To describe the clinical course of eight patients with focal epilepsy and painful semiology, thereby contributing to a better understanding of this frequently misdiagnosed condition.

Painful seizures are a rare presentation of epilepsy, historically categorized into: Unilateral, Cephalic, and Abdominal. The reported prevalence ranges from 0.002% to 2.8%.

Eight patients with painful seizures were identified in a cohort of Epilepsy patients at our Comprehensive Epilepsy Center. Variables including demographics, presentation, management, and outcomes were collected through a retrospective chart review. A descriptive analysis of the findings were done.

Among eight ictal pain cases, two were abdominal, three unilateral, one whole body, one cephalic and one thoracic. Six were initially misdiagnosed: nonepileptic events (3), panic attacks (2), migraines (1). Final localization was based on: stereotactic EEG (sEEG) (4), MRI/scalp EEG (1), scalp EEG/PET (2), and semiology-based (1). The epileptogenic areas for the four sEEG cases were opercular (2), insular (1), and middle-middle temporal gyrus (1). Outcomes included: medication responsive (2), incomplete resection of epileptogenic zone (due to overlap with Broca’s area) followed by RNS failure to control painful seizures but improvement in other seizure types (1), failure to control seizures with insular resection and laser ablation with ongoing surgical workup (1), seizure freedom following anterior temporal lobectomy (1), stable pre- to post-RNS at one month follow-up (1), ongoing pre-surgical workup (1), and lost to follow-up (1).

Painful seizures can mimic headache disorders, neuralgias, musculoskeletal pain, visceral pain and non-epileptic spells. The reported prevalence of painful seizures is a likely underestimation due to misdiagnosis secondary to the diagnostic challenge. Our thoracic/chest pain type of ictal pain suggests a new semiology and may provide localizing value. Key to avoiding misdiagnosis is exploring spell characteristics suggestive of epilepsy especially when appropriate pain management fails. Painful seizures commonly indicate involvement of insular and/or opercular zones.