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 "Overview of the classification, etiology, and clinical features of pediatric seizures and epilepsy" 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 "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].