Treating migraines requires an individually tailored regimen to address the frequency, severity, and disability produced by the headache. Intermittent symptomatic, or abortive, analgesics are the mainstay for treatment of infrequent, intense episodes of migraine. Symptomatic therapy requires early administration of an analgesic, rest, and sleep in a quiet, dark room. Acetaminophen or a nonsteroidal anti-inflammatory drug such as ibuprofen or naproxen sodium is often effective. Hydration and antiemetics are also useful adjunctive therapies. If these first-line medications are insufficient, triptan agents may be considered. Triptans, available in injectable, nasal spray, oral disintegrating, and tablet form, are serotonin receptor agonists that may alleviate migraine symptoms promptly. Triptans are contraindicated for patients with focal neurological deficits associated with their migraines or signs consistent with basilar migraine (syncope) because of the risk of stroke.
Many children suffer with severe and frequent migraines that disrupt their daily lives. Children with more than one disabling headache per week may require daily preventive agents to reduce both attack frequency and severity. Preventative medications include tricyclic antidepressants (amitriptyline, nortriptyline), anticonvulsants (topiramate, valproic acid),antihistamines (cyproheptadine), beta-blockers (propranolol), and calcium channel blockers (flunarizine, verapamil).
Before initiating daily medications, lifestyle modifications must be put into place to regulate sleep, daily routines, and exercise and identify any precipitating or aggravating influences, eliminating as many as possible (caffeine, certain foods, stress, missed meals, dehydration). Other adjunctive treatment options include psychological support, counseling, stress management, and biofeedback.
A seizure is a transient occurrence of signs or symptoms resulting from abnormal excessive or synchronous neuronal activity in the brain.
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Migraine and variants Paroxysmal torticollis of infancy Paroxysmal vertigo (benign)
Syncope Vasovagal syncope Breath-holding spells Cardiac syncope (arrhythmias, long QT syndrome) Apnea
Metabolic disorders Hypoglycemia Inborn errors of metabolism
Sleep disorders Narcolepsy, cataplexy Night terrors
The differential diagnosis of paroxysmal disorders includes seizures and nonepileptic events (Table 181-1). Nonseizure paroxysmal events are often normal or benign phenomena, although some are clinically significant and consequential. A thorough medical history from the patient and primary witnesses is the most reliable tool for establishing the correct diagnosis.
Acute symptomatic seizures are secondary to an acute problem affecting brain excitability, such as electrolyte imbalance or infection (Table 181-2). Epilepsy is defined as recurrent, unprovoked seizures. Epileptic seizures are generally classified as focal (or partial), arising from one region of the cortex, or generalized seizures, which arise from both hemispheres, simultaneously (Table 181-3). Approximately 4% to 10% of children experience at least one seizure. The incidence of childhood epilepsy is 1% to 2%.
Simple focal (or partial) seizures arise from a specific anatomic focus and may or may not spread to surrounding brain regions. Clinical symptoms include motor (tonic, clonic, myoclonic), sensory, psychic, or autonomic abnormalities, but consciousness is preserved. The location and direction of spread of the seizure focus determine the clinical symptoms.
Complex partial seizures can have similar sensorimotor signsbut also have associated alteration of consciousness. Althoughthe child may not be completely unresponsive, subtle slowing or alteration of mental status (dyscognitive features) may occur.Along with altered responsiveness, patients may have staring