Subtle temporal lobe epilepsy with headache as the major complaint: What can we learn from the long-delayed diagnosis?

The association between epilepsy and headache remains controversial. Among the three forms of epilepsy-related headaches (preictal, ictal, and postictal), ictal headache is the rarest and the least understood. Ictal headache, termed hemicrania epileptica in the International Classification of Headache Disorders, Second Edition (ICHD-II, 2004), was defined as a type of headache lasting seconds to minutes, occurring synchronously with partial (focal) epileptic seizures, ipsilateral to the ictal discharge, and resolving immediately after cessation of the discharges. However, a few recent cases challenged this definition of ICHD-II. According to the glossary and terminology of the International League Against Epilepsy (ILAE), ictal headache was ill-defined and was considered to be one of the manifestations of autonomic seizure.More recently, Parisi et al. proposed ‘‘ictal epileptic headache (IED)’’ as a dedicated term to define a condition where a headache attack is the only manifestation of an epileptic seizure, which seemingly intensified the long-standing debate. To date, there are about 20 convincing reports of ictal headache, and all attacks occurred in patients with epilepsy.Here we report a previously healthy young man presenting with paroxysmal, brief headaches only giving rise to misdiagnosis and inappropriate managements for as long as 2 years. The nature of his attacks was