Post-Traumatic Headache with Scintillating Scotoma Treated with Phenytoin(Dilantin)

Lawrence Robbins, M.D.*

*Dept. of Neurology, University of Illinois at Chicago.

Reprint requests to: Lawrence Robbins, M.D., Director, Robbins Headache Clinic, 1535 Lake-Cook Road,Northbrook, Illinois 60062.

Accepted for Publication: June 5, 1989

SYNOPSIS

A post-traumatic headache patient was experiencing "flashing lights" in her visual field that correlatedwith sharp waves on the EEG. Phenytoin markedly improved the symptoms. The value of the EEG inpost-traumatic headaches is reviewed. The use of phenytoin in headache syndromes and in prevention ofpost-traumatic epilepsy is discussed.

(Headache 29:515-516, 1989)

CASE REPORT

A 63-year-old female was in the passenger seat of a car struck on the driver's side by another auto. She had noamnesia for the event. She did not suffer direct head injury but immediately began having continuous right frontalheadaches, with frequent nausea. She experienced occasional "flashing lights" in her left peripheral field; they firstpresented as white spots and then quickly became black spots. When she pressed on the area of her right temple,the headache lessened. Ice in that area also decreased her headache. The patient also complained of mild visualblurring, light-headedness, and difficulty with concentration.

Neurologic examination was normal. CAT scans of the brain with and without infusion were normal.

The patient was diagnosed as post-traumatic headache, and given amitriptyline 25 mg q.h.s. and fenoprofen600 mg b.i.d. She did not improve and continued to be bothered by the flashing lights and the headaches. Onemonth after the accident, an EEG with brain mapping was performed which revealed sharp waves in the righttemporal area, and a slow wave focus on the brain mapping with increased delta in the right temporal area. Theamitriptyline and the fenoprofen were discontinued and the patient was started on phenytoin (Dilantin) 200 mgq.a.m. Two days after beginning the phenytoin, the headaches were markedly decreased and the flashing lightswere gone. The patient stopped the phenytoin after one month because she ran out of medication and the flashinglights in her left peripheral vision returned, as did the headache. She went back on the phenytoin and the headacheand flashing lights in her left peripheral vision resolved as they had done the first time on the phenytoin. Threemonths after the first EEG, a repeat test was done and was normal. The brain mapping also had returned tonormal.

DISCUSSION

In this patient there was no response to tricyclic and anti-inflammatory medication. Possibly, beta blockers, anincreased dose of tricyclic, or a monoamine oxidase inhibitor would have helped. However, with sharp wavespresent on the EEG in the location of the headache, and visual phenomena in the opposite visual field, phenytoinwas used and proved extremely helpful.

The EEG in head injury has been studied extensively. From 10% to 30% of patients have had abnormalEEG's.1,2 Gibbs felt that focal EEG abnormalities following head trauma correlated with "brain damage" ;3 afterhead injury, patients with severe brain damage had EEG abnormalities more often, and were increasingly likely todevelop epilepsy. Courjon concluded that long-lasting EEG abnormalities after head injury were characteristic ofmajor organic cerebral injury.4 According to Jung, early in the post-traumatic stage, there may be a goodcorrelation between the EEG abnormality and the symptomatology of the patient,5,6 but a normal EEG cannotguarantee that late epilepsy will not occur. Courjon has noted that, besides sharp waves in the EEG, low voltagerecords and posterior theta records are seen.4 As time from the injury passes, the EEG abnormalities do decrease.

Following trauma phenytoin has been advocated to prevent seizures. Hoff and Hoff12 concluded that small doses ofphenytoin are sufficient to protect against post-traumatic epilepsy. Wohns and Wyler13 reported 62 head injury patients, of severitysufficient to cause a high probability of post-traumatic seizures. Ten percent of phenytoin-treated patients developed late onset seizures, asopposed to 50 per-

cent of the untreated patients. Young, et al.,14 reported 84 patients with Severe head injuries treated withphenytoin; only five of the patients went on to develop seizures. Servitz and Musil15 treated 144 brain injuredpatients with phenytoin and phenobarbital. Only 2.1% in the treated group developed seizures, while 25% of theuntreated control group had seizures. White, Penry, et al.,16 did a double-blind study and concluded that patientstreated with phenytoin and phenobarbital had a lower incidence of post-traumatic epilepsy than in the control group.North, Penhall, et al.,17 reported a series with 140 patients in the phenytoin group and 141 in the placebo group.There was a significantly lower incidence of seizures in the phenytoin group at both one month and one year.

Phenytoin has been used for many decades in treating headaches.7 In several studies, phenytoin wascombined with caffeine in the treatment of a variety of headache syndromes.8,9 Jonas10 gave phenytoin to 18patients with migraine, nine of whom had complete relief. Millichap11 reported phenytoin being effective in 47 of 70children. There have been no good double-blind studies utilizing phenytoin in the treatment of headache.

In post-traumatic headaches the EEG occasionally is useful in guiding therapy. Phenytoin should be consideredas an alternative treatment for the headaches if the pain is not responding to conventional therapy (tricyclics, betablockers, anti-inflammatories) and the EEG reveals sharp waves. In addition, if the injury was severe, phenytoincould be considered for the prevention of post-traumatic epilepsy.

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