PO-10 | Differential diagnosis between symptomatic focal occipital epilepsy and headache: a case report

Background: Headache and epilepsy are classified among chronic paroxysmal neurological disorders and, to a certain extent, share common diagnostic approaches and therapeutic strategies (1). Numerous studies investigate the potential pathophysiological and genetic correlations between the two conditions, given their frequent comorbidity, particularly during infancy and adolescence (2). Case report: We report the case of a 14-year-old girl presenting with headache and neuroradiological evidence of focal cortical dysplasia. Her medical history was unremarkable for developmental disorders. Maternal familiarity for migraine was reported. For two years, the patient had reported headache episodes preceded or accompanied by visual scotomas and phosphenes in the left visual hemifield; concomitant episodes of pulsating bitemporal headache have also been reported, occasionally associated with vomiting and paraesthesia involving the left hemibody. Over time, a progressive worsening of the episodes had been observed in terms of intensity, frequency, duration and irresponsiveness to analgesic therapy. Last September, the patient underwent a first neuroimaging revealing right focal cortical thickening near the occipital convexity. One month later, she presented to the ER due to worsening symptoms. The EEG showed focal posterior paroxysmal activity, leading to the treatment with topiramate. A transient improvement was registered for two weeks, when only visual scotomas persisted without functional impairment. Subsequently, a relapse of symptoms occurred, with no response to analgesics. She presented again to the ER, where the EEG revealed recurrent focal seizures originating from the right temporo-occipital region. Treatment with lacosamide and clobazam was initiated; topiramate was discontinued. During follow-up, the patient reported overall clinical stability, with no occurrence of prolonged epileptic or headache episodes. Mild headache episodes persisted, self-limiting or responsive to analgesic therapy. Subsequent EEGs confirmed the presence of posterior paroxysmal abnormalities. Follow-up brain MRI confirmed the presence of the right occipital alteration consistent with cortical dysplasia. Conclusion: Given the instrumental findings and clinical considerations, a diagnosis of symptomatic focal epilepsy appears likely, thereby rendering her a candidate for functional epilepsy surgery. Therefore, headache may represent a comorbidity within the epileptic framework, or alternatively, it might constitute ictal epileptic (3) residual symptoms in the setting of only partially controlled epilepsy.