the clinical history and video - eeg features of a young boy , who presented with episodic chest pain , is described to illustrate this atypical presentation . a 14-year - old boy preparing for his final exams was brought by his mother for evaluation of episodic left - sided chest pain of 2  weeks duration . the pain which lasted a few seconds to half a minute was described as sharp , excruciating and localized to the lower chest on the left side and involved an area of only two finger breadths . the frequency varied from 1 to 8 episodes per day with variable severity but consistent location . there were no accompanying clinical features like breathlessness , diaphoresis , palpitation , fear , abnormal behavior or movements . there was no antecedent illness or trauma ; no history of febrile seizures , encephalitis or perinatal insult . he was evaluated by a pulmonologist and cardiologist who performed relevant investigations including a chest ct scan , electrocardiogram , and echocardiogram which returned normal findings . he was referred to a psychiatrist but the family preferred to get an opinion at our neurology center . an interictal eeg was initially performed which showed spike - and - wave discharges in the awake state distributed frontocentrally over the left hemisphere ( fig . 1 ) . this prompted us to obtain a long term video - eeg recording . during the 24  h of study , five events were recorded of which only one was associated with a clear - cut ictal pattern . the clinical semiology was dominated by severe localized chest pain in the right lower chest ( as opposed to the typical left - sided location for chest pain ) . however some paucity of movements were observed on the right side especially the right upper limb . the initial part of the ictal recording was obscured by artifact while a nicely evolving 4.04.5  hz rhythm was noted in the parasagittal region a few seconds after clinical onset . a 910  hz faster rhythm was also observed in the left mid and posterior temporal regions which did not show evolution ( fig . 2 ) . a 1.5 tesla mri of the brain did not reveal any focal pathology . the electroclinical data offered definitive proof for the ictal origin of the phenomenology from the left hemisphere . this drug was chosen as first line , because the family wanted seizure freedom in a short time as his exams were due in two days . he has had no seizures , behavioural or cognitive abnormalities during the last four months of follow - up . epileptic pain as a somatosensory manifestation of seizures is not uncommon but as a solitary presentation of epilepsy is extremely rare and diagnostically challenging . pazarci et al . who searched for this elusive symptom in their data base of 4736 patients identified only 9 patients . their experiences consisted of nuchal pain , headache , abdominal pain and pain in the extremities ( peripheral pain ) . the ictal eeg more often showed hemispheric or diffuse abnormalities than focal well - defined ictal activity . in our patient the lateralization was clearly evident compared to localization although the parasagittal region showed the most unequivocal changes . all the patients in their study who had lateralized peripheral pain had an abnormal mri while our report describes mr - negative  algic  seizures . structural abnormalities were a universal feature of patients with peripheral pain in a previous series of 8 patients with ictal pain . one of the patients had only biparietal atrophy evident on mri whose spect study corroborated the finding . the electrographic abnormalities were either restricted to the parietal area or hemisphere on the surface eeg . intracranial recordings in three patients showed seizure onset from inferior parietal lobule / parietal operculum or medial parietal lobe . in another analysis of retrospective data of more than five thousand patients , the authors found pain associated with seizures associated with epilepsy in 10 patients of whom 8 had peripheral location of pain . three of their patients had a normal mri while two had a central location of ictal onset which is comparable to our observation . however none of these patients in any of the above mentioned series had pain as the sole manifestation of epilepsy thus making our observation a novel one . the major studies which address epileptic pain due to seizures associated with epilepsy are summarised in table 1 
 , , , . none of the patients in these reports had isolated chest pain as an ictal manifestation which makes this case unique and challenging . the patient had several events during the long term recording without any eeg abnormalities until he had an event with definite ictal abnormalities . this emphasizes the need for a high index of suspicion to discover the ictal origin of unexplained pain . pain has a localization more or less similar to somatosensory aura . when the seat of origin is the primary sensory area , a secondary sensory area ( ssa-2 ) involvement produces vague or complex sensations which are more diffuse in distribution . posterior insular involvement can also produce sensory phenomena like warmth or dysesthesias which encompasses a widespread cutaneous distribution . supplementary somatosensory - motor area and cingulate cortex are the other anatomical sites whose involvement can result in sensory manifestations . the ictal origin of pain in the present report was established by the presence of electrographic abnormalities and response to antiseizure drugs . this bears resemblance to  ictal epileptic headache  observed especially in the pediatric age group diagnosis of painful seizures which is based on similar grounds . the location and nature of ictal pain is variable as evidenced in this report of pure left - sided chest pain . a dedicated evaluation by video - eeg telemetry can be invaluable in establishing the diagnosis in such cases .