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Schmerz und Epilepsie

Eine klinisch-neuroanatomisch-pathophysiologische Übersicht

Pain and epilepsy

A clinical, neuroanatomical and pathophysiological review

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Zusammenfassung

Schmerzen im Rahmen von Epilepsien kommen als Kopfschmerzen nach Anfällen häufig vor, sind aber insgesamt selten. Sie verdienen Beachtung als klinische Phänomene, die zu erkennen, zu diagnostizieren und differenzialdiagnostisch abzugrenzen sind, sowie als Symptomatik, deren anatomische und physiologische Grundlagen Aufschluss über Schmerzphänomene im Allgemeinen geben können. Epilepsiebezogene Schmerzen werden einerseits nach Lokalisation als somatosensorische (unilaterale), abdominelle oder die Kopfregion betreffende Schmerzen und andererseits nach zeitlicher Beziehung zur epileptischen Erregungssteigerung als iktale, periiktale und interiktale Schmerzen eingeteilt. Dieser Systematik folgend wird eine Übersicht über Schmerzphänomene im Zusammenhang mit epileptischen Anfällen gegeben. In Bezug auf iktale somatosensorische Anfälle werden funktionell neuroanatomische Aspekte, in Zusammenhang mit abdominellen Epilepsien die Differenzialdiagnostik betrachtet. Bei epilepsiebezogenen Kopfschmerzen werden Nomenklatur und v.a. genetisch-epidemiologische und pathophysiologische Beziehungen zwischen Migräne und Epilepsien dargestellt.

Abstract

Besides postictal headaches, epileptic seizures are infrequently associated with pain experiences. Nevertheless, seizure-associated pain is an important clinical symptom to recognize, diagnose and to differentiate from non-epileptic disorders. Seizure-associated pain may shed light on the anatomical and pathophysiological foundation of pain in general. According to its localization seizure-related pain is classified as unilateral somatosensory, abdominal and cephalic epileptic pain and according to its temporal relationship as ictal, peri-ictal, and interictal pain. Different aspects of pain phenomena in the context of epileptic seizures will be addressed by following these systematic classifications. In relation to seizures with unilateral somatosensory manifestation the functional anatomical context is described while differential diagnostic aspects in association with abdominal epilepsies are emphasized and terminological points as well as genetic epidemiological interrelationships between epilepsy and migraine are highlighted.

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Interessenkonflikt

P. Martin gibt an, dass kein Interessenkonflikt besteht.

Dieser Beitrag beinhaltet keine von den Autoren durchgeführten Studien an Menschen oder Tieren.

CME-Fragebogen

CME-Fragebogen

Wie werden epilepsiebezogene Schmerzen in ihrer zeitlichen Beziehung zum Anfall eingeteilt?

Intra- und extraiktal

Para- und epiiktal

Iktal, paraiktal (prä-/postiktal) und interiktal

Epi- und periiktal

Trans-, sub- und interiktal

Wie werden epilepsiebezogene Schmerzen meist entsprechend ihrer Lokalisation eingeteilt?

Anfalls-/epilepsiebezogene Kopf‑, Bauch- und (einseitige) somatosensorische Schmerzen

Anfalls-/epilepsiebezogene Kopf‑, Brust- und Bauchschmerzen

Anfalls-/epilepsiebezogene Glieder- und Muskelschmerzen

Anfalls-/epilepsiebezogene Arm‑, Bauch- und Beinschmerzen

Anfalls-/epilepsiebezogene nozizeptive und neuropathische Schmerzen

Welche Aussage zu Anfällen, die sich in Schmerzen im Bereich einer Körperhälfte äußern, ist richtig?

Sie kommen v. a. bei Kindern vor.

Sie kommen v. a. im Erwachsenenalter vor.

Sie sind in ihrem Charakter überwiegend stechend und pulsierend.

Sie kommen, bezogen auf alle epileptischen Anfälle, nur sehr selten vor.

Sie sind in der Regel diffus lokalisiert.

In welcher anatomischen Region findet sich die epileptische Anfallsaktivität, die mit einseitigen somatosensorischen Anfällen korreliert?

Pulvinar thalami

Operkuloinsuläre Region (inkl. S2)

Primär somatosensorische Rinde (S1)

Gyrus cinguli

Gyrus praecentralis

Welche Großhirnregion ist am wenigsten in die zerebrale Schmerzverarbeitung involviert?

Inselrinde

Primärer und sekundärer somatosensorischer Kortex (S1 und S2)

Gyrus cinguli

Thalamus

Area striata (primäre Sehrinde)

Was ist ein wesentliches diagnostisches Kriterium einer abdominellen Epilepsie?

Übelkeit und Erbrechen

Fieber über 39,5 °C

Paroxysmaler Schwindel, der unter antikonvulsiver Therapie abklingt

Abdominelle Schmerzen, die paroxysmal auftreten und auf keine andere, nichtepileptologische Ursache zurückgeführt werden können

Paroxysmale abdominale oder thorakale Schmerzen, die stechend und streng einseitig sind

Welche Schmerzen kommen als Differenzialdiagnose epileptischer abdomineller Schmerzen am wenigsten in Betracht?

Schmerzen im Rahmen einer tabischen Krise

Gürtelförmige Schmerzen bei Pankreaskarzinom

Schmerzen bei paroxysmaler nächtlicher Hämoglobinurie

Nephroptose

Abdominale Migräne

Welche Kopfschmerzen sind die häufigsten mit Epilepsien verbunden Schmerzen?

Clusterkopfschmerzen

Hemicrania epileptica

Iktale epileptische Kopfschmerzen

Postiktale Kopfschmerzen

Kopfschmerzen im Sinne einer Migralepsie

Wie häufig kommen postiktale Kopfschmerzen vor?

Bei 0,5–1 % der Epilepsiepatienten.

Bei ≤50 % der Epilepsiepatienten.

Bei 75–80 % der Epilepsiepatienten.

Bei nahezu allen Epilepsiepatienten.

Verlässliche Daten hierzu gibt es noch nicht.

Welche Aussage zu Traumen im Rahmen von epileptischen Anfällen trifft zu?

Es besteht wahrscheinlich keinerlei Zusammenhang zwischen Stürzen im Rahmen von epileptischen Anfällen und degenerativen Halswirbelsäulenveränderungen.

Zungenbisse durch epileptische Anfälle sind nicht schmerzhaft, da sie meist von den betroffenen Patienten amnesiert werden.

Schwere Traumen kommen nur vor, wenn Anfälle von Stürzen begleitet sind.

Das Risiko von Knochenbrüchen infolge epileptischer Anfälle ist bei Osteopenie/Osteoporose erhöht.

Wirbelfrakturen können nicht allein durch die starken Kräfte, welche durch die Anspannung der Muskulatur im Anfall ausgeübt werden, erklärt werden.

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Martin, P. Schmerz und Epilepsie. Schmerz 32, 301–320 (2018). https://doi.org/10.1007/s00482-018-0298-2

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