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Hitting two birds with one stone: daily scheduled opioids in preventing migraine and migraine‐related epilepsy (migralepsy)

Dear Editor: As a neurologist with interest in migraine and epilepsy, I read the recent important contribution by Verrotti and colleagues with great interest [1]. I am specifically addressing the issue of intractable seizures seen in group B of their patients characterized with poorly controlled epilepsy of different kinds (i.e. grand mal, focal and absence epilepsies). The group constituted almost 50% of the cohort of 129 studied. At the end of a long-term follow-up, lasting 10–23 years, the percentage of medication/seizure-free patients was significantly higher in group A (45 patients, 89.7%) than in group B patients (15 patients, 68.8%). From the data provided it seems obvious that the severity of seizure disorder determined the course of the illness. Valproate, carbamazepine, topiramate, levetiracetam, clobazam, phenobarbital, lamotrigine, oxcarbazepine and ethosuximide were the anticonvulsants used to control the seizures (either as monotherapy or polytherapy). Nevertheless, seizures proved intractable in 20% of the studied population. This figure is similar to that found in a cohort of epileptics studied recently by Wilner and colleagues and on which I have commented elsewhere [2,3]. According to my experience (unpublished), daily scheduled opioid treatment provides the most satisfactory treatment for pain (headache, cervicalgia) as well as preventing migrainerelated seizures in those who suffer from the twin conditions called migralepsy. As an example, a 24-year-old patient (DHW) who had suffered from migraine since age 9, occurring three to four times per week, developed epileptic attacks 7 years later. Multiple trials of conventional anticonvulsants proved unsatisfactory in suppressing both conditions. Progressively increasing the dose of oxycodone to a daily dose of 180 mg per day proved satisfactory in stopping both the migraines and the seizures. Later conversion to conventional medications due to unavailability of the narcotic analgesic resulted in the return of his symptoms. Recent molecular understanding concerning the release of calcitonin gene-related peptide in underpinning the neurogenic meningeal vasodilatation may be related to the effectiveness of opioids and triptans in alleviating headaches as well as preventing the ictal epilepsy associated with the same [4–6]. The similarity of antimigraine action of opioids to those of triptans has been documented in experiments conducted on rats [4].