Side‐to‐side and other complex head movements as ictal signs in epilepsy: A video‐ EEG case series and review of literature

Side-to-side head shaking is often considered a distinctive clinical sign that differentiates functional seizures from epileptic seizures; however, it may also occur as an ictal phenomenon in focal epilepsy. We retrospectively reviewed all video-telemetry reports of patients with drug-resistant focal epilepsy undergoing presurgical evaluation between 2015 and 2025. All reports were electronically screened for mentioning side-to-side or other complex head movements and the video-EEG of these patients was reviewed and included if associated with ictal EEG changes. Seventeen patients were identified who experienced 631 seizures in total, 201 of which included such movements (median: 2 per patient, range: 1-160). One patient (No. 5) accounted for 79% of these events and represented an outlier. Head movements were predominantly horizontal (93.5%), followed by mixed (5%) and rotatory (1.5%). While small-amplitude movements predominated overall, larger amplitudes were more frequent after excluding the outlier case. In six patients, head movements were the initial observed feature of seizure semiology and typically represented a brief component of the seizure, although prolonged in the outlier case. Interrater agreement ranged from fair to good across semiological variables. Presumed epileptogenic zones were heterogenous, including frontal, temporal, anterior quadrant, and hemispheric regions. Ictal side-to-side and other complex head movements can occur in focal epilepsies but lack localizing or lateralizing value. They likely reflect seizure propagation and involvement of broader neuronal circuits. Further studies are needed to clarify their mechanisms and clinical significance.