Mack, Kenneth J.

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This study was performed to determine if there were a time of year that children were more likely to transition into a chronic daily headache. We retrospectively reviewed records of 103 patients with chronic migraine and 104 patients with new daily persistent headache. Of these, 56 chronic migraine and 92 new daily persistent headache patients were able to identify the specific month in which they began to experience daily headaches. Thirty-nine percent of new daily persistent headache patients had an onset of daily headache in either September or January, months traditionally associated with the start of the school semester in the United States. Only a single patient reported onset in May or June. Data for the transition from episodic to chronic migraine also showed higher rates in September and January, but did not reach statistical significance. These data demonstrate the higher rates of new daily persistent headache onset during school start months and question what factors may be responsible for this association.

The cause and treatment of functional movement disorders and nonepileptic spells in children is poorly understood, and an association with migraine has not previously been reported. We retrospectively reviewed children diagnosed with chronic or episodic migraine at our institution from 2006 to 2013 to determine the proportion with nonorganic movement disorders, their phenomenology, provoking factors, and natural history. Thirty-two patients were identified, representing 4.3% of patients with chronic migraine and 0.9% of patients with episodic migraine. Twenty-four of the 32 (75%) had chronic migraine, whereas 8 (25%) had episodic migraine. Nonepileptic spells was the most common phenomenon in both cohorts, followed by tremor and functional gait disorders. Severe migraine attacks preceded these movements in the majority of patients. With appropriate migraine therapy, significant reduction or resolution of these movements was reported. We conclude that nonorganic movement disorders are observed in pediatric migraine, are more prevalent among chronic migraineurs, and can resolve with improved pain control.

OBJECTIVE: To evaluate the evidence since the 1999 assessment regarding efficacy and safety of vagus nerve stimulation (VNS) for epilepsy, currently approved as adjunctive therapy for partial-onset seizures in patients >12 years. METHODS: We reviewed the literature and identified relevant published studies. We classified these studies according to the American Academy of Neurology evidence-based methodology. RESULTS: VNS is associated with a >50% seizure reduction in 55% (95% confidence interval [CI] 50%–59%) of 470 children with partial or generalized epilepsy (13 Class III studies). VNS is associated with a >50% seizure reduction in 55% (95% CI 46%–64%) of 113 patients with Lennox-Gastaut syndrome (LGS) (4 Class III studies). VNS is associated with an increase in ≥50% seizure frequency reduction rates of ~7% from 1 to 5 years postim-plantation (2 Class III studies). VNS is associated with a significant improvement in standard mood scales in 31 adults with epilepsy (2 Class III studies). Infection risk at the VNS implantation site in children is increased relative to that in adults (odds ratio 3.4, 95% CI 1.0–11.2). VNS is possibly effective for seizures (both partial and generalized) in children, for LGS-associated seizures, and for mood problems in adults with epilepsy. VNS may have improved efficacy over time. RECOMMENDATIONS: VNS may be considered for seizures in children, for LGS-associated seizures, and for improving mood in adults with epilepsy (Level C). VNS may be considered to have improved efficacy over time (Level C). Children should be carefully monitored for site infection after VNS implantation. Neurology® 2013;81:1–7

This commentary is on the original article by Kuczynski et al. on pages 636–641 of this issue.

Diabetic ketoacidosis (DKA) is a life-threatening condition and a major cause of morbidity and mortality in children with type 1 diabetes mellitus. The deficiency of insulin leads to metabolic decompensation, causing hyperglycemia and ketosis that resolves with the administration of insulin and fluids. However, an induced state of ketosis is the basis for the success of the ketogenic diet (KD), which is an effective therapy for children with intractable epilepsy. We report the case of a 2-year-old girl who presented to the emergency department with 1-week history of decreased activity, polyuria, and decreased oral intake. Her past medical history was remarkable for epilepsy, for which she was started on the KD with a significant improvement. Her laboratory evaluation was compatible with DKA, and fluids and insulin were given until correction. Because of concerns regarding recurrence of her seizures, the KD was resumed along with the simultaneous use of insulin glargine and insulin aspart. Urine ketones were kept in the moderate range to keep the effect of ketosis on seizure control. Under this combined therapy, the patient remained seizure-free with no new episodes of DKA.