Seizures, epilepsy and headaches in children

Question 1

What is the cause of epileptic seizures?

Answer 1

An epileptic seizure is caused by acute disturbances in the electric activity of the brain. (Synchronized hyper-activation of brain cells.)

Question 2

What conditions may induce an epileptic attack?

Answer 2

Infections, head trauma, fever (especially in children), drugs/alcohol, sleep deprivation, structural brain lesions etc.

Question 3

What is meant by genetic epilepsy?

Answer 3

Genetic epilepsy is caused by mutations in genes that code for ion channels (or their accessory sub-units). In genetic epilepsy there is no obvious structural lesion or damage.

Question 4

What are the basic classification of seizure types?

Answer 4

Focal onset. Aware or impaired awareness. Motor or Non-motor. (May evolve into a bilateral convulsion seizure.)

Generalized onset. Motor (tonic-clonic or other) or non-motor (absence).

Unknown onset. Motor (tonic-clonic or other) or non-motor.

Question 5

What characterizes a generalized tonic-clonic seizure?

Answer 5

Loss of consciousness.
Initial tonic phase, subsequently a clonic phase.
May pass urine and stool.
May bite the tongue.

Question 6

What are the three forms of status epilepticus (SE)?

Answer 6

1. Early SE: Duration 5-30 min.
2. Established SE: A seizure lasting longer than 30 min or a series of seizures without a return to baseline level of alertness between the seizures.
3. Refractory SE: Seizures that persist despite treatment with adequate doses of an initial 2 or 3 anticonvulsant medications.

Question 7

Are neonatal seizures dangerous?

Answer 7

Yes, it is associated with high mortality and morbidity, as well as an increased risk of neurological sequela and post-neonatal epilepsy.

Question 8

What is the peak age of onset for infantile spasms (West syndrome)?

Answer 8

3-7 months. (Onset rarely occurs after 18 months of age.)

Question 9

“Developmental stop or even regression. Spasms are variable in frequency and may be brief. Spasms might present as sudden, and subtle head nods and are easily missed” What condition is this characteristic of?

Answer 9

Infantile spasms (West syndrome).

Question 10

What is associated with a favorable prognosis for children with infantile spasms?

Answer 10

Normal development at onset
Unknown cause
Rapid response to treatment

Question 11

What is the peak incidence for febrile seizures?

Answer 11

Peak incidence between 12-24 months.

Question 12

What is a febrile seizure?

Answer 12

Seizures in febrile children between the ages of 6 months and 5 years who do not have an intracranial infection, metabolic disturbance, or history of afebrile seizures.

Question 13

How are febrile seizures classified?

Answer 13

Simple febrile seizure: Generalized seizure. Duration < 15 min. Occur once in a 24-h period.

Complex febrile seizure: Focal seizures, prolonged (> 15 min) and/or multiple; occur more than once in a 24-h period.

Question 14

What are risk factors for development of febrile seizures? How often do febrile seizures occur on children without risk factors?

Answer 14

Family history, developmental delay and prematurity are risk factors.

In 50 % of cases there are no risk factors.

Question 15

If a child has only 1-3 simple febrile seizure attacks there

is no increased risk of developing epilepsy. What can slightly increase the risk of epilepsy?

Answer 15

Complex febrile seizures
Positive family history of epilepsy
Delayed development/neurological abnormalities

Question 16

True or false: In general EEG has no predictive value with regard to risk of developing epilepsy following a febrile seizure and should not be taken.

Answer 16

True. EEG should only be taken if there are clinical signs of neurological disease or after repeated complex seizures.

Question 17

How should a febrile seizure be managed?

Answer 17

Antipyretics may improve the comfort of the child, but they will not prevent febrile seizures.
Always prescribe diazepam if needed later – Administer if seizure duration > 4-5 min.
Information to the parents + empathy!

Question 18

When is the usual age of onset for benign childhood epilepsy? Is benign childhood epilepsy more common i girls or boys?

Answer 18

3-13 years.

More common in boys.

Question 19

“75% of seizure attacks during sleep. Lateralized facial contraction and a grunting sound, without loss of consciousness. Sometimes the homolateral upper limb is involved. Secondary generalization 1/3 - 2/3 of cases.” What type of seizure if described?

Answer 19

A typical seizure in benign childhood epilepsy.

Question 20

What should be included in the clinical examination during a work up investigating an unprovoked seizure in a child?

Answer 20

Neurological, skin, and ocular assessment, and measurement of head circumference.

Question 21

What is the procedure of choice for neuroimaging?

Answer 21

MRI.

Question 22

What are factors associated with favorable prognosis for children with seizures?

Answer 22

Normal intelligence
No neurological abnormalities
Unknown cause (”idiopathic”)
Age at onset more than 2 years
Infrequent seizures
Limited numbers of “GTC” seizures
Only one seizure type
Absence of tonic-atonic seizures (drop-attacks)
Rapid response to anti-epileptic drugs (AED)

Question 23

What are differential diagnosis to epilepsy in children?

Answer 23

Psychogenic non-epileptic seizures (PNES)
Breath-holding spells
TIA (rare in children)
Migraine
Hypoglycemia (always check glucose)
Movement disorders/tics
Gastro-esophagal reflux (dystonic posturing)
Night terrors
Cardiogenic syncope (long QT-syndrome, AV-block)
Self gratification behavior (girls 2-4 years)

Question 24

What is treatment of epileptic seizures outside of hospitals?

Answer 24

Protect the head, place patient in recovery position.
Do not put anything in the mouth.
Health personnel are required only in long standing seizures.
If the seizure lasts longer than 4-5 minutes, medical treatment is indicated:
Diazepam (rectally) or midazolam (buccal).
Call 113 if the seizure lasts longer than 5-10 minutes.

Question 25

What are ways to prevent epileptic seizures?

Answer 25

Avoid precipitating factors – Sleep deprivation, psychological stress etc.
Antiepileptic drugs (AED).
Vagus nerve stimulation (VNS).
Surgical treatment.
Ketogenic diet.

Question 26

What are the first choice of medicine in focal epileptic seizures, generalized epileptic seizures, and status epilepticus?

Answer 26

Focal: Carbamazepine.
Generalized: Valproat.
SE: Benzodiazepines (diazepam/stesolid iv. eller rectally).

Question 27

What is the role of vagus nerve stimulation in the treatment of epileptic seizures?

Answer 27

It is used as adjunctive treatment in pharmaco-resistant epilepsy. Vagus nerve stimulation may reduce seizure frequency. (The mechanism of action not fully understood.)

Question 28

The is the role of a ketogenic diet on the treatment of epileptic seizures?

Answer 28

High concentrations of ketone bodies have been
correlated with better seizure control. The mechanism of action not entirely known, but ketone bodies increase degradation of glutamate and increase the conversion of glutamine to inhibitory GABA. (Gives reduction in seizure frequency.)

Question 29

What are common comorbidities associated with epilepsy?

Answer 29

Learning problems/struggling at school – In up to 70% of children with epilepsy.
ADHD.
Behavioral problems.
Psychiatric problems.

Question 30

What are “alarm bells” associated with headaches in children?

Answer 30

Abnormal neurology
Change in behavior
Visual disturbances
Headache at night/early morning
Headache + seizures
Nausea and vomiting in the morning

Question 31

Are migraines more common in boys or girls?

Answer 31

Migraines are equally as common in boys and girls until puberty. Afterwards it is more common in girls.

Question 32

What are symptoms of migraine in children?

Answer 32

Pounding/throbbing headache, lasts between 1-2 hours, and may involve one or both sides of the head or the entire head.
Often accompanied by severe nausea and vomiting.
Sensitivity to light and noise; the child often wants to lay down in a dark, cool room.
Often pain relief after sleep.

Question 33

What are ways to prevent/treat migraines in children?

Answer 33

If possible; avoid triggers: Stress, sleep deprivation, hunger etc.

Abortive treatment during migraine attack: Young children: Ibuprofen, paracetamol and in some cases antinausea medications. Older children: same as above + sometimes a triptan given by nasal spray.

Preventive treatments: Should be considered if > 3-4 attacks each month. (Not used frequently.)