Evidence based pediatrics - part 6 pptx

Localization-related local, focal, partial epilepsies and syndromes 1.1 Idiopathic with age-related onset Benign childhood epilepsy with centro-temporal spikes Childhood epilepsy with oc

39 Apley J, Naish N Recurrent abdominal pains: a field study of 1,000 school children Arch Dis Child 1958;33:165–70.

40 Feldman W, Rosser W, McGrath P Recurrent abdominal pain in children Can Fam Physician 1988;34:629–30.

41 Rosenberg AJ Constipation and encopresis In: Wyllie R, Hyams JS, editors Pediatric testinal disease: pathophysiology, diagnosis, management Philadelphia: W.B Saunders Com- pany; 1993 p 198–208.

gastroin-42 Loening-Baucke V Constipation in early childhood: patient characteristics, treatment and term follow-up Gut 1993;34:1400–4.

long-43 Abrahamian FP, Lloyd-Still JD Chronic constipation in childhood: a longitudinal study of 186 patients J Pediatr Gastroenterol Nutr 1984;3(3):460–7.

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1, 2nd ed Philadelphia: J.B Lippincott Company; 1993 p 415–8.

45 Winesett M Inflammatory bowel disease in children and adolescents Pediatr Ann 1997;26(4):227–34.

46 Shanon A, Martin DJ, Feldman W Ultrasonographic studies in the management of recurrent abdominal pain Pediatrics 1990;86(1):35–8.

47 Wewer V, Strandberg C, Paerregaard A, Krasilnikoff PA Abdominal ultrasonography in the nostic work-up in children with recurrent abdominal pain Eur J Pediatr 1997;156:787–8.

diag-48 Hotopf M, Carr S, Mayou R, et al Why do children have chronic abdominal pain, and what pens to them when they grow up? Population based cohort study Br Med J 1998;316:1196–200.

hap-49 Sanders MR, Shepherd RW, Cleghorn G, Woodford H The treatment of recurrent abdominal pain

in children: a controlled comparison of cognitive-behavioral family intervention and standard pediatric care J Consulting Clin Psychol 1994;62(2):306–14.

50 Feldman W, McGrath P, Hodgson C, et al The use of dietary fiber in the management of simple, childhood, idiopathic, recurrent, abdominal pain Am J Dis Childhood 1985;139:1216–8.

51 Anderson DM Dorland’s illustrated medical dictionary 28th ed Philadelphia: W.B Saunders Company; 1994.

52 Lemoh JN, Brooke OG Frequency and weight of normal stools in infancy Arch Dis Child 1979;54:719–20.

53 Weaver LT, Streiner H The bowel habits of young children Arch Dis Child 1984;59:649–52.

54 Colon AR, Jacob LJ Defecation patterns in American infants and children Clin Pediatr 1977;16(10):999–1000.

55 Fontana M, Bianchi C, Cataldo F, et al Bowel frequency in healthy children Acta Pediatr Scand 1989;78:682–4.

56 Loening-Baucke V Chronic constipation in children Gastroenterology 1993;105(5):1557–64.

57 Rockney RM, McQuade WH, Days AL The plain abdominal roentgenogram in the management

of encopresis Arch Pediatr Adolesc Med 1995;149:623–7.

58 Blethyn AJ, Jones KV, Newcombe R, et al Radiological assessment of constipation Arch Dis Child 1995;73:532–3.

59 Barr RG, Levine MD, Wilkinson RH, Mulvihill D Chronic and occult stool retention Clin atr 1979;18(11):675–86.

Pedi-60 Starrveld JS, Pols MA, Van Wijk HJ, et al The plain abdominal radiograph in the assessment of constipation Z Gastroenterology 1990;28:335–8.

61 Bewley A, Clancy MJ, Hall JRW The erroneous use by an accident and emergency department of plain abdominal radiographs in the diagnosis of constipation Arch Emerg Med 1989;6:257–8.

62 Benninga MA, Buller HA, Staalman CR, et al Defecation disorders in children, colonic transit time versus the Barr-score Eur J Pediatr 1995;154:277–84.

63 Berg I, Forsythe I, Holt P, Watts J A controlled trial of `senekot’ in fecal soiling treated by ioural methods J Child Psychiatry Psychol 1983;24(4):543–9.

behav-64 Halpern WI The treatment of encopretic children Am Acad Child Psychol 1977;16:478–99.

65 Perkin JM Constipation in childhood: a controlled comparison between lactulose and ized senna Curr Med Res Opin 1977;4(8):540–3.

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69 Davidson M, Kugler MM, Bauer CH Diagnosis and management of children with severe and tracted constipation and obstipation J Pediatr 1963;62(2):261–75.

pro-70 Gleghorn EE, Heyman MB, Rudolph CD No-enema therapy for idiopathic constipation and encopresis Clin Pediatr 1991;30(12):669–72.

71 Sprague-McRae JM, Lamb W, Homer D Encopresis: a study of treatment alternatives and torical and behavioural characteristics Nurse Practitioner 1993;18:52–3, 56–63.

his-72 Beach RC Management of childhood constipation Lancet 1996;348:766–7.

73 Fleischer DR Encopresis, enemas and gold stars Pediatrics 1978;61:155–6.

74 Martin RR, Lisehora GR, Braxton M Fatal poisoning from sodium phosphate enema JAMA 1987;257:2190–2.

75 Clayden GS, Lawson JON Investigation and management of long-standing chronic constipation

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76 Snape WJ The effect of methylcellulose on symptoms of constipation Clin Thera 1989;11(5):572–9.

77 Muller-Lissner SA Effect of wheat bran on weight of stool and gastrointestinal transit time: a meta-analysis Br Med J 1988;296:615–7.

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alpha-toco-Seizure DisordersPeter Camfield, MD, FRCPCCarol Camfield, MD, FRCPC

O

Seizures in children are common and have many causes This chapter concentrates on taneous, unprovoked seizures that tend to recur, as well as febrile seizures Seizures can beprovoked by nearly any acute disturbance to the cerebral neocortex Provoked seizures, irre-spective of the cause, have a very low rate of recurrence, provided that the provoking factorcan be treated or avoided For example, only about 10 percent of people who have seizuresprovoked by a major head injury will later develop epilepsy.1

spon-The decision that a child has had a seizure is almost always based on the history sincemost seizures are brief and have stopped by the time the child is seen by a physician Onlythe history can exclude such disorders as syncope, breath-holding, or vertigo Even expertsinterpreting the same history may have difficulty, on occasion, in agreeing on the nature of

a child’s “event”2(level II-2) In our opinion, if the history is unclear, it is less harmful to await

a recurrent event than to falsely label a child as having an epileptic disorder

There are different kinds of seizures, and if seizures are recurrent, there are differenttypes of epilepsy Seizures can be categorized into partial (or focal) and generalized types.Partial seizures begin in one part of the brain They are subdivided into simple partial, if con-sciousness is retained, or complex partial, if consciousness is altered or lost Generalizedseizures arise diffusely all over the brain at once; they can be thought of as a “system failure”

or “system overload.” The main types of generalized seizures are generalized tonic-clonic,absence, and myoclonic seizures If a seizure begins in one part of the brain and spreads toinvolve the entire brain, a partial seizure with secondary generalization is said to haveoccurred The patient may have an “aura” followed by a generalized tonic-clonic seizure Theaura is really a simple partial seizure Therefore, a child with a “grand mal” or generalizedtonic-clonic seizure may have had a primarily generalized seizure or a partial seizure withsecondary generalization

When all of the details of a child’s seizure disorder are combined with the cephalography (EEG), an epilepsy syndrome can usually be defined The diagnosis of anepilepsy type may assist in understanding the cause and in defining the prognosis Table 12–1outlines the main epilepsy syndromes and serves to emphasize the variety of types ofepilepsy.3 The clinician is urged to consider seizures as the result of many different brainprocesses

electroen-FEBRILESEIZURES

About 3 to 4 percent of children will have one or more febrile convulsions, making this themost common convulsive event in humans.4The usual age range is 6 months to 5 years with

a peak age at 18 to 22 months To make the diagnosis, there must be documented fever and

a clear history of a convulsion It is important to note that syncope in small children may beprecipitated by fever5(level III)

When a child presents with an ongoing febrile seizure, the first task is to stop the seizure.Intravenous diazepam or lorazepam appear to be roughly equivalent6(level I, recommen-dation A) Although rectal diazepam has not been subjected to a randomized controlled trial

Table 12–1 International classification of epilepsies and epileptic syndromes and related

seizure disorders

I Localization-related (local, focal, partial) epilepsies and syndromes

1.1 Idiopathic (with age-related onset)

Benign childhood epilepsy with centro-temporal spikes

Childhood epilepsy with occipital paroxysms

Primary reading epilepsy

1.2 Symptomatic

Chronic progressive epilepsia partialis continua

Syndromes characterized by seizures with specific modes of precipitation Temporal lobe epilepsies

Frontal lobe epilepsies

Parietal lobe epilepsies

Occipital lobe epilepsies

1.3 Cryptogenic

II Generalized epilepsies and syndromes

2.1 Idiopathic (with age-related onset)

Benign neonatal familial convulsions

Benign neonatal convulsions

Benign myoclonic epilepsy in infancy

Childhood absence epilepsy

Juvenile myoclonic epilepsy

Epilepsy with grand mal seizures (GTCS) on awakening

Other generalized idiopathic epilepsies

Epilepsies with seizures precipitated by specific modes of activation

2.2 Cryptogenic or symptomatic

West syndrome

Lennox-Gastaut syndrome

Epilepsy with myoclonic-astatic seizures

Epilepsy with myoclonic seizures

2.3 Symptomatic

2.3.1 Non-specific etiology

Early myoclonic encephalopathy Early infantile epileptic encephalopathy with suppression burst Other symptomatic generalized epilepsies

Severe myoclonic epilepsy of infancy

Epilepsy with continuous spike waves during slow wave sleep

Acquired epileptic epilepsies

Other undetermined epilepsies

3.2 Without unequivocal generalized or focal features

IV Special syndromes

4.1 Situation-related seizures

Febrile convulsions

Isolated seizures or isolated status-epilepticus

Seizures occurring only with acute metabolic or toxic events

(RCT), the nature of status epilepticus and the prompt response to rectal diazepam convince

us that it is effective to stop seizures at a dose of 0.5 mg/kg7(level III, recommendation B).Rectal lorazepam has been less studied but is apparently effective at 0.1 mg/kg8(level III).Once the seizure has stopped, it is very unlikely that it will start again (level III); therefore,

we do not usually give further acute medications (recommendation D)

After the seizure has stopped, the physician must take the necessary steps to excludemeningitis Almost all children with seizures and meningitis have important clinical featuresthat allow them to be distinguished.9,10A child with a febrile seizure and who quickly returns

to neurologic well-being does not have meningitis and need not be subjected to a lumbarpuncture (LP) (recommendation D) Children less than 1 year of age or with suspicious neu-rologic or physical findings should have an LP done (recommendation A), although the yield

is still only about 15 percent11(level II-2)

There is good evidence that complete blood count (CBC), electrolytes, and serum cose provide insufficient yield to be worth measuring (level II-211–13and level III,14recom-mendation D) There is some evidence that children with a first febrile seizure are more likely

glu-to have a recurrence within that illness if the serum sodium is lowered15(level II-2) Thismakes a case for checking electrolytes in children with a first febrile seizure, not to help withthe acute management but rather to help with prediction of recurrence within that illness(recommendation B)

Neuroimaging studies (CT and MRI) and skull radiography have no value in childrenwith febrile seizures, even complex febrile seizures14(level III, recommendation E) The EEG

is also of no predictive value in this setting and is not recommended (level III,14level II-2,16recommendation E)

Families of patients get very upset by febrile seizures, and most parents indicate that theythought that their child was dying during the event17,18(level III) Since the child will recoverunscathed, much of the acute management must be devoted to parental reassurance There

is no data to indicate the value of admitting the child to the hospital; however, if admission

is contemplated, the rationale would be reassurance of parents or further ment of the fever The febrile seizure is no longer an issue The value of an admission forparental reassurance has not been studied, but the expense of admission and lack of benefit

investigation/treat-to the child strongly suggest that admission is usually not of value (recommendation D).Following the febrile seizure, there are two possible sequellae—recurrence of febrileseizures in 30 to 40 percent19and epilepsy in 2 to 4 percent.20Recurrent febrile seizures can

be reasonably predicted by the following risk factors: age of seizure <14 months, low fever

at the time of the seizure, a short duration of illness prior to the seizure, and family history

of febrile seizures A child with all four factors has about an 80 percent chance of recurrence,while a child with no risk factors has only about 10 to 15 percent of recurrence.19,21

Rigorous antipyretic use does not prevent recurrent febrile seizures This might soundridiculous, since fever is a necessary ingredient; however, the literature is very consistent22–25(level I, recommendation E)

The most rigorous studies of daily phenobarbital or valproic acid suggest that thesemedications can reduce recurrences22,26,27(level I); however, there is rarely a convincing rea-son to prescribe daily medication for febrile seizures (recommendation E) A meta-analysis

of randomized trials of phenobarbital or valproate disputes their efficacy,28although the als with the most rigorous methodology and compliance are at odds with this conclusion.Compliance is a major confounder Daily phenobarbital has a high rate of severe behavioralreactions, and there is some evidence that the child’s learning abilities may be affected.26,27Valproic acid has been associated with fatal hepatitis in small children, possibly at a rate of1:500.29The importance of these side effects and the uncertainty of the efficacy of these med-ications mean that there is rarely a convincing reason to prescribe daily medication (recom-mendation D)

tri-Diazepam can be used intermittently in children with febrile seizures One approach is

to use liquid injectable diazepam in a dose of 0.5 mg/kg up to 20 mg given rectally during

an actual seizure30,31(levels II-2 and II-3) The medication can be drawn up in a small syringe,the needle removed, and the syringe inserted into the rectum, thus obviating the need for arectal tube The medication is quickly absorbed, and the seizure stops promptly Parents usingthis approach need careful instruction, as an overdose can cause apnea This approach willprevent prolonged febrile seizures but requires a well-organized family for the child It may

be of some use for those living in very remote areas (recommendation B)

The other approach is to use diazepam at the time of a fever to prevent recurrent febrileseizures Since a febrile seizure is frequently the initial manifestation of the illness, clearly thisapproach will never be completely successful Rectal liquid diazepam 0.5 mg/dose given every

12 hours during the illness is as effective as daily phenobarbital30(level I) Oral diazepam at

a dose of 0.3 mg/kg every 8 hours during the illness is associated with a modest reduction infebrile seizure recurrence31(level I) However, it is necessary to treat 14 children to prevent 1febrile seizure recurrence.32Twenty-five percent of children have side effects from 0.3 mg/kgoral diazepam In Uhari’s study, a lower dose of 0.2mg/kg was shown to be ineffective23(levelI) We do not recommend this approach to treatment because the rate of seizure reduction

is very low and the incidence of side effects very high (recommendation E)

It is fortunate that only 2 to 4 percent of children with a febrile seizure later developepilepsy.20There is no evidence that the febrile seizures actually cause the subsequent epilepsyand likewise no evidence that prevention of febrile seizures prevents subsequent epilepsy.33Risk factors noted at the time of a first febrile seizure are associated with an increased risk ofsubsequent epilepsy These factors include focal seizure, prolonged febrile seizure,≥2 seizureswithin an illness, developmental abnormalities at the time of the febrile seizure, and familyhistory of epilepsy Each of these factors increases the risk of subsequent epilepsy to about 4

to 6 percent Combinations of the factors increase the risk to about 10 to 15 percent Thuseven in the “high-risk” group, 85 percent of children will not develop epilepsy20,21(level II-2) This reassuring information should be kept in mind because as many as 40 percent of chil-dren with a first febrile seizure will have a risk factor for subsequent epilepsy19,20(level II-2)

AFEBRILESEIZURES

This section is divided into two parts The first deals with types of epilepsy that can presentwith a single seizure When a child is seen after a first seizure, there are special issues con-cerning evaluation and treatment The second part of this section deals with epilepsies thatvirtually always present with multiple seizures The issues for evaluation of these are some-what different, but treatment decisions are usually more straightforward

Evaluation of a Child with a Single Seizure

Most children presenting with a single seizure have had a generalized tonic-clonic, partial withsecondary generalization, or a dramatic complex partial seizure Simple partial seizures andmany complex partial seizures are initially not recognized by parents to be very significant.Once the child has been stabilized, the clinician must decide if a seizure has occurredand if the seizure was provoked by factors such as CNS infection, head injury, electrolyte dis-turbance, and hypoglycemia Usually, the history and physical examination will determineprovoking factors, and treatment will flow directly from the diagnosis A conundrum occurswhen there are no clear provoking factors: how much acute investigation is needed?

Lumbar Puncture and Blood Tests

In the absence of fever, there is no clear value for a lumbar puncture34(level III) Aside fromthe detection of meningitis/encephalitis, the LP cannot provide any useful diagnostic infor-mation in this setting If the child is completely well, the chance of CNS infection must be very

remote, and therefore there is no need for an LP (recommendation D) Blood work, ing electrolytes, calcium, glucose, and urea, rarely gives useful results; however, the literature

includ-on children studied with these routine tests is not very extensive35–37) (level III) In a well child,there does not seem to be much justification for routine blood work (recommendation D)

Neuroimaging Studies

Brain tumors in children virtually never present with a first unprovoked seizure After a firstunprovoked seizure, brain imaging studies, especially MRI, are abnormal in about 15 per-cent38(level III) Fortunately, most of these abnormalities do not require direct treatment.Their value is a fuller understanding of the cause of the seizure, but their significance in pre-dicting recurrent seizures is unstudied Conditions that might require immediate neurosur-gical intervention, such as intracerebral hemorrhage from an arteriovenous malformation

or acute hydrocephalus, are expected to manifest significant clinical findings It is safe to clude that a child with a first seizure who has recovered completely rarely benefits from anemergency imaging study (recommendation E) If an imaging study is to be carried out, itcan be done electively In addition, when the EEG (see below) shows evidence of an idio-pathic epilepsy, there is no need for an imaging study If the EEG is normal or shows a focalabnormality, an elective MRI is the best imaging study, although CT will detect most majorabnormalities39(level II-2) If the child has not recovered from the seizure or there are newneurologic abnormalities on examination, clearly an urgent imaging study is required toexclude such disorders as intracranial hemorrhage, hydrocephalus, or other acute processes

con-A CT scan is adequate in this acute assessment

Electroencephalography

Following a first unprovoked seizure, an EEG is always recommended (recommendation A)

A single study in adults suggested that the sooner the EEG is performed, the higher the yieldwill be, with the greatest yield within 24 hours of the seizure40(level III) Nonetheless, an EEGshould be regarded as an elective investigation Its role is to help classify the seizure disorderand assist in the prediction of recurrence The possible increased yield from very early EEGmust be balanced with the fact that early EEG recordings may be contaminated by transientpostictal slow-wave abnormalities Such findings may require another later EEG to determinethe significance of the slow waves In most clinical settings, especially outside of normalworking hours, emergency EEG is not available Until there is more evidence for the optimaltiming of the EEG, our preference is to delay it until the postictal changes are likely gone,perhaps in 48 hours (recommendation B)

The EEG can give clear evidence of an idiopathic epilepsy, that is, the etiology is geneticand no further work-up is needed The two most important disorders to consider are benignfocal epilepsy of childhood with centro-temporal spikes (benign rolandic epilepsy) and juve-nile myoclonic epilepsy

The presence of spike discharge on EEG after a first seizure increases the risk of rence from about 20 percent to about 70 percent41(level II-2)

recur-Treatment after a first seizure

After a first unprovoked seizure, about 50 percent of children will never have anotherseizure37(level II-2) The diagnosis of epilepsy is reserved for those with two seizures becausethe recurrence risk after two seizures is about 80 percent42,43(level II-2) Factors that helppredict further seizures are neurologic abnormality (or remote symptomatic etiology) andfocal seizure and epileptic (spike) discharge on EEG Remote symptomatic etiology meansthat the child has a longstanding brain abnormality that has now caused a seizure (for exam-ple, a brain malformation or previous severe head injury) With all of these factors, the recur-rence risk is about 75 percent; with none, it is about 15 percent.41,42

There is little reason to offer antiepileptic medication after a first seizure in childhood(recommendation E) In population-based studies, the rate of recurrence is not altered bythe prescription of medication, presumably because of compliance issues42,44(level II-2) Inrandomized trials, the rate of recurrence is decreased but not enough to be medically sig-nificant45,46(level I) For example, in the largest trial, the recurrence risk for those treated wasstill 25 percent, compared with 51 percent for the untreated over a 2-year period.46Thismeans that treated patients continue to have a high rate of recurrence and must make thesame adjustments to lifestyle as those not treated Those not treated after a first seizure havethe same rate of long-term remission as those treated after repeated seizures47(level I) Par-ents need to know that most recurrences happen within a few months of the first seizure andrecurrence after 6 months is very uncommon.42 No studies have addressed the value ofrestrictions in the child’s daily activities; after a first seizure, we do not usually recommendany change48(level III, recommendation D).

Approach after Two or More Seizures

When a child presents with a possible first seizure, there is often a history of other moreminor but convincing events Partial seizures may be dismissed by the family as unimpor-tant, until there is a secondarily generalized seizure A history of less severe events means thatthe child has epilepsy Alternatively, a true first seizure may be followed by a second Oncethe diagnosis of epilepsy has been made, there are several important considerations that con-cern investigation and management The first and most critical decision must be the defin-ition of the child’s epilepsy syndrome The approach to a benign focal epilepsy may be muchmore relaxed than that to a symptomatic partial epilepsy To come to a syndrome diagnosis,the history must be evaluated by an expert (recommendation B) The success of an expert

in assigning a correct diagnosis of a syndrome has not been compared with the skills of otherphysicians; however, given that the current classification of epilepsy includes >100 syn-dromes, it would seem likely that an expert would be more accurate The EEG and imagingstudies must be interpreted in the context of the history

The evaluation of a child who has had two or more seizures is essentially the same asafter the first seizure If the clinical history and examination, supplemented by the EEG, yield

a diagnosis of idiopathic epilepsy, there is no need for brain imaging studies This means thatchildren with disorders such as benign Rolandic epilepsy or juvenile myoclonic epilepsy donot derive any additional benefit from a CT scan or MRI

Once there have been two or more seizures, prescription of an antiepileptic drug(AED) may be considered These medications do not “cure” epilepsy but do suppressseizures The rate of long-term remission of the epilepsy is the same if treatment is delayedfor up to at least 10 seizures49(level II-2) Many experts suggest starting medication aftertwo seizures It is acceptable to wait longer, provided there is no clear “down side” to thechild, in terms of excessive supervision or exclusion from normal activities49(level II-2, rec-ommendation B)

Initial Medication for Epilepsies that may present with a Single Seizure (once further seizures have occurred)

There is good evidence that carbamazepine and valproic acid are equally effective on the basis

of the British “Epiteg” study, an open-label but randomized, multi-centered trial of newlytreated children50 (level I) Phenytoin, valproate, and carbamazepine were equivalent inanother randomized trial; however, phenobarbital was inferior because of a much higher rate

of unacceptable side effects51(level I) The only large, double-blind, comparative trial ofantiepileptic drugs (AEDs) in childhood epilepsy is the Canadian Clobazam Trial52(level I).This study randomized children in double-blind fashion to clobazam, phenytoin, and car-bamazepine Each drug was equally efficacious as measured by the time retained on med-ication, although the data for carbamazepine and clobazam were most secure

Studies in adults suggest that lamotrigine is roughly equivalent to carbamazepine53(levelI) and vigabatrin is equivalent to carbamazepine54(level I).

The bottom line is that many medications are interchangeable at the beginning of ment On the basis of relative lack of side effects and ease of use, our personal preference is

treat-to use carbamazepine or clobazam first for children with partial epilepsies (partial seizures

or partial with secondary generalization) (recommendation B) Although there are no domized trials, there is a very wide consensus that valproate is best for juvenile myoclonicepilepsy and carbamazepine may exacerbate this disorder (level III, recommendation B)

ran-Evaluation of Epilepsies that Always Present with Multiple Seizures

A variety of epilepsies always present with multiple seizures The seizure types in theseepilepsies include infantile spasms, generalized absence, akinetic (drop) seizures, andmyoclonus The most common epilepsy types are West’s syndrome, typical childhoodabsence, and Lennox-Gastaut syndrome

If the child is intellectually normal and has absence seizures from the history confirmed

by EEG, then there is no need for further evaluation (level III, recommendation A) Absenceepilepsy is dealt with separately below

If the epilepsy with many seizures at presentation is of any other type, a careful searchfor etiology is needed Nearly all of these epilepsies have an underlying etiology; they are con-sidered “remote symptomatic,” meaning that there is a pre-existing brain problem Etiolo-gies include diffuse brain injury from neonatal or postnatal hypoxia, developmental brainabnormalities such as neuronal migration problems, or neurocutaneous syndromes such astuberous sclerosis Evaluation must include a very careful history and physical examination

A brain imaging study and consultation with an expert are always indicated because thecauses may be subtle, the treatment difficult, and there is a high rate of either long-termintractable epilepsy and/or mental handicap (level III, recommendation B)

Treatment depends on the epilepsy type Perhaps the most complex is infantile spasm.This devastating disorder has its onset in the first year of life The spasms usually appear inclusters, but the child becomes dull, withdrawn and less interested in life between theseizures The EEG shows a special pattern called hypsarrhthymia with a chaotic continuouselectrical disaster—the spasms are the tip of the iceberg for a very serious condition, andrapid treatment is indicated, even though the long-term mental outcome is nearly alwaysunfavorable There is evidence from a large open case series55(level III), a small randomizedplacebo-controlled trial56(level I), and a comparative trial that vigabatrin is often effectivewithin 1 to 2 days57(level I) It is not as powerful as adrenal corticotrophic hormone (ACTH)treatment, where the response rate is >80 percent.57Because of the side effects of ACTH, mostexperts suggest initial treatment with vigabatrin If it fails to stop the spasms after 48 to 72hours, then ACTH can be started (recommendation B) The dose of ACTH and length oftreatment varies; a low dose of 4 to 5 units/kg/day for a month seems to be as effective ashigher doses for most patients.58Oral prednisone may also be effective59(level III); however,there have not been definitive randomized trials comparing prednisone with ACTH.58For other epilepsies always presenting with repeated seizures, valproic acid is usually thefirst drug, even though there are no comparative drug trials Open-label case series have con-sistently shown reasonable efficacy (level III, recommendation B) Ethosuximide is very effec-tive for absence seizures but has no action against generalized tonic-clonic seizures (level III)

A benzodiazepine such as clobazam or nitrazepam, is often started first

GENERALIZEDABSENCEEPILEPSY

About 10 percent of children with epilepsy have absence seizures (“petit mal”) There areseveral different types of absence epilepsy but the most common is typical childhoodabsence epilepsy with onset between ages 3 to 10 years The children have many seizures a

day, and virtually all will have an actual seizure during EEG, which confirms the diagnosis.The ictal EEG pattern is typically generalized 3 Hz spike and wave The cause of typical child-hood absence epilepsy appears to be genetic, although the specific inheritance patternremains unknown Once EEG indicates this diagnosis, there is no value in further work-up.Specific medications may be effective for this disorder Ethosuximide is equivalent to valproicacid for absence epilepsy, although valproate has additional efficacy against generalizedtonic-clonic seizures60(level I) Also effective are clobazam61(level II-1) and lamotrigine62(level I, recommendation A) In our opinion, any of these medications may be used.

Routines in Clinical Practice for Antiepileptic Drug Therapy

When a medication is started, there is hope that the seizures will be completely suppressedwithout side effects In clinical practice, these two issues need to be balanced For nearly allAEDs, one can usually expect increased seizure control with an increased dose Determina-tion of serum levels of AEDs has been used to try to optimize treatment There are no care-fully designed trials to determine the optimal serum level of any AED In Canada, and likely

in all countries, it is possible to have the same level interpreted in one center as peutic and potentially toxic in another63(level III) For patients with controlled seizures,there is evidence that further assessment of serum levels interferes with management Theonly randomized trial of this issue indicated that the use of serum levels actually increasedside effects without improving seizure control64(level I) The “therapeutic range” for all AEDsshould be used only as a rough guide for dosing In general, the dose is correct if there are

subthera-no seizures and subthera-no side effects (recommendation E)

Our current practice is to order very few serum levels If there is an issue of compliance,

it seems that direct questioning of the child and family more often gets useful informationthan checking blood levels65(level III) Since there is a lot of individual sensitivity to thebehavioral and cognitive side effects of AEDs, asking about these side effects is likely ofgreater value than measuring serum levels (recommendation B)

Clinicians are appropriately concerned about severe catastrophic reactions to AEDs.These include liver failure, aplastic anemia, nephritis, and Stevens-Johnson reaction Thesereactions are idiosyncratic and are not related to dose, although they tend to occur early intreatment (first few months) None of these reactions can be predicted in asymptomaticpatients from screening blood and urine tests67(level II-2) There is an important consensus

in Canada that screening tests are of no value and may interfere with treatment68(level III)

We recommend that patients be warned of these reactions and asked to call the physicianimmediately if such a reaction is suspected At that time the child can be investigated, as theclinical situation appears to warrant (recommendation E)

Duration of Treatment

Epilepsy in children is often outgrown For only about 40 percent is it a life-long disorder68,69(level II-2) Once a child has had 1 to 2 seizure-free years, it is reasonable to consider stop-ping medication Overall, such children have a 60 to 70 percent chance of remaining seizure-free This percentage is about the same if the seizure-free interval has been 1, 2, 4, or 5 years70(level II-2) Therefore, in general, consideration of stopping medication is appropriate once

a child has been seizure-free for 1 year71(level II-2, recommendation A)

The group of children with the best chance of remaining seizure-free off medication arethose with normal intelligence, normal neurologic examination, generalized epilepsy, and age

at onset <12 years This group has a 80 to 90 percent chance of remaining free of furtherseizures, once off medication Those with teenage onset of partial seizures in association withneurologic deficits have only a 10 to 15 percent chance of successfully stopping medica-tion69,70These children may be candidates for longer treatment

Recommendations for the treatment of seizure disorders are listed in Table 12–2

and child appears well

or child of any age appears ill

Febrile seizure work-up Glucose, CBC, electrolytes II-2, III D

Febrile seizure work-up Skull radiography, CT, or MRI III E

treatment

2 Febrile seizure drug Reduction of recurrences with I E treatment daily prophylactic AEDs

3 Febrile seizure drug Intermittent rectal diazepam II-2, II-3 B

4 Febrile seizure drug Intermittent oral diazepam I E treatment during febrile illness

First Afebrile Seizure

First afebrile work-up Glucose, calcium, electrolytes, III D

urea

First afebrile work-up EEG in 48 hours Not studied D

Recurrent Afebrile Seizures

2 or more afebrile seizures Referral to expert Not studied B

(continued)

Pro-4 Nelson KB, Ellenberg JH Predictors of epilepsy in children who have experienced febrile seizures.

N Engl J Med 1976;295:1029–33.

5 Stevenson JBP Fits and faints Oxford: MacKeith Press; 1990.

6 Treiman DM, Myers PD, Walton NY, et al A comparison of four treatments for generalized vulsive status N Engl J Med 1998;339:792–8.

con-Table 12–2 Recommendations (continued)

Level of

Absence seizures, intellectually Further evaluation III E normal, typical EEG (neuroimaging studies)

Multiple generalized afebrile Further evaluation needed: III B seizures (West’s or history, physical examination,

Lennox-Gastaut syndrome, neuroimaging

myoclonic, etc)

afebrile seizures

clobazam, lamotrigine

by history

blood/urine for severe side effects

Afebrile seizures, seizure-free Discontinuation of AEDs II-2 A

>12 months

AED=antiepileptic drug; CBC=complete blood count; EEG=electroencephalography; CT=computed tomography; MRI=magnetic resonance imaging

7 Knudsen FU Rectal administration of diazepam in solution in the acute treatment of convulsions

in infants and children Arch Dis Child 1979;54:855–7.

8 Appelton R, Sweeney A, Choonara I, et al Lorazepam vs diazepam in the acute treatment of epileptic seizures and status epilepticus Dev Med Child Neurol 1995;37:682–8.

9 Offringa M Seizures associated with fever: management controversies Sem Pediatr Neurol 1993;1:90–101.

10 Joffe A, McCormich M, DeAngelis C Which children with febrile seizure need lumbar puncture?

15 Kiviranta T, Airaksinen EM Low serum sodium levels are associated with subsequent febrile seizures Acta Ped 1995;84:1372–4.

16 Frantzen E, Lennox-Buchthal M, Nygaard A, Stene J Longitudinal EEG and clinical study of dren with febrile convulsions Electroencephalogr Clin Neurophysiol 1968;24:197–212.

chil-17 Rutter N, Metcalfe DH Febrile convulsions: what do parents do? Br Med J 1978;2:1345–6.

18 Balslev T Parental reactions to a child’s first febrile convulsion Acta Paediatr Scand 1991;80:466–9.

19 Berg AT, Shinnar S, Hauser WA, et al Predictors of recurrent febrile seizures: a prospective study

of the circumstances surrounding the initial febrile seizure N Engl J Med 1992;327:1122–7.

20 Nelson K, Ellenberg J Prognosis in children with febrile seizures Pediatrics 1978;61:720–7.

21 Annegers JF, Hauser WA, Shirts SB, Kurland LT Factors prognostic of unprovoked seizures after febrile convulsions N Engl J Med 1987;316:493–8.

22 Camfield PR, Camfield CS, Shapiro S, Cummings C The first febrile seizure—antipyretic tion plus either phenobarbital or placebo to prevent a recurrence J Pediatr 1980;97:16–21.

instruc-23 Uhari M, Rantala H, Vainionpaa L, Kurttila R Effect of acetaminophen and of low dose mittent diazepam on prevention of recurrences of febrile seizures J Pediatr 1995:126;991–5.

inter-24 Van Stuijvenberg M, Derksen-Lubsen G, Steyerberg EW, et al Randomized controlled trial of ibuprofen syrup administered during febrile illnesses to prevent febrile seizure recurrences Pediatrics 1998;102:51e.

25 Schnaiderman D, Lahat E, Sheffer T, Aladjem M Antipyretic effectiveness of acetaminophen in febrile seizures: ongoing prophylaxis versus sporadic usage Eur J Pediatr 1993;152:747–9.

26 Farwell J, Lee YJ, Hirtz DG, et al Phenobarbital for febrile seizures—effects on intelligence and

on seizure recurrence N Engl J Med 1990;322:364–9.

27 Mamelle N, Pleasse JC, Revol M, Gilly R Prevention of recurrent febrile convulsions—a domized therapeutic assay: sodium valproate, phenobarbital and placebo Neuropediatrics 1984;15:37–42.

ran-28 Newton RW Randomized controlled trials of phenobarbitone and valproate in febrile sions Arch Dis Child 1988;63:1189–92.

convul-29 Dreifus FE, Santilli N, Langer DH, et al Valproic acid hepatic fatalities: a retrospective review Neurology 1987;37:379–85.

30 Knudsen FU, Vestermark S Prophylactic diazepam or phenobarbitone in febrile convulsions: a prospective, controlled study Arch Dis Child 1978;53:660–3.

31 Camfield CS, Camfield PR, Smith E, Dooley JM Home use of rectal diazepam to prevent status epilepticus in children with convulsive disorders J Child Neurol 1989;4:125–6.

32 Rosman NP, Colton T, Labazzo J, et al A controlled trial of diazepam administered during febrile illnesses to prevent recurrence of febrile seizures N Engl J Med 1993;329:79–84.

33 Camfield PR, Camfield CS, Gordon K, Dooley JM Prevention of Recurrent febrile seizures torial] J Pediatr 1995:129;991–2.

[edi-34 Report of the Quality Standards Subcommittee of the American Acadamy of Neurology Practice parameters: lumbar puncture Neurology 1993;43:625–7.

35 Eisner RF, Turnbull TL, Howes DS, Gold IW Efficacy of a “standard” seizure workup in the gency department Ann Emerg Med 1986;15:69–75.

36 Turnbull TL, Vanden Hoek TL, Howes DS, Eisner RF Utility of laboratory studies in the gency department patient with a new-onset seizure Ann Emerg Med 1990;19:373–7.

emer-37 Smith RA, Martland T, Lowry MF Children with seizures presenting to accident and emergency.

J Accid Emerg Med 1996;13:54–8.

38 O’Dell C, Shinnar S, Mitnick R, et al Neuroimaging abnormalities in children with a first afebrile seizure Epilepsia 1998;38(Suppl 8):184.

39 Kuzneicky RI Neuroimaging in pediatric epilepsy Epilepsia 1996;37(Suppl 1):S10–21.

40 King MA, Newton MR, Jackson GD, et al Epileptology of the first-seizure presentation: a cal, electroencephalographic and magnetic resonance imaging study of 300 consecutive patients Lancet 1998;352:1007–11.

clini-41 Berg AT, Shinnar S The risk of seizure recurrence following a first unprovoked seizure: a analysis Neurology 1991;41;965–72.

meta-42 Camfield PR, Camfield CS, Dooley JM, et al Epilepsy after a first unprovoked seizure in hood Neurology 1985;35:1657–60.

child-43 Hauser WA, Rich SS, Lee JR, et al Risk of recurrent seizures after two unprovoked seizures N Engl

49 Camfield CS, Camfield PR, Gordon K, Dooley J Does the number of seizures before treatment influence ease of control or remission of childhood epilepsy? Not if the number is 10 or less Neurology 1996;46:41–4.

50 Verity CM, Hosking G, Easter DJ, on behalf of The Pediatric EPITEG Collaborative Group A ticenter comparative trial of sodium valproate and carbamazepine in pediatric epilepsy Dev Med Child Neurol 1995;37:97–108.

mul-51 De Silva M, MacArdle B, McGowan M, et al Randomized comparative monotherapy trial of nobarbitone, phenytoin, carbamazepine, or sodium valproate for newly diagnosed childhood epilepsy Lancet 1996;347:709–13.

phe-52 Canadian Clobazam Co-operative Study Group Clobazam in treatment of Refractory Epilepsy: the Canadian Experience A retrospective study Epilepsia 1991;32:407–16.

53 Brodie MJ, Richens A, Yuen AW Double-blind comparison of lamotrigine and carbamazepine in newly diagnosed epilepsy UK Lamotrigine/Carbamazepine Monotherapy Trial Group Lancet 1995;345:476–9.

54 Kalviainen R, Aikia M, Saukkonen AM, et al Vigabatrin vs carbamazepine in patients with newly diagnosed epilepsy Arch Neurol 1995;52:989–96.

55 Aicardi J, Mumford JP, Duma C, Wood S Vigabatrin as initial therapy for infantile spasms: a pean retrospective study Epilepsia 1996;37:638–42.

Euro-56 Appleton R A double-blind study of vigabatrin for infantile spasms 1999 [In press]

57 Vigevano F, Cilio MR Vigabatrin vs ACTH as first line treatment for infantile spasms: a domized prospective study Epilepsia 1997;38:1270–4.

ran-58 Baram TZ, Mitchell WG, Tournay A, et al High-dose corticotrophin (ACTH) versus prednisone for infantile spasms: a prospective, randomized, blinded study Pediatrics 1996;97:375–9.

59 Schlumberger E, Dulac O A simple, effective and well-tolerated treatment regime for West drome Dev Med Child Neurol 1994;36:863–72.

syn-60 Sato S, White BG, Penry JK, et al Valproic acid vs ethosuximide in the treatment of absence seizures Neurology 1982;32:157–63.

61 Canadian Clobazam Cooperative Study Group Clobazam in treatment of refractory epilepsy: the Canadian experience A retrospective study Epilepsia 1991;32:407–16.

62 Frank LM, Enlow T, Holmes GL, et al Lamictal monotherapy for typical absence seizures in dren Epilepsia 1999;40:973–9.

63 Dooley JM, Camfield PR, Camfield CS, et al The use of antiepileptic drug (AED) levels in dren: a survey of Canadian pediatric neurologists Can J Neurol Sci 1993;20:217–21.

chil-64 Woo E, Chan YM, Yu YL, et al If a well-stabilized epileptic patient has a subtherapeutic drug level, should the dose be increased? A randomized prospective study Epilepsia 1988;29:129–39.

65 Schoeman JF, Elyas AA, Brett EM, Lascelles PT Correlation between plasma carbamazepine 10,11 epoxide concentrations and drug side effects in children with epilepsy Dev Med Child Neu- rol 1984;26:756–64.

66 Camfield CS, Camfield PR, Smith E, Tibbles JAR Asymptomatic children with epilepsy: little efit from screening for anticonvulsant-induced liver, blood or renal damage Neurology 1986;36:838–41.

ben-67 Camfield PR, Camfield CS, Dooley J, et al Routine screening of blood and urine for severe tions to anticonvulsant drugs in asymptomatic patients is of doubtful value Can Med Assoc

70 Berg AT, Shinnar S Relapse following discontinuation of anti-epileptic drugs: a meta-analysis Neurology 1994;44:601–8.

71 Dooley JM, Gordon K, Camfield PR, et al Discontinuation of anticonvulsant therapy in children free of seizures for 1 year Neurology 1996;46:969–74.

Headaches in ChildhoodJ.M Dooley, MBBCh, FRCPCK.E Gordon, MD, MS, FRCPC

O

Headaches impose a significant burden upon society They occur in almost 75 percent of dren1,2and are associated with a total annual cost in the United States in excess of $17 bil-lion.3Despite this prevalence, there have been insufficient randomized controlled trials toallow an evidence-based approach to many aspects of childhood headache management.Where such data are not available, the best available evidence is presented

chil-EPIDEMIOLOGY

Epidemiologic studies of childhood headache are frequently compromised by the selectionbias inherent in clinic-based studies and by the tendency of questionnaires to depend on thememories of parents or patients for details

In 1962, Bille published his landmark paper on headache.1 This study, consisting ofalmost 9,000 Scandinavian children, showed that by 7 years of age, approximately 40 percenthad experienced headaches and 75 percent by 15 years of age.1

Similar prevalence rates have been found in other studies By 3 years of age, 3 to 8 cent of children will have experienced headache.5Headaches occur in 19.5 percent of chil-dren at 5 years of age and 37 to 51.5 percent of children at 7 years.6In a British prospectivestudy, mothers reported headache during the previous month in 4 percent of their 3-year-old children.5The presence of headaches was closely associated with depression as well asmarital problems and poor health in the mothers.5

per-The value of historical reports is limited More recent data suggest an increase in theprevalence of headache in schoolchildren from 14.4 percent in 1974 to 51.5 percent in 1992.2

The reason for this increase in prevalence is unclear

When specific headache types are studied, similar trends are seen

Acute Headache

Acute headaches are usually associated with acute illnesses, such as infection.7Few data areavailable on the incidence or prevalence of illness-related headache Such headaches may per-sist for 3 to 4 weeks after the illness and are more common in those with a family history ofmigraine.8

Acute Recurrent Headache

Acute recurrent headaches comprise both migraine and tension-type headaches

Migraine is slightly more common in boys aged 3 to 7 years, but thereafter, the trend

is reversed.1,9Migraine prevalence may be increasing Using the same nine-item naire, migraine prevalence in 7-year-old school children increased from 1.9 percent in

question-197410 to 5.7 percent in 1992.2 Similar increases were found in both boys and girls.Migraine, therefore, has a prevalence of 1.2 to 3.2 percent at 7 years of age and 4 to 11 per-cent between 7 and 15 years of age.1,9,10A recent meta-analysis has shown that genderaccounts for 14 percent of the variance among studies and for approximately 30 percent

of the variation when combined with age.11When three factors were combined (differences

in case definition, age, and sex of the study populations), 70 percent of the varianceamong studies was explained.11

Tension-type headache is reported to be uncommon before 7 years of age.12,13This hasbeen disputed by a Finnish population-based study of 6-year-old children, which found a14.6 percent prevalence of headache that disturbed activity within the preceding 6 months.14Among these children, 25 percent were classified as having episodic tension-type headacheand 15 percent as having tension-type headache not fulfilling all International HeadacheSociety (IHS) criteria.14As in migraine, the prevalence of tension-type headache increaseswith age Tension-type headaches, within the previous month, occurred in 27.3 percent of 8

to 9-year-old Finnish children.15Clinic-based case studies add more evidence for an increase

in tension-type headaches during adolescence, particularly in females.4,13,16,17

Cluster headache is extremely rare in childhood, but the exact incidence is unknown.Among adults with cluster headache, childhood onset is reported by 2 percent and adoles-cent onset by 10 percent.18

Chronic Progressive Headache

Chronic progressive headache may be secondary to raised intracranial pressure Causes ofchronic progressive headache have not been well studied Headache secondary to idiopathicintracranial hypertension (pseudotumor cerebri) is rare We reported an incidence of thistype of headache in childhood of 8.4 per 1,000,000.19

Chronic Nonprogressive Headaches

There is increasing evidence that some children experience chronic daily headache.20Theincidence and prevalence of these headaches are unclear, using current diagnostic criteria

IMPACT OFHEADACHE

There are inconclusive data regarding the use of health-care resources by children withheadache One study reported physician consultation by only 11.3 percent of 3- to 11-year-olds with migraine.23The reasons for not seeking a medical opinion were ignorance of diag-nosis, assumption that little could be done to help, and a parental attempt to prevent thelearning of illness behavior.23In contrast, another study found that 51.8 percent of childrenaged 11 to 13 years had consulted a doctor because of headache.24The children who had con-sulted a doctor were more likely to report associated nausea and were more likely to comefrom a densely populated area.24They were also more likely to have missed more days fromschool.24Those who visited a doctor wanted (1) the cause to be found, (2) to receive painrelief, and (3) to receive reassurance that they did not have a brain tumor.25In one popula-tion-based study, tension-type headache was thought to be as worrisome as migraine fromthe parent’s perspective.14The impact of headache on school attendance varies among stud-ies In one study, headache accounted for only 1 percent of school days missed and for schoolabsenteeism in only 3.7 percent of children.26In another study, 10 percent of children withmigraine missed 1 day of school over a 2-week period, and nearly 1 percent missed 4 days.27The recently recognized entity of chronic daily headache has been associated with higher lev-els of impairment than migraine.28

PATHOGENESIS

As the cerebral cortex itself is insensitive, headache results from stimulation of nerve fiberssurrounding the large cerebral vessels, pial vessels, venous sinuses and dura mater.29Thesechiefly unmyelinated nerve fibers arise from the ophthalmic division of the trigeminal gan-glion and contain substance P and calcitonin gene-related peptide (CGRP), which arereleased following trigeminal ganglion stimulation.30In the posterior fossa, the nerve fibersarise from the upper cervical dorsal roots.29

Acute Headache

Headache is a frequent accompaniment of febrile illness in childhood The pathogenesis

of illness-related headache is believed to be through bacterial and viral toxins, which ulate the release of endogenous pyrogens such as interleukin-1 and interferon Thesepyrogens give rise to headache through the release of prostaglandins and vasoactive peptides.31

stim-Acute Recurrent Headache

Migraine was previously considered a solely vascular disorder, involving dilatation ofintracranial vessels Although dilatation of these blood vessels results in pain,32the vasculartheory did not explain all migraine phenomena, such as the spread of symptoms across vas-cular territories The current “neurovascular” theory proposes that migraine is primarilyneurogenic, with secondary vascular changes This hypothesis originated with recognitionthat migraine can be produced in nonmigraine sufferers by stimulating certain areas withinthe brainstem.33Similarly, positron emission tomography (PET) scan studies have shownactivation of brain stem regions during spontaneous migraine episodes.34Dysfunction ofthese migraine “generators” results in an alteration in sensory and vascular responses.35Vasodilatation induces activation of the trigeminal sensory nerves, which release vasoac-tive peptides and induce further vasodilatation Thus, a circular cascade is initiated.36Individuals with a genetic propensity for migraine experience a headache when exposed

to appropriate triggers These triggers, such as stress or hormonal changes, stimulate the

“migraine generator” within the brain stem This leads to the stimulation of vasodilatationand extravasation through the walls of the intracranial blood vessels This results in pain andalso stimulates the release of factors that cause further vascular dilatation A cycle is thus cre-ated, which results in an ongoing headache

The pathogenesis of the aura in migraine is also unclear The hypothesis, as initiallydescribed by Leao in 1944,37that a spreading wave of neuronal depolarization is followed by

a wave of neuronal suppression across the surface of the brain is still the most widelyaccepted Woods and colleagues have shown a similar bilateral hypoperfusion starting in theoccipital lobes and spreading across the cortex during a migraine headache.38The aura maysubsequently affect the trigeminal ganglia in the brain stem39and may thus influence the evo-lution of the headache

Although currently these theories seem plausible, it is essential to acknowledge that thepathogenesis of migraine, as well as the pain experienced in many other types of headache,remains obscure Conclusive evidence on this topic is currently beyond our reach

Essentially no research has been carried out on the pathogenesis of episodic tension-typeheadaches in childhood

CLASSIFICATION ANDETIOLOGY

Evaluation of the temporal profile of headache results in an easily applied clinical tion Many children will experience more than one headache type, and it is important to ana-lyze each type individually (Table 13–1)

Acute Recurrent Headache

Acute recurrent headache comprises both migraine and tension-type headache Without adefinitive diagnostic test, the diagnosis of migraine depends on clinical criteria, which havenot received universal acceptance

Distinction between migraine and tension-type headache has presented a dilemma tophysicians and researchers alike Cluster-analysis studies of symptom complexes have failed

to identify any reliable clusters that resemble currently proposed diagnostic criteria.41,42A

“headache continuum,” rather than a dichotomous approach to migraine and tension-typeheadache, has recently been suggested.43

In 1955, Vahlquist proposed the presence of aura, nausea, unilateral pain, and positivefamily history as criteria for migraine.44In 1988, the IHS proposed a new classification ofheadaches45(Table 13–2) These criteria largely dichotomize headaches into migraine or ten-sion-type Subsequently, there has been considerable dispute regarding the applicability ofthe IHS criteria to children.46–48

Table 13–1 Clinical Classification of Pediatric Headaches

Temporomandibular joint dysfunction Post–lumbar puncture

Arteriovenous malformation

Others

Hypertension

Pediatric migraine headaches are often of shorter duration than the 2-hour minimumrequired by the IHS criteria Similarly, pediatric migraine is often bilateral, in contrast to uni-lateral adult migraine Photophobia and phonophobia are more common in children than

in adults, but the quality of the headache in children is often difficult to establish In 1995,Winner and colleagues proposed revisions to the IHS criteria49(see Table 13–2) For migrainewith aura, they suggested reducing the required duration of headaches from 2 to 48 hours

to 1 to 48 hours In a multicenter prospective study, these revised IHS criteria revealed a nostic rate of 93 percent compared with the 66 percent with the unrevised IHS criteria.50The role of genetics in migraine is unclear Although 72 to 89 percent of children withmigraine have a positive family history, the relative contributions of genetics and other fac-tors have not been established.51For children with tension-type headache, 47 percent have apositive family history.14In adults with chronic tension-type headache, first-degree relativeshave a 3.2 relative risk of developing a similar headache.52

diag-Chronic Progressive Headache

Children with headaches that are becoming more severe or are associated with other logic features are more likely to have a sinister etiology (Table 13–3)

neuro-Table 13–2 Migraine Diagnostic Criteria

IHS Criteria 45 IHS-R (revised) Criteria 49 *

Pediatric Migraine without Aura Pediatric Migraine without Aura

A At least five attacks fulfilling B to D A At least five attacks fulfilling B to D

B Headache attacks lasting 2 to 48 hours B Headache attack lasting 1 hour to 48 hours

C Headache has at least two of the following: C Headache has at least two of the following:

1 Unilateral location 1 Unilateral location

3 Moderate to severe intensity 3 Moderate to severe intensity

4 Aggravation by routine physical activity 4 Aggravation by routine physical activity

D During headache, at least one of the following: D During headache, at least 1 of the following

1 Nausea and/or vomiting 1 Nausea and/or vomiting

2 Photophobia and phonophobia 2 Photophobia and/or phonophobia

Pediatric Migraine with Aura Pediatric Migraine with Aura

(Idiopathic recurring disorder, headache (Idiopathic recurring disorder, headache usually lasts 2 to 48 hours in patients less usually lasts 1 to 48 hours)

than 15 years of age)

A At least two attacks fulfilling B A At least two attacks fulfilling B

B At least three of the following: B At least three of the following:

1 One or more fully reversible aura 1 One or more fully reversible aura symptoms indicating focal cortical symptoms indicating focal cortical and/or brainstem dysfunction and/or brain stem dysfunction

2 At least one aura developing gradually 2 At least one aura developing gradually over 4 minutes or two or more symptoms over 4 minutes or two or more occurring in succession symptoms occurring in succession

3 No auras lasting more than 60 minutes 3 No auras lasting more than 60 minutes

4 Headache follows aura with a free 4 Headache follows aura with a free interval of less than 60 minutes interval of less than 60 minutes

*for children under age 15

With permission from 45,49

Chronic Nonprogressive Headache

Chronic daily headache, with almost daily or persistent headaches, has recently been posed as an alternative diagnostic category.53 For children, five subtypes exist: (1) trans-formed migraine, (2) chronic tension-type headache, (3) new daily persistent headache, (4)hemicrania continua, and (5) “comorbid headache.”20

pro-• Patients with transformed migraine have met criteria for migraine in the past but havehad daily headaches for more than 1 month, with increasing headache frequency anddecreasing migraine symptoms

• The criteria for chronic tension-type headache are outlined in Table 13–4

• New daily persistent headache presents with constant headache for more than 2weeks, without previous headaches

• Hemicrania continua is typified by steady unilateral nonparoxysmal headache over thefrontal region, which has a frequency in excess of 15 days monthly for more than 1month Indomethacin is usually effective in treating hemicrania continua.54

• Comorbid headache is concurrent daily tension-type headache with intermittentmigraine headache

A recent prospective clinic-based classification study of chronic daily headache showedthat 40 percent had comorbid headache, 35 percent had new daily persistent headaches, 15percent had transformed migraine, 5 percent had chronic tension-type headache, and 5 per-cent were unclassified.20

CLINICALFEATURES ANDDIAGNOSIS

The diagnosis of headache in childhood is almost always dependent on the clinical history.Where possible, the history should be taken directly from the child and from the child’s care-taker However, care must be taken, given the suggestibility of younger children Childrenexposed to information about the prevalence of headache are more likely to complain ofheadache.55The value of a focused psychosocial history, particularly in adolescents, cannot

be overemphasized Academic, social, and family stressors should be explored, and, whenappropriate, a history of depressive symptoms or previous physical or sexual abuse should

Table 13–3 IHS Classification of Migraine45

1.1 Migraine without aura

1.2 Migraine with aura

1.2.1 Migraine with typical aura

1.2.2 Migraine with prolonged aura

1.2.3 Familial hemiplegic migraine

1.2.4 Basilar migraine

1.2.5 Migraine aura without headache

1.2.6 Migraine with acute onset headache

1.3 Ophthalmoplegic migraine

1.4 Retinal Migraine

1.5 Childhood periodic syndromes that are precursors to or associated with migraines

1.5.1 Paroxysmal vertigo of childhood

1.5.2 Alternating hemiplegia of childhood

1.6 Complications of migraine

1.6.1 Status migrainosus

1.6.2 Migrainous infarction

1.7 Migrainous disorder not fulfilling the above criteria

With permission from Headache Classification Committee of the International Headache Society Classification and diagnostic criteria for headache disorders, cranial neuralgias and facial pain Cephalgia 1988;8(Suppl 7):1–96.