by the general neurologists.

Prevalence of photoparoxysmal response in patients with epilepsy: Effect of the underlying syndrome and treatment status.

OBJECTIVE: To prospectively study the prevalence of photoparoxysmal response (PPR) and its determinants in epilepsy patients. METHODS: Consecutive patients, older than 2 years, undergoing EEG from January 2016 to December 2019 were prospectively studied for the presence of PPR. Patients with emergent EEG and those with only sleep record were excluded. Intermittent photic stimulation was performed as per standard techniques with frequencies from 1-30 Hz. RESULTS: Of the 1893 subjects included, 1492 (78%) patients had epilepsy while 401 (22%) had other diagnoses. In epilepsy group, 1028 (68.7%) had focal epilepsy, 343 (21.6%) had generalized epilepsy, while (9.7%) patients had unclassified epilepsy. Overall, 36 (2.2%) patients with epilepsy had PPR. The mean age of these patients was 19.5 ± 9.4 years and 75% were females. PPR was noted in 5 (0.5%) patients with focal epilepsy and 31 (9%) patients with generalized epilepsies [p < 0.0001; Odds ratio: 20.3 (95% CI, 7.8 - 52.7)]. PPR was noted in 1.5% of treated and 18% of untreated patients with genetic generalized epilepsy (n = 145) and 22% of untreated patients with juvenile myoclonic epilepsy (n = 86). Patients with untreated epilepsy had 17 times higher odds of having PPR [p < 0.0001; Odds ratio: 17.6 (95% CI, 4.1 - 75.6)]. CONCLUSION: Underlying epilepsy syndrome and treatment status are the two most important determinants of PPR. Variability in these two factors is largely responsible for the variable reported prevalence of PPR.

Vitamin D Deficiency in Patients With Chronic Tension-Type Headache: A Case-Control Study.

OBJECTIVE: To see the interrelation between chronic tension-type headache (CTTH) and serum vitamin D levels. BACKGROUND: Several studies have suggested an association between chronic pain and vitamin D deficiency. Anecdotal evidence suggests that vitamin D deficiency may be associated with tension-type headache and migraine. METHODS: This case-control study was carried out to examine the association between CTTH and serum 25-hydroxy vitamin (25(OH) D) levels. One hundred consecutive adult (>18 years) patients with CTTH and 100 matched healthy controls were enrolled. RESULTS: The serum 25(OH) D levels were significantly lower in CTTH patients than in the controls (14.7 vs 27.4 ng/mL). The prevalence of vitamin D deficiency (serum 25 (OH) D < 20 ng/mL) was greater in patients with CTTH (71% vs 25%). CTTH patients had a significantly high prevalence of musculoskeletal pain (79% vs 57%), muscle weakness (29%vs 10%), muscle tenderness score (7.5 vs 1.9), and bone tenderness score (3.0 vs 0.8) in comparison to controls. CTTH patients with vitamin D deficient group (<20 ng/mL) had a higher prevalence of musculoskeletal pain (58% vs 31%), muscle weakness (38%vs 7%), muscle and bone tenderness score, associated fatigue (44% vs 17%) and more prolonged course (15.5 months vs 11.2 months). A strong positive correlation was noted between serum vitamin D levels and total muscle tenderness score (R2 = 0. 7365) and total bone tenderness score (R2 = 0. 6293). CONCLUSION: Decreased serum 25(OHD) concentration was associated with CTTH. Intervention studies are required to find out if supplementation of vitamin D is effective in patients with CTTH.

A Cross-Sectional Clinic-Based Study in Patients With Side-Locked Unilateral Headache and Facial Pain.

OBJECTIVE: To undertake the epidemiological evaluation of the patients presenting with side-locked headache and facial pain in a tertiary neurology outpatient clinic. BACKGROUND: Side-locked unilateral headache and facial pain include a large number of primary and secondary headaches and cranial neuropathies. A diagnostic approach for the patients presenting with strictly unilateral headaches is important as many of these headache disorders respond to a highly selective drug. Epidemiological data may guide us to formulate a proper approach for such patients. However, the literature is sparse on strictly unilateral headache and facial pain. METHODS: We prospectively recruited 307 consecutive adult patients (>18 years) with side-locked headache and facial pain presenting to a neurology outpatient clinic between July 2014 and December 2015. All patients were subjected to MRI brain and other investigations to find out the different secondary causes. The diagnosis was carried out by at least two headache specialists together. All patients were classified according to the International Classification of Headache Disorder-third edition (ICHD-3ß). RESULTS: The mean age at the time of examination was 42.4 ± 13.6 years (range 18-80 years). Forty-eight percent of patients were male. Strictly unilateral headaches accounted for 19.2% of the total headaches seen in the clinic. Headaches were classified as primary in 58%, secondary in 18%, and cranial neuropathies and other facial pain in 16% patients. Five percent of patients could not be classified. Three percent of patients were classified as per the Appendix section of ICHD-3ß. The prevalence of secondary headaches and painful cranial neuropathies increased with age. A total of 36 different diagnoses were made. Only two diseases (migraine and cluster headache) had a prevalence of more than 10%. The prevalence of 13 diseases varied between 6 and 9%. The prevalence of other 14 groups was ≤1%. Migraine was the most common diagnosis (15%). Cervicogenic headache was the most common secondary headache. Classical trigeminal neuralgias and persistent idiopathic facial pain were two most common diagnoses in the painful cranial neuropathies and other facial pain groups. Sixty-one percent fulfilled the definition of chronic daily headaches, and hemicrania continua and cervicogenic headache were the two most common diagnoses in this group. CONCLUSIONS: A large number of primary and secondary headaches and cranial neuropathies may present as side-locked headache and facial pain syndromes. Therefore, a sound knowledge of diagnostic approach is required for the optimal management of side locked headaches and facial pain.

Cardiac cephalalgia: First case from India.

A 67-year-old male smoker had exertional headaches for 2 years. The headaches were holocephalic, very severe, excruciating, and occasionally accompanied by nausea. Physical examinations and neuroimaging were normal. Electrocardiogram (ECG) showed old infarct in inferior leads. Sublingual nitrate provided relief in headaches. Stress test was positive with recurrence of similar headaches with ECG changes suggestive of myocardial ischemia. Coronary angiogram revealed three-vessel disease. Coronary artery bypass surgery provided complete resolution of headaches.

Serotonin syndrome presenting as febrile encephalopathy with CSF pleocytosis: a report of three cases.

Serotonin syndrome (SS) is an iatrogenic, drug-induced clinical syndrome caused by serotoninergic hyperstimulation. SS may have protean manifestations and can mimic a variety of medical conditions. Herein, we describe three cases of febrile encephalopathy who were on serotonergic agents. All three cases fulfilled Hunter's criteria for SS and responded to the removal of the offending agents and the administration of cyproheptadine. All three patients had abnormal cerebrospinal fluid (CSF) examinations (pleocytosis in three patients and increased protein in two patients) which returned to normal with therapy. We suggest that SS presenting as febrile encephalopathy may have transient CSF abnormalities. Severe SS is a medical emergency. Therefore, a trial of cyproheptadine can be given in patients fulfilling the SS criteria even in the presence of CSF abnormalities. In parallel, the patients should be investigated for other causes of febrile encephalopathy and CSF pleocytosis.

Vitamin D deficiency mimicking chronic tension-type headache in children.

Headache, musculoskeletal pain and vitamin D deficiency, with possible inter-relationship, are common in the general population. We report cases of three premenarchal girls presenting with chronic tension-type headache and generalised body pain. The patients did not show any response to conventional therapy for tension headache. Investigations showed a severe vitamin D deficiency and biochemical osteomalacia in all three patients. The headaches and musculoskeletal pain responded markedly to vitamin D therapy. We suggest that musculoskeletal pain and headache together in a patient may be part of a single symptom complex, with vitamin D deficiency being the possible cause.

Recurrent Spontaneous Paresthesia in the Upper Limb Could Be Due to Migraine: A Case Series.

Transient neurologic dysfunction is a characteristic feature of migraine. About 20% of migraineurs may experience various symptoms in the absence of any headache at one time or another. Visual auras are the most common auras of migraine, and migraine is considered as the most common cause of transient vision loss in young patients. Sensory auras are the second most common migrainous auras. However, the literature is silent for isolated sensory aura as a migraine equivalent. Herein we report 14 patients with recurrent episodic paresthesia in the limbs and other body parts. All patients fulfilled the diagnostic criteria of "typical aura without headache" of ICHD-3ß. All patients were subjected to various investigations to rule out secondary causes. Ten patients received antimigraine drugs and all showed a positive response to therapy. Recurrent spontaneous paresthesia is quite common in the general population and many patients remain undiagnosed. We speculate that a subset of patients might be related to migrainous sensory auras.

Hemicrania continua with contralateral cranial autonomic features: a case report.

BACKGROUND: Hemicrania continua is characterized by continuous strictly unilateral head pain with episodic exacerbations. Episodic exacerbations are associated with ipsilateral cranial autonomic features. CASE DESCRIPTION: We report a 24-year female with a 2-year history of continuous right-sided headache with superimposed exacerbations. Episodic exacerbations were associated with marked agitation and contralateral cranial autonomic features. The patient showed a complete response to indomethacin within 8 hours. DISCUSSION: The dichotomy of pain and autonomic features is in accordance with the concept about the possibility of two separate pathways for pain and autonomic features in trigeminal autonomic cephalalgias.