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    EEG-BM &

    Headache

    Sub-bag Neurofisiologi/Poli Elektromedik

    FK- UGM/RS Sardjito

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    THE ELECTROENCEPHALOGRAM IN THE EVALUATION OF HEADACHE

    The American Academy of Neurology 1994

    Headache disorders are clinicalsyndromes defined by historical criteria.

    The EEG is not included in the diagnostic

    criteria of the International HeadacheSociety for migraine or other majorheadache categories.

    The majority of headache sufferers do nothave an identifiable structural lesion thatexplains their pain.

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    therefore

    An EEG could be considered useful in theevaluation of headache if abnormalitieswere observed that :

    (1) separate persons with and withoutheadache, potentially shedding light on theunderlying pathophysiology of headaches;

    (2) define subgroups associated with differentnatural histories or responses to therapy; or

    (3) effectively identify patients with a definablestructural etiology.

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    THE EVIDENCES

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    Electroencephalographic mapping in migraine during the critical and

    intercritical periods

    Rev Electroencephalogr Neurophysiol Clin. 1987 Sep;17(3):289-99.

    Twenty-nine migraineurs underwent spectralanalysis and topographic EEG mapping.

    Migraine with a complex aura, posterior-anteriorspreading of slow activities and depression of alphaactivity contralateralto the neurological signs were the

    prominent findings. Migraine with a visual aurahad unilateral reduction of

    alpha and theta activity.

    Common migrainethe only abnormality was markedly

    reduced alpha activity over one occipital region andreduction of theta activityin the same location.

    Note: In all patients, except one, restudied at least 7 days after an attack, EEGasymmetries had disappeared

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    Cont.

    Unilateral EEG changes can thus be detectedduring attacks of both classic and commonmigraine. The posterior-anterior spreading ofslow activities during an induced attack ofclassic migraine has temporal and spatialsimilarities with the "spreading oligemia.

    This suggests that common, as classic, migraineis associated with unilateral disturbances ofcortical electrogenesis, which might reflect anunderlying metabolic abnormality.

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    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.

    http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term=%22Hughes+JR%22%5BAuthor%5Dhttp://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term=%22Robbins+LD%22%5BAuthor%5Dhttp://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term=%22Robbins+LD%22%5BAuthor%5Dhttp://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term=%22Hughes+JR%22%5BAuthor%5D
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    Results demonstrate that there are nosignificantdifferences between the controlgroup and the tension-type headache group.

    Neither were differences found in migrainewithout aura group but in migraine with aurathere was an increase of the theta/alpharatioin the temporal posterior and occipital zones.

    This ratio could be used as a neurophysiologicalindicator in the evolution of the migraine withaura pathology.

    EEG in migraine: a review of the literature.

    Sand T.Funct Neurol. 1991 Jan-Mar;6(1):7-22.

    http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term=%22Sand+T%22%5BAuthor%5Dhttp://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term=%22Sand+T%22%5BAuthor%5D
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    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 sufferingfrom migraine with or without aura werecompared to the brain maps of 20 normalcontrols and 20 patients with tension-type

    headaches. Only the migraine group showed a significant

    decrement of alpha rhythm power, during restwith eyes closed, at the posterior areas of thebrain, and a significant increment of alphapowerat the same regions during IPS at 20c/sec.

    http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term=%22Tsounis+S%22%5BAuthor%5Dhttp://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term=%22Varfis+G%22%5BAuthor%5Dhttp://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term=%22Varfis+G%22%5BAuthor%5Dhttp://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term=%22Tsounis+S%22%5BAuthor%5D
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    In migraine between attacks EMG studiesare normal.

    Temporalis exteroceptive silent period

    is useful in the differential diagnosis ofheadaches and sheds some light on thepathophysiology of tension-typeheadache.

    Clinical neurophysiology studies in headache: a review of data

    and pathophysiological hints.

    Schoenen J.

    Funct Neurol. 1992 May-Jun;7(3):191-204.

    http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term=%22Schoenen+J%22%5BAuthor%5Dhttp://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term=%22Schoenen+J%22%5BAuthor%5D
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    Prominent photic driving at high flash

    frequencies (H-response) in migraine

    patients is the most consistently reported

    difference between headache patients andcontrols.

    THE ELECTROENCEPHALOGRAM IN THE EVALUATION OF

    HEADACHE

    The American Academy of Neurology 1994

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    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 significantdifferences between the control group and thetension-type headache group.

    Neither were differences found in migrainewithout aura group but in migraine with aurathere was an increase of the theta/alpha ratio inthe temporal posterior and occipital zones.

    This ratio could be used as a neurophysiologicalindicator in the evolution of the migraine withaura pathology.

    http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term=%22Valdizan+JR%22%5BAuthor%5Dhttp://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term=%22Andreu+C%22%5BAuthor%5Dhttp://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term=%22Almarcegui+C%22%5BAuthor%5Dhttp://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term=%22Olivito+A%22%5BAuthor%5Dhttp://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term=%22Olivito+A%22%5BAuthor%5Dhttp://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term=%22Almarcegui+C%22%5BAuthor%5Dhttp://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term=%22Andreu+C%22%5BAuthor%5Dhttp://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term=%22Valdizan+JR%22%5BAuthor%5D
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    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 theclinical history suggests a possible diagnosis of

    epilepsy (differential diagnosis).

    Ictal EEG could be useful in certain patients

    suffering from hemiplegic and basilar migraine.

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    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 activitywas 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.

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    Review

    In a few controlled and blinded studies, however, slight excess of various EEGrhythms has been found in migraine patients.

    Similar prevalences of interictal EEG abnormalities have generally been found inpatients with classic and common migraine, but the diagnostic classification may nothave been precise enough in some studies.

    During visual aura, either slow waves, depression of background activityamplitudeor normal EEGhave been reported.

    The most definitely abnormal EEGs with unilateral or bilateral delta activityhavebeen recorded during attacks of hemiplegic migraine, and during attacks of migrainewith disturbed consciousness.

    The relationship between migraine and epilepsyhas still not been adequatelyclarified. The connection seems to exist in several small entities (e.g. migraine-likeheadache as an epileptic manifestation, epileptic seizures triggered by epilepticattacks, 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, arepromising tools in this field. So far, mostly small studies have been published withsomewhat inconsistent results. A pattern of increased alpha rhythm variability(and/or asymmetry) in the headache-free phase seems to emerge, however.

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    Evidence Migraine TTH

    1987 Posterior-anterior spreading of slow activities

    Depression of alpha activity contralateral

    Reduction of alpha and theta activity.

    -

    1990 High amplitude theta on 0(1) and alpha on

    0(1) and T6Increase 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.

    No marker

    1991 Increase of the theta/alpha ratio in the

    temporal posterior and occipital zones.

    No marker

    1992 Decrement of alpha rhythm power, during rest

    Increment of alpha power at during IPS

    No marker

    1992 EMG studies are normal. Temporalis exteroceptive silent period

    1994 Prominent photic driving at high flash

    frequencies (H-response)

    No abnormality

    1994 children Theta/alpha ratio in the temporal posterior and

    occipital zones

    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

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    THE

    RECOMMENDATIONS

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    The EEG is not usefulin the routineevaluation

    of patients with headache.

    This does not exclude the use of EEG toevaluate 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 recommendedto exclude

    a structural cause for headache (option).

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    CONCLUSION

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    Current QEEG methods are not routinely

    indicatedin the diagnostic evaluation of

    headache patients.

    Quantitative frequency analysis of EEG

    must always be recorded with raw EEG

    dataand interpreted by a skilled physicianin order to avoid misinterpretationof

    technical artifacts, normal state

    fluctuations and various physiologicalrhythms.