Visual Auras in Epilepsy and Migraine - An Analysis of Clinical Characteristics

ObjectiveTo evaluate the characteristics of visual auras (VA) in epilepsy and migraine. BackgroundBoth disorders are usually diagnosed on clinical grounds, but differentiation might be challenging in isolated auras or because of the similar presentation in migraine and epilepsy. MethodsA retrospective study of two cohorts was performed to compare the VA characteristics of 27 epilepsy patients and 27 age-matched migraine patients. ResultsThe duration of VA was significantly shorter in epilepsy (median: 56s; 1st quartile Q1: 26s; 3rd quartile Q3: 130s) than in migraine (20min; Q1: 10min; Q3: 30min) (P<.0001). A cutoff duration of 5 minutes identified all migraine patients (100% sensitivity, 92% specificity). VAs of epileptic etiology were characterized by restriction to a visual hemifield (74.1% vs 29.6% in migraine, P=.0024) with stereotypic affection of one hemifield (55.5% vs 7.4% in migraine, P=0.0003). Centrifugal or centripetal spread of visual phenomena only occurred in migraine (37.0%), but not in epilepsy (P=0.0007). If present, accompanying symptoms such as nausea/vomiting (19/27) or photo-/phonophobia (17/27) identify migrainous auras (vs 0/27 in the epilepsy patients; P<.0001). Headache presented in all migraine patients, but was also observed in six of the epilepsy patients during cephalic auras or the postictal phase (P<.0001). None of the visual migrainous auras evolved into an epileptic seizure, a concept called migralepsy. ConclusionsSeveral clinical characteristics differentiate VA of epileptic and migrainous origin - if presenting in classical manner. Additional EEG evaluations should be performed in patients with VA of unclear etiology and epileptic VA features added to current classifications to increase their discriminatory power.