Nonepileptic paroxysmal disorders in children
- Thien T Nguyen, MD, PhD
Thien T Nguyen, MD, PhD
- Assistant Professor of Neurology
- Johns Hopkins University School of Medicine
- Peter W Kaplan, MB, FRCP
Peter W Kaplan, MB, FRCP
- Professor of Neurology
- Johns Hopkins University School of Medicine
- Angus Wilfong, MD
Angus Wilfong, MD
- Chief of Neurology
- Barrow Neurologic Institute at Phoenix Children's Hospital
Epilepsy is a condition characterized by recurrent seizures. The term seizure refers to a transient occurrence of signs and/or symptoms due to abnormally excessive neuronal activity of the brain. Many pediatric epilepsy centers find that least 20 percent of referrals do not have epileptic seizures [1-4] Many of these children are referred for evaluation of spells that are later determined to be temper tantrums, oppositional defiant behavior, and attention deficit disorder/attention deficit hyperactivity disorder (ADD/ADHD). Others have stereotyped paroxysmal disorders that may look like seizures and may even have loss of consciousness and unusual motor phenomena. A few children have behavior that initially sounds like true seizures but on video-electroencephalogram (EEG) monitoring proves to be nonepileptic. Nonepileptic paroxysmal events are not uncommon in children and can lead to multiple trials of anticonvulsant medications before the correct diagnosis is recognized.
The common nonepileptic disorders that can mimic seizures in children will be reviewed here. A more detailed discussion of the clinical and historical phenomena that help distinguish true seizures from nonepileptic events and the emergent evaluation of children and adolescents with syncope is discussed separately. Nonepileptic paroxysmal events more common in infancy and in adolescents are presented separately. (See "Seizures and epilepsy in children: Classification, etiology, and clinical features" and "Emergent evaluation of syncope in children and adolescents" and "Nonepileptic paroxysmal disorders in infancy" and "Nonepileptic paroxysmal disorders in adolescents and adults".)
Recurrent headaches with a family history of migraine rarely present a diagnostic dilemma. However, acute neurologic events without significant headache, particularly those with loss or alteration of consciousness, can be misdiagnosed as seizures. A migraine attack may be dominated by neurologic symptoms, including visual hallucinations, confusion, stupor and coma, total blindness, hemiparesis, or brainstem signs including diplopia, vertigo, and ataxia, so-called basilar-type migraine. (See "Classification of migraine in children" and "Migraine with brainstem aura (basilar-type migraine)".)
Post-traumatic migraine is a well-defined syndrome characterized by predominantly neurologic signs occurring after relatively minor head trauma. Some children given the diagnosis of cerebral concussion in reality have suffered an attack of migraine.
True epileptic seizures are rarely triggered by a migraine, and it is unusual for a headache to precede an epileptic seizure. More commonly, a migraine-like headache follows a seizure. This latter association is particularly common with generalized tonic-clonic seizures and after partial seizures arising in the occipital regions. Migraine should be suspected if the child has vomiting with the episode, a history of severe headaches without neurologic symptoms exists, or the family has a strong history of headaches [5-9].
- Uldall P, Alving J, Hansen LK, et al. The misdiagnosis of epilepsy in children admitted to a tertiary epilepsy centre with paroxysmal events. Arch Dis Child 2006; 91:219.
- Hindley D, Ali A, Robson C. Diagnoses made in a secondary care "fits, faints, and funny turns" clinic. Arch Dis Child 2006; 91:214.
- Hamiwka LD, Singh N, Niosi J, Wirrell EC. Diagnostic inaccuracy in children referred with "first seizure": role for a first seizure clinic. Epilepsia 2007; 48:1062.
- Bye AM, Kok DJ, Ferenschild FT, Vles JS. Paroxysmal non-epileptic events in children: a retrospective study over a period of 10 years. J Paediatr Child Health 2000; 36:244.
- Hockaday JM. Basilar migraine in childhood. Dev Med Child Neurol 1979; 21:455.
- Jensen TS. Transient global amnesia in childhood. Dev Med Child Neurol 1980; 22:654.
- Sheth RD, Riggs JE, Bodensteiner JB. Acute confusional migraine: variant of transient global amnesia. Pediatr Neurol 1995; 12:129.
- Haas DC, Pineda GS, Lourie H. Juvenile head trauma syndromes and their relationship to migraine. Arch Neurol 1975; 32:727.
- Golden GS. The Alice in Wonderland syndrome in juvenile migraine. Pediatrics 1979; 63:517.
- Ludvigsson P, Hesdorffer D, Olafsson E, et al. Migraine with aura is a risk factor for unprovoked seizures in children. Ann Neurol 2006; 59:210.
- Finkelhor BK, Harker LA. Benign paroxysmal vertigo of childhood. Laryngoscope 1987; 97:1161.
- Drigo P, Carli G, Laverda AM. Benign paroxysmal vertigo of childhood. Brain Dev 2001; 23:38.
- Rödöö P, Hellberg D. Creatine kinase MB (CK-MB) in benign paroxysmal vertigo of childhood: a new diagnostic marker. J Pediatr 2005; 146:548.
- North KN, Ouvrier RA, Nugent M. Pseudoseizures caused by hyperventilation resembling absence epilepsy. J Child Neurol 1990; 5:288.
- Watemberg N, Tziperman B, Dabby R, et al. Adding video recording increases the diagnostic yield of routine electroencephalograms in children with frequent paroxysmal events. Epilepsia 2005; 46:716.
- Patel H, Scott E, Dunn D, Garg B. Nonepileptic seizures in children. Epilepsia 2007; 48:2086.
- Kutluay E, Selwa L, Minecan D, et al. Nonepileptic paroxysmal events in a pediatric population. Epilepsy Behav 2010; 17:272.
- MacCormick JM, McAlister H, Crawford J, et al. Misdiagnosis of long QT syndrome as epilepsy at first presentation. Ann Emerg Med 2009; 54:26.
- Sethi NK, Labar D, Torgovnick J. Myoclonic epilepsy masquerading as a tic disorder. Clin Neurol Neurosurg 2007; 109:509.
- Demirkiran M, Jankovic J. Paroxysmal dyskinesias: clinical features and classification. Ann Neurol 1995; 38:571.
- Bruno MK, Hallett M, Gwinn-Hardy K, et al. Clinical evaluation of idiopathic paroxysmal kinesigenic dyskinesia: new diagnostic criteria. Neurology 2004; 63:2280.
- Lotze T, Jankovic J. Paroxysmal kinesigenic dyskinesias. Semin Pediatr Neurol 2003; 10:68.
- Bhatia KP. The paroxysmal dyskinesias. J Neurol 1999; 246:149.
- Walters AS. Clinical identification of the simple sleep-related movement disorders. Chest 2007; 131:1260.
- Manni R, Terzaghi M. Rhythmic movements during sleep: a physiological and pathological profile. Neurol Sci 2005; 26 Suppl 3:s181.
- Derry CP, Duncan JS, Berkovic SF. Paroxysmal motor disorders of sleep: the clinical spectrum and differentiation from epilepsy. Epilepsia 2006; 47:1775.
- Plazzi G, Vetrugno R, Provini F, Montagna P. Sleepwalking and other ambulatory behaviours during sleep. Neurol Sci 2005; 26 Suppl 3:s193.
- Mason TB 2nd, Pack AI. Sleep terrors in childhood. J Pediatr 2005; 147:388.
- Huppertz HJ, Franck P, Korinthenberg R, Schulze-Bonhage A. Recurrent attacks of fear and visual hallucinations in a child. J Child Neurol 2002; 17:230.
- Lombroso CT. Pavor nocturnus of proven epileptic origin. Epilepsia 2000; 41:1221.
- MIGRAINE SYNDROME
- BENIGN PAROXYSMAL VERTIGO
- NONEPILEPTIC STARING SPELLS
- PSYCHOGENIC NONEPILEPTIC SEIZURES
- MOVEMENT DISORDERS
- Tics and stereotypies
- Paroxysmal dyskinesia
- SLEEP DISORDERS
- Rhythmic movement disorders
- Sleep walking, night terrors, and confusional arousals
- Sleep starts
- INFORMATION FOR PATIENTS