Seasonal Variation in Emergency Department Visits Among Pediatric Headache Patients.

OBJECTIVE: To ascertain whether seasonal variation occurs in emergency department (ED) visits for headache among children and adolescents. METHODS: A retrospective review was conducted using the electronic medical records of ED visits for headache at a tertiary children's hospital through calendar years 2010-2014. Using ICD-9 diagnostic codes for headache and migraine, the numbers of headache visits were determined and compared by season and during school months vs summer months. RESULTS: A total of 6572 headache visits occurred. Headache visits increased during the fall season (133 ± 27 visits per month) compared with other seasons (101 ± 19 visits per month), P ≤ .002, but did not differ when comparing school months (113 ± 25 visits per month) and summer months (100 ± 24 visits per month), P = .1. CONCLUSIONS: The corresponding increase in ED visits during the fall season coincides with the start of the school year. Academic stressors and the change in daily schedule may lead to more headaches and more ED headache visits among school-aged youth.

Pediatric migraine prophylaxis with divalproex.

We followed 23 patients with pediatric migraine, ranging in age from 7 to 17 years, who were treated with preventive divalproex sodium for migraine prophylaxis. Patients were evaluated for the presence or absence of comorbid psychiatric disorders or epilepsy to assess the possible differential effects of divalproex therapy. Doses ranged from 3.1 to 32.9 mg/kg/day. Seven patients had comorbid psychiatric disorders, whereas six patients had epilepsy (three rolandic, two generalized, and one indeterminate). Fifteen patients had a greater than 50% reduction in migraine; six patients became headache free. Divalproex doses used were not statistically different among the three groups. A favorable response and headache freedom were more likely in patients with migraine alone or with comorbid epilepsy, and less likely in patients with psychiatric comorbidity. Divalproex was well tolerated, and no significant side effects were reported. No notable changes were noted in behavioral problems, and patients with epilepsy were well controlled. In our cohort of patients, divalproex was most effective in patients with migraine alone or comorbid epilepsy.

New avenues in treatment of paediatric migraine: a review of the literature.

BACKGROUND: Headaches are a common problem in paediatric practice. Recurrent headaches can be a significant source of stress for patient and parents, and disruptive regarding school obligations and parental work responsibilities. Most treatment interventions are developed from research data extrapolated from adult studies, with resultant concerns of safety and efficacy when utilizing these therapeutic conclusions in children. METHODS: This paper incorporates current treatment strategies in paediatric migraine utilizing a Medline search of English language studies from January 1988 to December 1999, with a literature search referencing the terms of paediatrics, migraines, headaches, therapy and treatment. Reference sections of the articles were reviewed for pertinent information prior to January 1988. Articles were evaluated systematically to formulate concise terms for diagnosis of paediatric migraine and applicability to clinical treatment studies. Particular emphasis was placed on newer options with relevance in adult treatment such as triptans and anti-epileptic drugs, and their benefit in therapy of paediatric migraine. Non-pharmacological options were also subjected to organized review to determine relevance in treatment of paediatric migraine. RESULTS: The review of the literature indicates that although migraine in childhood and adolescence appears to be increasing in prevalence, few clinical studies are available, with most current treatment recommendations utilizing data from adult studies. CONCLUSION: Further headache treatment studies in the paediatric population are necessary in order to ascertain safety and efficacy of pharmaco-therapeutics in these children. Also, much current interest in treatment in adults with recurrent headaches involves non-pharmacological areas-dietary modification and stress management. Application of these avenues especially warrants further clarification with regard to relevance in paediatric migraine treatment.

Psychogenic seizures after head injury in children.

A total of 148 patients with a history of probable seizure disorder were studied prospectively with long-term video electroencephalography over a 1-year period. Sixteen (11%) were identified with psychogenic seizures. Eleven (69%) of 16 were boys, with a mean age of 10.5 years. Seven (44%) of the 16 had an antecedent history of head injury prior to the development of these episodes; of these patients 85% were boys. Our results suggest that contrary to findings in the adult population, psychogenic seizures can be commonly seen in boys. The prevalence of antecedent head injury suggests that it is a notable risk factor in children as well as adults in the occurrence of psychogenic seizures.

Psychogenic status epilepticus in children: psychiatric and other risk factors.

The authors studied six children with repetitive psychogenic seizures severe enough to mimic status epilepticus. All received IV antiepileptic drugs in an emergency setting. Most had a family history of epilepsy. Affective and anxiety disorders predominated as comorbid psychiatric diagnoses. Acutely stressful situations precipitated all episodes of nonepileptic status epilepticus. With aggressive psychotherapeutic intervention and pharmacologic treatment of their underlying psychiatric diagnosis, the patients improved.

Racial variation in retinopathy of prematurity. The Cryotherapy for Retinopathy of Prematurity Cooperative Group.

OBJECTIVES: To determine and compare the incidence of severe, vision-threatening retinopathy of prematurity (ROP) in black and white low-birth-weight infants. DESIGN: Prospective cohort study. SETTING: Seventy neonatal intensive care units in 23 US participating centers in the Multicenter Trial of Cryotherapy for Retinopathy of Prematurity. PATIENTS: A total of 4099 premature infants weighing less than 1251 g at birth were enrolled to evaluate the natural history of ROP. This 'Natural History' cohort included 2158 white infants and 1584 black infants who were followed up prospectively according to a Natural History protocol. MAIN OUTCOME MEASURES: Incidence and severity of acute ROP. RESULTS: While ROP occurred with similar frequency in all racial subgroups, severe ROP was less common in black infants. One hundred sixty (7.4%) of 2158 white infants reached threshold ROP (defined as at least 5 contiguous or 8 cumulative clock-hours of stage 3 retinopathy in zone 1 or zone 2 in the presence of "plus disease" [dilation and tortuosity of the posterior pole blood vessels]), but only 51 (3.2%) of 1584 black infants progressed to threshold ROP. Using multiple logistic regression analysis, race emerged as a highly significant factor (P < .001) in the development of threshold disease, even when birth weight, gestational age status at delivery, sex, multiple births, and transport status were considered. CONCLUSIONS: Severe, vision-threatening ROP occurs with greater frequency in low-birth-weight white infants than in low-birth-weight black infants who are seemingly at equivalent risk. The reason for this disparity is unknown. We speculate that differences in retinal pigmentation may confer relative protection against free radical-mediated phototoxic injury in black infants.

EEG frequency analysis in obsessive-compulsive disorder.

The cerebral basis of obsessions and compulsions has attracted increasing attention in neuropsychology and neuropsychiatry. Clinical and imaging studies have suggested frontal lobe dysfunction in some cases of obsessive-compulsive disorder and Tourette syndrome with obsessional symptoms. We compared EEG spectral measures in 20 such patients not taking medications and 12 neurologically intact unmedicated controls. EEG was recorded from O1-A1+A2, O2-A1+A2, Fz-A1+A2, F7-C3, F8-C4, T5-O1 and T6-O2. One-minute epochs of artifact-free EEG were used for compressed spectral array and calculation of time domain descriptors. We measured modal alpha frequency (MAF), maximal alpha frequency (MxAF), spectral edge frequency and spectral mobility in left and right frontal regions (MOLF and MORF). MAF and MxAF were reduced in the frontal regions in patients as compared to controls, and MOLF and MORF were both lower. No significant differences between patients and controls were found in the temporal or occipital areas. These observations support the suggestions of a physiologic basis for obsessions and compulsions, and of frontal lobe disturbance in their pathophysiology.

Multiple sleep latency tests in epilepsy.

Seizure patients often complain of sleepiness or disturbed sleep. Although susceptible of medication effect, the multiple sleep latency test (MSLT) may quantify daytime sleepiness and help to establish whether qualitative sleep disturbance accompanies epilepsy. In order to measure daytime sleepiness in epilepsy patients, 30 patients with newly diagnosed or presently untreated complex partial seizures had MSLT after an overnight sleep EEG that showed no sleep deprivation or nocturnal seizures. Four 20-minute naps were undertaken at 09:00, 11:00, 13:00, and 15:00, and sleep latency was recorded along with 8 channels of EEG. Twenty of 30 seizure patients reported subjective sleepiness. Eight patients had average sleep latencies less than 8 minutes, and 3 had latencies less than 5 minutes. No sleep onset REM or respiratory disturbance was noted. Twenty-five patients had EEG abnormalities but none had ictal seizures. Right temporal epileptiform activity correlated with sleepiness. MSLT may quantify sleepiness in epilepsy patients, which is common but may be subjective or psychophysiological. Some patients with partial seizures have persistent daytime sleepiness independent of medication, possibly related to residual medication effects or non-specific effect of their epileptogenic foci.

Neuropsychological and event-related potential correlates of nonepileptic seizures.

A retrospective study of 14 patients with epileptic seizures and 11 with nonepileptic seizures, all taking antiepileptic drugs, found epileptic patients had significantly longer P160, N200, and P300 latencies on auditory event-related potential recordings. Patients with nonepileptic seizures had generally higher IQs and significantly greater psychopathology on neuropsychological scales.

Passive long-latency event-related potentials in mental retardation.

Long-latency auditory event-related potentials (ERPs) were passively recorded in ten mental retardates and ten age-matched normal controls. Patients were mildly to moderately retarded and had epilepsy controlled with monotherapy, ERPs were recorded from CA-A1+A2, with 1000 and 3000 Hz tones in an "oddball" paradigm. Latency and amplitude of N1, N2, P2, and P3 components were compared in controls and retardates. All ten patients had reproducible AEPs, but these were attenuated in amplitude in four, although amplitudes did not differ significantly from controls. P3 was prolonged in latency in four patients, but patients and controls did not differ significantly. AEP latency and amplitude was not correlated with degree of retardation. These findings suggest that "cognitive" evoked potentials an be recorded passively in persons with impaired cognition, but are not correlated with intellectual ability and may not reflect specific cognitive functions.

Neuropsychological and psychiatric correlates of intractable pseudoseizures.

Psychogenic seizures can mimic convulsive epilepsy and with repetitive attacks, iatrogenic complications from aggressive treatment of status epilepticus can occur. We studied neuropsychiatric features of 20 patients in whom psychogenic seizures were intractable and at times continuous. Nineteen of 20 patients seen were female, and all but one were under 40 years of age. All had convulsive attacks resistant to various medications, normal neurological examinations, and negative imaging studies and electroencephalograms (EEGs). Sixteen had previous evidence of epilepsy and the other four had epileptic relatives. Seizures were atypically prolonged, included back arching and pelvic thrusting, and persisted despite intravenous diazepam and therapeutic phenytoin and phenobarbital levels. Seizures terminated spontaneously in five, were stopped by suggestion in four, and persisted until respiratory arrest or elective intubation in 11. Ten patients had conversion disorder, six borderline or mixed personality disorder and four mental retardation. Fifteen had had some precipitating stressor and the remainder had histories of exhibiting attention-seeking behaviour. Nine of 10 patients with conversion disorder had 'conversion V' Minnesota Multiphasic Personality Inventory (MMPI) profiles, while personality disorder patients had elevation of several psychopathological scales. Patients with conversion disorder gradually improved with anticonvulsant discontinuation, while retarded individuals were helped by behaviour modification, situational change or neuroleptics. Personality disorder patients continued to have attacks and eventually discontinued follow-up. Clinical evidence of non-epileptic seizures includes clinical atypicality and long duration, exacerbation by medications and frequent attacks despite normal examination and studies.(ABSTRACT TRUNCATED AT 250 WORDS)

EEG and evoked potentials in episodic-dyscontrol syndrome.

The neurophysiologic correlates of explosive rage and violence are uncertain and controversial. We recorded 17-channel electroencephalograms (EEGs), brainstem auditory-evoked potentials (BAEPs), and long-latency auditory-event-related potentials (AEPs) in 23 patients with impulsive, aggressive and violent behavior satisfying criteria for episodic-dyscontrol syndrome. Most patients also satisfied criteria for intermittent explosive disorder, although some had had conduct disorders in childhood or had previously used psychoactive substances. Sixteen of 23 patients had normal EEGs, while 7 had diffuse or focal slowing not ascribable to drowsiness or the effects of medication. They differed significantly from 20 age-matched patients with headaches, of whom 1 had an abnormal EEG (chi 2 = 4.68, p < 0.05), and from 24 depressed patients, all of whose EEGs were normal (chi 2 = 4.83, p < 0.05). Patients and normal control subjects did not differ in BAEP latencies. N100 and P160 AEP amplitudes were lower in episodic-dyscontrol patients than in control, but the difference was not significant. These findings suggest that non-specific cerebral dysfunction and EEG changes may be associated with disordered impulse or behavior control. Episodic dyscontrol may be associated with other evidence of minimal brain dysfunction.

Central conduction time in progressive supranuclear palsy.

Progressive nuclear palsy (PSP) is a parkinson-like extrapyramidal disorder with pathological evidence of brain stem demyelination. We studied brain stem auditory (BAEP) and somatosensory (SSEP) evoked potentials in 8 patients with progressive supra-nuclear palsy to look for evidence of such central demyelination. We found minor alterations in BAEPs and frequently abnormal SSEPs, suggestive of brain stem white matter involvement in this disorder. Evoked potentials may assist in the differentiation of PSP from other parkinsonian conditions.

Neuropsychiatric aspects of psychogenic status epilepticus.

We studied 20 patients with continuous repetitive psychogenic seizures simulating status epilepticus. Most patients received intravenous doses of multiple anticonvulsants. Our definition used for status epilepticus was that of Delgado-Escueta et al, at least 30 minutes of repetitive seizures without regaining consciousness. Nineteen of 20 patients were young women, all but one under 40 years of age. Sixteen of these patients had a history of childhood seizures. In over 50% of patients, seizures continued until respiratory arrest and intubation occurred. Thorough neuropsychological testing and psychiatric interview were done after cessation of the acute episode. Long-term outcome and prognosis depended on definitive psychiatric diagnosis. Repetitive psychogenic seizures simulating status epilepticus are not uncommon, and such patients may incur serious iatrogenic complications from treatment for status epilepticus. Appropriate management and long-term prognosis may be determined by the type and severity of the underlying psychiatric disorder.

Sleep spindles in epilepsy.

Spindles are a ubiquitous phenomenon in sleep, but their physiology and the effects of neurologic disorder on their frequency and amplitude are incompletely understood. We compared the incidence of three commonly defined spindle types (14-15 Hz, 12-13 Hz, and 10 Hz) and the frequency and amplitude of spindles during Stage II sleep in 50 patients with complex partial, partial and secondarily generalized, and primary generalized seizures, with and without interictal behavioral symptoms. All patients had 12-13 Hz and 14-15 Hz spindles of symmetric character in C3-A1 and C4-A2 derivations during prolonged sleep-deprived EEG recordings, which were normal except for partial or generalized epileptiform activity. Seventy-one per cent of complex partial seizure patients had 10 Hz spindles, and they occurred in 50% of the other two groups, predominating among those with interictal behavioral symptoms in all groups. Spindle frequency was significantly less in patients with generalized epilepsy than with partial seizures, and patients with complex partial seizures and partial seizures with secondary generalization differed significantly in spindle frequency. Spindle frequency was significantly lower with polypharmacy than with monotherapy. Patients whose regimens included phenobarbital had significantly lower spindle frequencies and spindle frequencies differed significantly between phenytoin and carbamazepine. Differences in spindle frequency may be due to residual medication effects, underlying encephalopathy or physiological differences between partial and generalized epilepsy.

Auditory evoked potentials in borderline personality disorder.

Borderline personality disorder is an increasingly recognized condition and frequent management problem in psychiatric and nonpsychiatric practice. Paroxysmal changes in affect and behavior, high incidence of soft neurologic signs and frequent EEG alterations, and evidence of clinical response to antiepileptic drugs have suggested cerebral dysfunction, particularly involving the limbic system or reticular activating system. We recorded early latency brainstem auditory evoked potentials (BAEPs) and long-latency auditory event-related potentials (ERPs) in 20 patients fulfilling DSM-III-R criteria for this disorder. BAEPs were recorded from Cz to ipsilateral and contralateral ear reference, with rarefaction clicks presented at 11.1 per second and 70 dB SL. Two thousand averages were recorded and replicated for each ear, with filter band pass of 150-3000 Hz and 10 ms analysis time. ERPs utilized binaural stimulation with 1000 and 3000 Hz tones in an 80:20 ratio, with interstimulus interval 1.1 second, analysis time 1000 ms, and filter band pass 1-100 Hz. Two hundred averages were recorded and replicated from Cz with linked ear reference. No differences were evident in I-III, III-V, and I-V interpeak latencies between borderline patients and age-matched neurologically and audiologically normal controls. N1, P2, and N2 components of the AEPs were longer in latency and lower in amplitude in borderline patients, while P3 latency was longer and amplitude was attenuated in borderline patients as compared to controls. These findings may suggest differences from normals in attention maintenance and in limbic system function.

Auditory evoked potentials in anxiety disorder.

The pathophysiology of anxiety has received much recent attention. EEG findings in anxiety are nonspecific, and some changes in psychophysiological measures have been reported. We recorded short-latency brainstem auditory evoked potentials (BAEPs) and long-latency auditory event-related potentials (AEPs) in 12 patients with generalized anxiety disorder. All 12 patients had BAEP latencies within clinical norms, but I-V interpeak latencies were significantly longer in patients with anxiety than controls. N1, N2, P2, and P3 AEP components were within normal limits; N1 and P2 were reduced in amplitude in anxiety patients, but differences from controls were not significant. The BAEP findings may suggest altered brain-stem function in anxiety, which has been implied by biochemical studies of anxiety and depression. AEP differences may be related to difficulties in concentration and attention direction reported by anxious patients.

Amantadine hydrochloride for refractory generalized epilepsy in adults.

Amantadine hydrochloride has been shown in several open studies to benefit children with refractory generalized epilepsy. We used amantadine as adjunctive therapy in 10 adolescents and adults with generalized tonic-clonic, myoclonic, or absence seizures refractory to therapeutic levels of valproate, carbamazepine, phenytoin, and benzodiazepines. Seven patients were men and 3 were women aged 18-29 years, and 8 of 10 patients were mentally retarded. All patients had generalized epileptiform paroxysms on EEG, with generalized or absence seizure recorded in 9. Five patients had both absence and tonic-clonic seizures, and 2 had all three seizure types. Amantadine was added to the existing regimens in weekly increments to 400 mg/day. Two patients had greater than 90 per cent seizure reduction, both with vomiting and somnolence. Two patients had seizure reduction between 50 and 90 per cent, 1 with anorexia and sleepiness. Three patients had no change in seizures, and 3 had worse tonic-clonic seizures. Amantadine may have some antiepileptic efficacy of unknown mechanism, but it may worsen generalized tonic-clonic seizures and is likely to be of limited value in adults.

Auditory evoked potentials in narcolepsy and sleep terrors.

Dysfunction of brainstem reticular activating centers has been suggested in some sleep disorders, including narcolepsy and sleep terrors. Previous studies have suggested normal brainstem auditory evoked potentials (BAEPs) in narcolepsy and enhancement of long-latency auditory event-related potentials (ERPs) in sleep deprivation and conditions of pathological somnolence. Sleep terrors have not to date been studied neurophysiologically. We recorded early latency BAEPs and long-latency auditory ERPs in 8 patients with narcolepsy and 5 individuals with sleep terrors, and compared them to 10 normal controls. Narcolepsy patients and controls did not differ significantly in absolute or interpeak latency of BAEPs. Sleep terror patients had significant prolongation relative to controls of III-V and I-V interpeak latencies. The N1, N2, and P3 AEP components were prolonged in latency in narcoleptic patients as compared to controls, while sleep terror patients did not differ from controls. No significant differences in amplitude were found. These findings suggest that a disturbance of integration of brainstem centers subserving wakefulness and sleep may play a role in the disordered arousal of sleep terrors, but suggest no specific abnormality in brainstem function in narcolepsy. The AEP changes in narcolepsy may be a manifestation of pathological sleepiness.