Do patients with functional seizures commonly experience headaches?

Headache in Patients with Functional Seizures

Yes, headaches are common in patients with functional seizures, with approximately 65% of patients experiencing headaches that can trigger or accompany their functional seizure episodes. 1

Relationship Between Headaches and Functional Seizures

Functional seizures (also known as psychogenic non-epileptic seizures or dissociative seizures) frequently co-occur with headaches in several patterns:

• Migraine as a trigger: In a systematic review and case series, migraine attacks were found to trigger functional seizures in 65.1% of patients studied 1
• Temporal relationship: Headaches can occur:
  • Before the seizure (preictal)
  • During the seizure (ictal)
  • After the seizure (postictal) - most common pattern 2

Clinical Characteristics

The headaches associated with functional seizures have several notable features:

• Migraine-like presentation: Many headaches associated with functional seizures have migraine-like characteristics 1, 2
• Frequency: In patients who experience seizure-associated headaches, the headaches occur in more than 50% of their seizure episodes 3
• Duration: Postictal headaches typically last longer than 4 hours in 62.5% of patients 3
• Undertreatment: These headaches are frequently undertreated, with only 30% of patients self-medicating and none receiving prescribed treatment specifically for their headaches 3

Distinguishing Features

It's important to differentiate between:

1. Functional seizure-associated headaches: Common in patients with functional neurological disorder
2. Epileptic headache: A rare form of epilepsy where headache is the sole or predominant ictal manifestation 4
3. Postictal headache in epilepsy: Occurs in 37-51% of patients with epileptic seizures 3

Clinical Implications

The recognition of headaches in patients with functional seizures has important treatment implications:

• Treatment response: In 73% of patients with functional seizures triggered by migraine, treatment with migraine prophylactic medications alone reduced functional seizure frequency by more than 50% 1
• Diagnostic consideration: The presence of headaches should be actively inquired about, as they may be overlooked due to the more dramatic presentation of the seizure itself 2

Management Approach

For patients with functional seizures who report headaches:

1. Assess temporal relationship: Determine if headaches occur before, during, or after seizures
2. Characterize headache type: Evaluate for migraine-like or tension-type features
3. Consider migraine prophylaxis: For patients with migraine-like headaches that appear to trigger functional seizures
4. Develop a seizure plan: Work with patients to create a plan for managing seizures, including addressing headache symptoms 5

Understanding the relationship between headaches and functional seizures can improve diagnosis and lead to more effective treatment strategies that address both conditions simultaneously.