Alternative Remedies for Migraine

The Migraine And Headache Program

This product was created by a Christian Goodman and a woman who has been suffering from migraine problems for over a decade. As she followed the advice in the book along with easy to do stationary movements, she was able to help unlock the path of the oxygen to the brain and make her migraines stop forever. This was done not by treating migraines by the triggers, but by the cause of the migraines which was the lack of the body to send the oxygen and work well. Finally, the creator of the product was able to locate the problem along with easy to do tricks that are not known to the public. Along with that, you will also learn how to sit and walk correctly and loosen the muscles in the body for easier airflow into the brain. You will no longer have to face migraines and let them cripple your ability as a person. These easy tricks will even make you feel better immediately as you start doing them. You won't even need any experience on how to do these exercises because they are all super easy to do. In addition to that, you can get started today in stopping your migraines and headaches by getting the guide. Read more here...

The Migraine And Headache Program Summary

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Recently several visitors of blog have asked me about this manual, which is being advertised quite widely across the Internet. So I purchased a copy myself to find out what all the publicity was about.

My opinion on this e-book is, if you do not have this e-book in your collection, your collection is incomplete. I have no regrets for purchasing this.

Migraine and Other Headache

Serum PRL measured between migraine attacks is normal in men and women (54). Endocrine challenge studies of migraineurs have shown that I-deprenyl, which increases the availability of endogenous dopamine, produces greater decrease in serum PRL in migraineurs than in normal subjects, implying increased dopamine receptor sensitivity in migraine. Simultaneous administration of TRH, luteinizing hormone releasing hormone, and insulin also produces greater PRL release for migraineurs than for normal controls, suggesting serotonergic hyperactivity in migraine (55). The effects of acute migraine attacks have not been studied.

Migraine

EEG changes may occur during and after migraine attacks. Unfortunately, the literature is beset with frequent imperfections that may mislead the unsuspecting reader. This consists of the grouping of dissimilar patients, the lack of adequate controls, and vague definitions of what constitutes an EEG abnormality. Phenomena consistent with spreading depression and alterations of cerebral blood flow underlie the acute-appearing EEG abnormalities that occur principally, if not exclusively, in patients with migraine with aura. Several studies of migraine have employed a variety of methods to measure cerebral blood flow including single photon emission computed tomography (SPECT) scan, transcranial Doppler, and perfusion weighted imaging studies. Unilateral or bilateral hypoperfusion have been noted during these attacks (66-71). Hyperperfusion has been found in a minority of patients, usually following an episode of hypoperfu-sion (67,68). Spreading depression has been considered a likely...

Secondgeneration Aeds

Felbamate is a broad-spectrum anti-epileptic drug. It is not considered to be a first-line drug because of its potential for serious idiosyncratic side-effects, including potentially fatal aplastic anaemia (incidence of 1 in 3000) and hepatic failure (incidence of 1 in 10 000) 43 . Recent analyses indicate that aplastic anaemia and liver failure occur almost exclusively within the first year of therapy. During this period, safety monitoring consisting of liver function tests and blood counts is recommended with a frequency of up to twice monthly, despite lack of evidence that early detection of changes will prevent serious health problems, even if the drug is discontinued. Yet, felbamate may still be an important drug in the armamentarium for refractory patients, because it may control seizures when other drugs fail, and tends to be alerting rather than sedating. It has been found to be particularly effective in patients with Lennox-Gastaut syndrome 44 . Felbamate should be started at...

Tonicclonic seizures grand mal seizures

The plantar responses are usually extensor at this time and the tendon jerks are diminished. Confusion is invariable in the postictal phase. The patient often has a severe headache, feels dazed and extremely unwell, and often lapses into deep sleep. On awakening minutes or hours later, there may be no residual symptoms or, more commonly, persisting headache, dysthymia, lethargy, muscle aching and soreness (including stiffness of the jaw).

Paroxysmal Movement Disorders

Alternating hemiplegia in infants is often claimed to be related to migraine, although it has a more severe course. The diagnosis is made clinically. The first attacks in early infancy consist of episodic dystonia of the trunk and limbs that can be mistaken for tonic seizures. Later, the child exhibits episodes of unilateral paralysis alternating from one side to the other, often mistaken for postictal paralysis. Alternating hemiplegia, however, can coexist with epileptic disorders, including pharmacoresistant epilepsies.

Routine Laboratory And Neuroimaging Tests

Index of suspicion based on the clinical history. Spells thought to be related to alcohol or drug abuse can be investigated by toxic screens of blood or urine. An impression of vestibular disease can be investigated with quantitative calorics and nystagmography. No blood tests or special diagnostic studies are presently widely accepted for the diagnosis of complicated migraine, although provocative tests, such as the histamine challenge, have been advocated by some. In general, routine laboratory studies and neuroimaging should be performed selectively in diagnosis of spells, based on a suspicion for particular etiologies.

Use Of Eec In The Diagnosis And Classification Of Epilepsy

Electroencephalography (EEG) is often helpful in the diagnosis and classification of epilepsy.10-27 However, it is essential to understand the scope and limitations of the technique when requesting an EEG examination and subsequently evaluating an expert report on the recording.2 Non-specific EEG abnormalities are relatively common, especially in the elderly, patients with migraine, psychotic illness and psychotropic medication. Non-specific abnormalities should not be interpreted as supporting a diagnosis of epilepsy.

Brain Infusion of Muscimol to Treat Epilepsy

Epilepsy) with a medical history, physical and neurologic examination, chest X-ray, electrocardiogram, blood and urine tests, electroencephalographic (EEG) monitoring and magnetic resonance imaging (MRI) of the head. Patients enrolled in this study will have the following procedures 1. Computerized tomography (CT) and magnetic resonance imaging (MRI) of the head to guide catheter electrode placement (see 2). 2. Depth catheter electrode placement into the presumed or possible location of the seizure focus (the part of the brain where the seizures originate) - Small holes are drilled through the skull. Electrodes with a hole in the center of the tubing that holds them are passed through the brain into the structures usually involved in intractable epilepsy. MRI will be done to check electrode placement. Video-EEG monitoring will continue for 5 days in patients in whom the location of the seizure focus is known but longer (up to 33 days) in patients in whom the seizure focus is difficult...

Cavernous haemangioma cavernoma

Vascular channels, located within the brain but without intervening neural tissue, with large feeding arteries or draining veins. Pathologically, they consist of endothelial-lined 'caverns' filled with blood and surrounded by a matrix of collagen and fibroblasts. They have the potential to haemorrhage, calcify or thrombose and are multiple in 50 of cases. They account for 5-13 of vascular malformations of the CNS and are present in 0.02-0.13 of autopsy series. The majority of these lesions present in the third and fourth decades of life, but 20-30 present earlier in childhood or early adult life. Cavernomas can increase in size and number over time, particular in genetically-determined cases and in those in whom cavernomas have developed after cerebral irradiation. However, in most cases, the factors influencing the development of new lesions or growth of existing lesions are unknown. At least 15 -20 of patients remain symptom free throughout their lives. Patients present with...

Alternating Hemiplegia

The paroxysmal features and neurology of alternating hemiplegia of childhood are remarkable and fascinating. In their original report Verret and Steele described eight cases from the Hospital for Sick Children, Toronto they regarded the condition as infantile-onset complicated migraine.67 Most recently, 44 patients were reported from Boston.68 These and other figures suggest that the condition has in the past been both underdiagnosed and underreported.

Psychogenic Nonepileptic Events

L. was a 24-year-old woman who had the onset of spells at 22 years of age. Episodes were characterized by a headache and tired feeling, followed by loss of consciousness and jerking movements of the trunk and extremities. Loss of consciousness lasted up to 5 min. The patient reported that incontinence occurred rarely. The frequency of episodes varied from one per week at the onset of her illness, to one per day at the time of referral. She was treated with phenytoin, gabapentin, and lamotrigine without control. Etiological factors included a motor vehicle accident that resulted in less than 5 min of impaired consciousness just prior to the onset of events. There were no neurological sequelae following the accident. The examination was normal.

Differential diagnosis

In this case presentation, the diagnostic possibilities encompass more than just seizures . Given the prominent autonomic findings and confusional state, toxic ingestions and metabolic disturbances need to be quickly excluded The history of emesis, con-fusional state, and seizure should raise concerns for a meningoencephalitis Other less likely considerations include stroke and migraine variants

Other Benefits of VNS Therapy

Beneficial clinical effects beyond changes in seizure frequency have been observed. Malow and colleagues84 found that in 16 patients treatment with low stimulus intensities improved daytime sleepiness and promoted alertness. The use of VNS Therapy to reduce morbid obesity,85 86 improve memory,87 improve treatment-resistant depression 8 and to elevate mood59-91 have been reported. Pilot studies investigating the role of VNS Therapy for Alzheimer's disease, obsessive-compulsive disorder, migraine headaches, and anxiety disorders are underway.

Other Tropical Diseases

Malaria is endemic in tropical America, Africa, and some Asian countries. Cerebral malaria is an acute encephalopathy, which occurs only with infection by Plasmodium falciparum.'41 Clinically, cerebral malaria presents itselfwith fever, headache, delirium and confusion progressing to coma. Despite appropriate treatment, cerebral malaria carries a mortality of 22 .42 Generalized seizures occur in 40 of adult patients and in most children. Epilepsy has long been recognized as a late sequel of cerebral malaria.41 Pathological examination of the brain in fatal cases has shown severe vasculopathy with hemorrhages, and granuloma of Durck formed by astroglial reaction.42 These lesions may act as epileptogenic foci in those who survive, giving rise to chronic epileptic seizures. A special relationship has been described between cerebral malaria and febrile convulsions. Together they may lead to 5 of pediatric emergency consultations in endemic areas such as central Africa and the Amazon...

Transient global amnesia

Transient global amnesia is an illness of uncertain aetiology. Some authorities feel it represents cerebrovascular disease, others attribute it to migraine and still others regard it as an epileptiform phenomenon 84 . Most would agree, however, that it is not an epileptic event. These stereotypic events are quite characteristic and easily recognized by the experienced clinician 85 . Amnesic episodes are recurrent in 8 . Although slightly perplexed or agitated during the attacks, no focal neurological abnormalities are found. EEGs and structural imaging are normal, and blood tests provide no clues. However, the description of events is so characteristic that the diagnosis is generally straightforward. Most patients have a history of migraine, and sometimes the episodes are followed by headache 86 , Rare causes include lacunar stroke seizures. If the seizure was not recognized then the most striking feature of a seizure might be a postictal con-fusional state afterwards but it is...

Approach To Newonset Seizures In The Hospital

Additional diagnostic testing should be guided by the patient's specific clinical situation. Lumbar puncture may be needed in the setting of headache, meningismus, rash or other signs of infection, immunosuppression or recent neurosurgery. Following repetitive seizures or status epilepticus, the cerebrospinal fluid (CSF) white cell count may be mildly and transiently elevated, and CSF protein might also be mildly elevated secondary to blood-brain barrier breakdown 4 .

Seizures And Behavior Disturbance In A

He also experienced severe headaches that were 'caused by balls permeating from my head rolling down my face'. During these headaches, he clutched his head, screamed with pain and became completely limp and unresponsive for a brief period. After these headaches he would vomit. Once, after four successive episodes, he described vivid visual hallucinations, such as seeing his dead aunt or seeing evil and good fighting on the wall.

Other Conditions Which May Benefit From Aed Treatment

Migraine affects approximately 15 and epilepsy 2 of the population at any one time 88, 89 . As both are so common it is likely that some patients will have both epilepsy and migraine simply by chance however, the literature suggests a clear association between the two 90 . One theory behind their association is that both conditions are channelopathies. In some cases, the underlying aetiology may be a clear risk factor for headache and seizures, such as arteriovenous malformations or Sturge-Weber syndrome 91 . In addition, there are several neurological syndromes in which epilepsy and migraine co-occur as part of the syndrome, such as cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL) and mitochondrial diseases. Several of the AEDs, such as topiramate, gabapentin, valproate, lamotrigine and carbamazepine, are effective in migraine prophylaxis 92-96 . Pregabalin is also used in migraine, despite a lack of good evidence in the literature...

Manipulative and Body Based Methods

Bioelectromagnetic-based therapies involve the unconventional use of electromagnetic fields to treat illnesses or manage pain. These therapies are often used to treat asthma, cancer, and migraine headaches. Types of electromagnetic fields which are manipulated in these therapies include pulsed fields, magnetic fields, and alternating current or direct current fields.

Aeds Have Many Distinct Cellular Mechanisms Of Action

The other agents, including valproate, topiramate and levetiracetam, have broader utility. With very few exceptions, each AED acts in a mechanistically distinct way. This is not the situation in other therapeutic areas. For example, the triptans used to abort migraine attacks all act in a similar fashion as agonists of serotonin 5-HTj B and 5-HTjd receptors the selective serotonin reuptake inhibitors used to treat depression all block the serotonin transporter the many statins are all HMG-CoA reductase inhibitors and the proton pump inhibitors all have the same molecular target. In contrast, each AED generally acts on a unique set of molecular targets. Even when they share the same molecular target, as is the case for AEDs that act on voltage-activated sodium channels, the biophysical details for each drug are sufficiently different that the mechanisms must be considered distinct.1 For example, there may be important differences in binding rate, binding affinity,2 the ability to block...

Inflammatory And Autoimmune Disorders

The term acute disseminated encephalomyelitis (ADEM) describes any immune-mediated encephalomyelitis resulting from infections, allergies, or vaccinations. Typically this is a monophasic illness occurring in pediatric patients, mostly prepubertal, and follows a preceding illness commonly by 1 to 6 weeks. Presenting symptoms include headache, encephalopathy, depressed level of consciousness, paresis, sensory changes, and ataxia. Approximately 25 will present with seizures (192, 193). Laboratory findings may be unremarkable, though about half will have elevated protein on CSF testing, and a mild pleocytosis is not unusual. The most consistent finding is obtained on MRI, with images typically showing fuzzy, poorly defined lesions and a high lesion load in the white matter, associated with thalamus or basal ganglion lesions (194). Good recovery is seen with most patients, but up to half may have some deficit, mild in most cases but potentially severe. Up to 9 may have a residual seizure...

Case presentation

Encephalitis Eeg

Fever and confusion should immediately alert the physician to the possibility of central nervous system (CNS) involvement Partial seizures, though sometimes seen in other causes of encephalitis, are often a presenting symptom in herpes encephalitis In a patient presenting with a seizure, meningitis, and other infectious processes, focal malignant or benign lesions, or a fever or illness that may have lowered the seizure threshold, have to be ruled out Other symptoms suggestive of HSV include headache (irritability in younger children), unusual behavior, lethargy, vomiting, and other neurological symptoms such as cranial nerve findings and localized deficits Symptoms are more nonspecific in very young children who may present with decreased activity or irritability and inconsolable crying

Table 45 MRI Characteristics of Astrocytic Neoplasms

Tumor Posterior Temporal Lobe

Evolution of a tumor in a young patient with intractable partial seizures of 2 years' duration. The CT findings were negative. A. First MR image axial (2000 30) study shows a heterogeneous lesion on the left mesial temporal region. Calcifications were present. Pathologic examination demonstrated oligodendroglioma. B. Follow-up MR image (675 10) 1 year after surgery. The patient was seizure-free and not receiving medication. C. Follow-up MR image 2 years after initial surgery. Headaches had developed. An abnormal signal was detected with a lesion in the posterior temporal lobe. Biopsy revealed an anaplastic astrocytoma. FIG. 4.62. Evolution of a tumor in a young patient with intractable partial seizures of 2 years' duration. The CT findings were negative. A. First MR image axial (2000 30) study shows a heterogeneous lesion on the left mesial temporal region. Calcifications were present. Pathologic examination demonstrated oligodendroglioma. B. Follow-up MR image (675 10) 1...

Paroxysmal Torticollis

Torticollis is an abnormal sustained posture of the head and neck in which the head tilts to one side and the face rotates to the opposite side. In paroxysmal torticollis, the events begin and end suddenly. The attacks can be brief or prolonged. The child is alert and responsive during an attack although the patient may appear uncomfortable and irritable. The EEG is normal during the event. The etiology of the attacks is unknown, although both a focal dystonia and labyrinth dysfunction have been suggested as the cause, as has migraine. Often a family history of migraines is noted, and children with benign paroxysmal torticollis may develop typical migraines later in life. Paroxysmal torticollis usually begins in the first few months of life, and resolves by age 3 years. No treatment is required (24).

SPECT single photon emission computerized tomography scanning

An excellent anticonvulsant for generalized and focal seizures. Recently it has started to be used for nonconvulsive disorders, including migraine prevention and as a mood stabilizer for bipolar disorders. Valproic acid comes in Depakene and Depakote forms. Seizures controlled with this medication include myoclonic seizures, absence seizures, and mixed-type seizures. Side effects include initial transient sedation and abdominal pain (better tolerated with the Depakote form). It may also increase the appetite (causing weight gain), cause some transient hair loss (which improves with zinc supplementation), or cause liver and blood count abnormalities, although this is rare. Hyperammonemia and pancreatic dysfunction have also been reported. In children younger than 3, and especially younger than 2, valproic acid may cause a severe fatal liver disease in a frequency as high as 1 in 300. Many patients taking valproic acid may have an associated carnitine...

Role of the interictal and periictal psychopathology in suicide

Kraepelin (1923) precisely described the intermittent dysphoric disorder of patients with epilepsy. Dysphoric episodes present with depressive moods ('very frequently with utter disgust of life and suicidal bent'), irritability, anxiety, headaches, insomnia or at times with euphoric moods. These polysymptomatic dys-phoric episodes occur without external triggers with rapid onset and termination and recur fairly regularly in a uniform manner in the absence of clouding of consciousness. Dysphoric symptoms can be observed as prodromes of an attack or in the aftermath of an attack, but they most commonly appear as phenomena independent of the seizures, with a frequency varying from every few days to every few months. A patient just awakens one day dysphoric, or the dysphoria develops insidiously through the course of a day. As a rule, the dysphoric state lasts from 1 to 2 days but might dissipate after just a few hours. Based on our own observations, we have added anergia and phobic fears...

The interictal dysphoric disorder

Parietal Lobe

It is obvious that the IDD can be recognized today with features that are different from those described by premodern psychiatry. For example, depressed mood and anergia may be much more evident than before because modern antiepileptic medications may accentuate the dysphoric symptoms. Himmelhoch (1984) and subsequently Kanner and Balabanov (2002), highlighted the chronic course of this state of moderate neurotic depression with symptom-free intervals typical of epilepsy, referring to a dimension very close to dysthymia. In our opinion, IDD patients have several features in common with a specific subset of cyclothymic subjects, where depressive periods and labile-angry-irritable moods dominate the clinical picture. Nonetheless, Blumer reported that patients with IDD benefit from a combined therapy of AEDs and antidepressant drugs (Blumer et al., 2004), a combination extensively used in psychiatry in bipolar depression, suggesting that IDD is close to the bipolar spectrum. It is,...

Childhood epilepsy with occipital paroxysms benign occipital epilepsy Gastaut typeidiopathic childhood occipital

This is a well-defined syndrome, with mean age of onset of 6 years, in which seizures occur with prominent visual symptomatology, including hemianopia and amaurosis, abstract and complex structured visual hallucinations, eye deviation and prominent postictal headaches with nausea and vomiting. There may be secondary generalization. The EEG shows prominent occipital epileptiform spike-wave activity which appears after eye closure and is suppressed by eye opening. The condition has an excellent prognosis with full remission in most cases. The condition needs to be differentiated from migraine and also from symptomatic occipital epilepsies, which include those due to mitochon-drial disease (Alpers disease, MELAS), coeliac disease or cortical dysplasia. Seizures show a complete response to carbamaze-pine in over 90 of cases, and the prognosis is excellent. However, some patients require long-term treatment.

Man With Shoulder Twitching

The past medical history was unremarkable. There was no recent history of head trauma, fever or headache. There were no risk factors for stroke except for a history of heavy cigarette smoking, and no past history of transient ischemic attack or cerebral infarction. There was no history of alcohol or drug abuse. He had never experienced a similar type of event in the past.

Specific Aeds For Specific Seizure Types And Epilepsy Syndromes

AEDs can be broadly grouped into three categories narrow spectrum, broad spectrum, and syndrome-specific (Table 5.1). In general, partial epilepsies may be treated with either narrow- or broad-spectrum AEDs. However, broad-spectrum AEDs are usually required for generalized or mixed epilepsy syndromes. Beyond the spectrum of action, selection of an AED also depends on the medicine's formulation - is the child able to swallow liquid, sprinkles or pills (Table 5.2) Special consideration of the child's other medical conditions, such as obesity, migraine, mood disorder or any complex chronic illness, is also important. Certain AEDs will have clear advantages and disadvantages, depending on the patient's situation (Table 5.3). Dosing guidelines are found in Tables 5.4 and 5.5. Migraine prevention Migraine prevention

Idiopathic Partial Epilepsies

Benign Familial Infantile Convulsions and Familial Hemiplegic Migraine migraine (FHM). The M731T mutation was found in a family with pure FHM, whereas the R689Q mutation was identified in a family in which FHM and benign familial infantile convulsions (BFIC) partially cosegre-gate. In this family, all available affected family members with FHM, BFIC, or both carry the ATP1A2 mutation. Like FHM linked to 19p13, FHM linked to 1q23 also involves dysfunction of ion transport, and epilepsy is part of its phenotypic spectrum.

Cadd And Modeling Anticonvulsant Drugs

Tricyclic Butterfly

(carbamazepine, oxcarbazepine) as well as psychosis (chlorpromazine), schizophrenia, depression (amitriptyline), headache, insomnia and chronic pain. In treating these many disorders, tricyclic drugs demonstrate an ability to bind to a plethora of different (and structurally quite distinct) receptors, including the voltage gated Na+ channel protein as well as multiple types of dopamine receptors, serotonin receptors and acetylcholine receptors.

Douglas R Nordli Jr Timothy A Pedley

___ he electroencephalogram (EEG) is often the single most informative laboratory test in evaluating a children with seizures. At the most rudimentary level, it helps in differentiating epileptic from nonepileptic behavior. Because many conditions, including breathholding spells, movement disorders, syncope, cardiac arrhythmias, sleep disorders, migraine, and various psychiatric syndromes, may mimic epilepsy, EEG findings are often essential in making an accurate diagnosis.

Diagnostic approach

Routine Head Mri

Seizures frequently accompany stroke-like episodes . Onset of a motor deficit may precede a cluster of prolonged seizures rather than seizures followed by Todd's paralysis however, this distinction is difficult to make in children . Fixed hemiparesis contralateral to the facial angioma eventually occurs in 50 of children . It often appears after a focal-onset seizure and progresses in severity in a stuttering fashion after subsequent seizures Transient episodes of hemiplegia, not related to clinical or EEG evidence of seizure activity, may also occur. Some patients have associated migrainelike headache, attention deficit disorder, and mental retardation Glaucoma occurs in

The Girl With Visual Seizures Who Wasnt Seeing Things Transient Blindness In A Young Girl

The first spell occurred a few days after her dog was killed by a car. She had about 30 or 35 spells over the 3 months before presentation at the clinic each spell was identical. The spells lasted from 30-60 seconds and she recovered quickly, but they were often followed by an occipital or retro-orbital throbbing headache, nausea and vomiting. Witnesses confirmed that Lauren was lucid during a spell - she can reply to questions and follow instructions. She recalls each spell clearly afterwards ('My mind was playing tic-tac-toe'). Witnesses also describe that her eyes 'dart back and forth rapidly' during a spell and Lauren describes 'shaky vision.' Spells seem to be more frequent when she is outside in the sun, looking out a window or watching television. Lauren is a healthy, normally developing girl. Pregnancy, labor and delivery were uneventful. She reached all developmental milestones on time and is a good student. She is active in dance. Her mother recently divorced and remarried....

Patient with Epilepsy Slips Down Some Attic Stairs

The patient had a history of seizures since the age of 16 (etiology and type unknown) and had been well controlled on phenobarbital and phenytoin since then. His seizures consisted of arm and leg shaking with loss of consciousness and occasional incontinence. Six months before admission, he slipped down some stairs and sustained head trauma with loss of consciousness for 10 min. At that time, he did not seek medical attention because he felt well. Over the ensuing 6 weeks, the patient developed increasing lethargy, memory impairment, decreased sensation on the right side of his body, headache, and visual impairment.

Early onset benign occipital epilepsy synonym Panayiotopoulos syndrome

This is another syndrome with age of onset between 1 and 14 years (mean 4-5 years). Estimates of prevalence have ranged from 0 to 0.6 of all children with epilepsy, and in one study it accounted for 28 of all benign focal epilepsies of childhood. Panayiotopoulos considers the condition to be due to diffuse maturation-related epileptogenicity activating emetic centres and the hypothalamus. The clinical presentation is distinctive. In the core syndrome, seizures take the form of eye deviation, nausea and vomiting, with subsequent evolution into clonic hemiconvulsions in some cases. They are often nocturnal and awareness may or nay not be altered. Other autonomic features occur including incontinence of urine, pallor, hyperventilation and headache. Typically, the seizures are prolonged, often lasting hours, and are therefore classified as episodes of status epilepticus (taking the form of absence or autonomic status epilepticus). Despite this high incidence of status, the prognosis of...

Autonomic status epilepticus

This is a form of SE which occurs typically in Panyiotopoulos syndrome. The exact prevalence of this syndrome is unclear, and estimates have ranged from 0 to 6 of all children with epilepsy. The seizures consist of episodes of nausea, retching and vomiting, and deviation of the eyes. There may or may not be altered awareness. Other autonomic features occur including incontinence of urine, pallor, hyperventilation and headache. The EEG shows occipital spiking or runs of 3 Hz spike-wave and there is also often evidence of photosensitivity. About half of the seizure last longer than 30 minutes and so are categorized as 'status epilepticus'. The prognosis of the syndrome is excellent and at least 50 of patients have only a single attack, and most require no treatment. If treatment is required, any of the conventional first-line antiepileptic drugs can be used in monotherapy.

Affective disorders and anxiety

The enduring remittance of depressive symptoms depends on complete seizure relief (Blumer et al., 1998 Hermann and Wyler, 1989). This finding is supported by our results. Moreover we found that our preoperatively depressed patients showed differences in psychopathology after surgery related to laterality dominant resections led to somatoform symptoms as surrogates of depression (headache, backache, etc.), while nondominant resected patients frequently had postoperative depressions.

Paroxysmal Dyskinesias

Benign paroxysmal torticollis in infancy (BPT). In BPT, infants have attacks of retro-, latero-, or torticollis that may last minutes to hours (115). In rare instances, they may last days. Typically, attacks begin in early infancy and remit by age 5. They may be triggered by movement, often in the early morning, and are heralded by irritability, pallor, vomiting, and in older children, clear ataxia. BPT is both a movement disorder and a migraine equivalent (116). Two patients with BPT in a recent series came from a family with familial hemiplegic migraine linked to a mutation in the voltage-gated calcium channel gene CACNA1A on chromosome 19 (117).

Ethosuximide

Ethosuximide has a very narrow therapeutic indication, with use limited to patients with absence seizures 41 . In most cases, it should be used as the sole agent only in patients who experience this seizure type in isolation, a condition seen primarily in childhood 42 . Occasionally, in patients with primary generalized epilepsy with seizure types other than absence, addition of ethosuximide as an adjunctive medication may improve seizure control. Ethosuximide can be started at 500 mg day, and titrated as tolerated, with weekly increments. Serum concentrations of 40-100 mg l are usually optimal. The most common side-effects noted with ethosuximide use include nausea and abdominal discomfort, drowsiness, anorexia and headache 41 . In rare cases, behavioural changes may be seen, including psychosis. Blood dyscrasias have been reported. Drug-drug interactions are minimal.

Lamotrigine

Patients may do well at serum concentrations of 2 mg l, while others may need levels of up to 20 mg l. Common dose-related side-effects of lamotrigine include mild tremor, double vision, headache and insomnia. Rash, including Stevens-Johnson syndrome and toxic epidermal necrolysis, can occur. Risk is increased for children under 16, and is also more common with concomitant valproate use, and in patients who have experienced rash on other AEDs 54 . Rash almost always occurs within the first 8 weeks of therapy. Other hypersensitivity reactions, although much rarer, may be seen, including lymphadenopathy, fever, hepatic or renal failure, disseminated intravascular coagulation and arthritis 55 . Discontinuation of lamotrigine is recommended in the presence of rash or other indication of hypersensitivity, and it is very important to tell patients to call immediately with such symptoms. Rapid discontinuation can prevent a more severe, potentially life-threatening reaction. In the absence of...

Serum Prolactin

Home or work setting to determine if infrequently recurrent spells are seizures. One remaining limitation of prolactin for diagnosis is a lack of available data on prolactin levels after several of the imitators of epilepsy, including cerebrovascular ischemia or migraine.

Fertility

Where co-morbidities are present, whether these are related to the seizure disorder (e.g. anxiety or depression) or unrelated (e.g. obesity, neuropathic pain or migraine) then some AEDs can prove helpful in their treatment. Many modern AEDs have sought and have had granted product licences for these other indications (Table 7.2).

Case Study

Presentation A 43-year-old woman was seen in the ER for repeated seizures occurring with fever, which started that morning. For 2 days, she had been suffering from headache, vomiting, and drowsiness. She had been having right partial motor then secondarily generalized seizures for two years. There was a history of blood transfusion prescribed for an operation 7 years ago. HIV2, HTLV-1, and syphilis seropositivity had been detected and confirmed 8 months before. She presented at that time with acute transitory meningitis, which resolved after 5 days of antibiotic therapy.

Neurocysticercosis

Furthermore, on the Indian subcontinent at least, single small enhancing lesions may not indicate cysticercosis and often disappear spontaneously (see Chapter 4). Consequently, the diagnosis of neurocysticer-cosis or findings of small calcifications in patients presenting with acute seizures does not necessarily mean that the seizures are due to this disturbance. Because viable (nonde-generating) cysts are commonly asymptomatic, antiparasitic administration in such patients with epilepsy due to another cause could unnecessarily create a second epilepto-genic lesion that would complicate diagnosis and treatment. An argument for antiparasitic treatment of viable cysts is that these will eventually die, with a risk of consequent seizures, and that treatment can permit the seizures to appear under more controlled conditions. Recent studies do not address this issue, but most specialists recommend not treating viable asymptomatic cysts. Caution should be exercised in patients presenting...

Figure 137

Arteriovenous malformations (AVM) are abnormal, often friable connections between cerebral arteries and veins without intervening capillaries. Thought to be congenital, AVMs may grow over time, resulting in hypoper-fusion and the development of aneurysms, and can cause seizures, neurologic deficits, headache, hydrocephalus, or hemorrhage (24). CT is most sensitive in the detection of hemorrhage that presents acutely. CT angiography with 3D reconstructions can help delineate feeding artery and draining vein anatomy (25) (Figure 13-10, long white

Surgically Related

Headache The most common side effects result from intermittent stimulation of the vagal innervation of the larynx. Such adverse events occur during trains of stimulation and include voice alteration (30-64 ), cough (43-45 ), throat discomfort (25-35 ), throat paresthesia (18-25 ), and dyspnea (11-25 ). Other less common side effects have been reported, such as muscle pain, chest pain, headache, chronic diarrhea, Horner syndrome, psychotic episodes, nausea and vomiting.66-68

Mood Disorders

Have more complex epilepsy.21,22 In a retrospective analysis of suicide at a specialist epilepsy center, 10,739 patients were seen over a 12-year period. Five people completed suicide in this population. In an attempt to better understand why patients may have suicidal intent, the authors recognized an interictal dysphoric disorder (depressive mood, irritability, anxiety, headaches, insomnia, phobic fears, and aner-gia are prominent symptoms) which occurs independently of seizures, appears suddenly, and may last for hours to a couple of days. This mood disorder responds to antidepressant treatment, and the authors use a combination of treatments.i2 A second study of 1,722 patients attending an epilepsy center over a 14-year period revealed six completed suicides. The important findings were that suicide occurred soon after a seizure in patients with TLE, were more common in men, and were often related to psychotic episodes.21

Episodic Ataxias

Episodic ataxia type 2 (EA2) is less frequently mistaken for epilepsy because the attacks are longer (minutes to hours), and there may be interictal cerebellar signs including eye movement control impairments. This disorder is associated with mutations in the voltage-gated calcium channel gene CACNA1A located on chromosome 19 (122). It is allelic with familial hemiplegic migraine and spinocerebellar ataxia type 6. In their pure forms, these are distinct disorders but overlap syndromes do occur. Partial seizures have been documented in familial hemi-plegic migraine families, and there is a case report of a child with a de novo truncating mutation in CACNA1A who has EA2 and absence epilepsy (123,124).

Infections

Any acute infection of the CNS may lead to seizures, including bacterial meningitis, viral encephalitis, focal cerebritides, and parasitic infections. Bacterial meningitis should be suspected and excluded by lumbar puncture in any child with seizures in the setting of headache, fever, and meningeal signs. The causal agent typically varies with patient age. patients may have a prodrome of malaise, fever, headache, and nausea. This is followed by acute or subacute onset of an encephalopathy whose symptoms include lethargy, confusion, and delirium. Headaches, seizures, aphasia, and other focal deficits may follow. Even with modern treatment, mortality in children may be as high as 20 , and an even larger percentage suffer permanent neurologic sequelae (77). Other viral encephalitides associated with seizures include California, Japanese, and St. Louis encephalitides as well as Eastern and Western encephalitides.

Potassium Channels

Thought to enhance neuronal excitability associated with benign neonatal seizures. On the other hand, M-channel openers decrease the hyperexcitability responsible for epileptic seizures and migraine. Indeed, retigabine is thought to produce antiepileptic effect by opening the KNCQ2 3 channels (47, 48). This is a promising area for novel anticonvulsant drug development.

Postictal Sleep

Postictal sleep is a common phenomenon after a generalized tonic-clonic seizure. The patient may pass through several stages from sleep to delirium to drowsiness before awakening. During the late postictal state, the heart rate begins to normalize from the typical ictal tachycardia. There is a decrease in muscle tone with bladder sphincter relaxation and incontinence that typically occurs in the early postictal phase. In the immediate postictal phase, there is partial obstruction of the airway resulting in stertorous respirations. Deep tendon reflexes are diminished and the plantar responses are sometimes extensor. The patient then may pass into sleep. If the seizure occurs during the night, the patient may sleep through the postictal period and awaken with complaints of tongue soreness, muscle aches, or nocturnal enuresis. Patients may often experience postictal morning headaches or unexplained bruises.

Epidemiology

Mendez et al. (1993) conducted a retrospective investigation of neurology clinic attenders. They found that interictal schizophrenic disorders occurred in 149 (9.25 ) of 1611 patients with epilepsy as compared to only 23 (1.06 ) of 2167 patients with migraine. They went on in the latter part of the study to compare 62 epilepsy and schizophrenia patients with 62 patients who had epilepsy alone on 6 seizure variables, and 62 patients with schizophrenia alone on 10 psychosis variables.

Diagnosis

Because only 20 of bruxist episodes are accompanied by noise, the majority of bruxists are unaware of their bruxing. Wear patterns on the teeth, tooth mobility, and fracture cusps suggest bruxing activity. Other individuals come to medical attention because of muscle or joint pain, fatigue, stiffness on waking, or headaches. The rhythmic myogenic artifact resulting from bruxism appearing on a polysomnogram has a characteristic appearance (Fig. 12.2).

Electrophysiology

Weilburg et al. (1995) studied 15 subjects who met DSM criteria for panic attack but who also had atypical features including at least one of the following sensory distortions, change in level of consciousness, aphasia, focal paraesthesia, altered sense of body position, hallucinations, sudden shifts in mood, headache or auto-nomic changes. These subjects underwent prolonged ambulatory EEG monitoring which included sphenoidal recordings. Eleven of their subjects were thus recorded during the course of at least one, and in three subjects multiple, panic attacks. In 45 (5 11, including the three recorded during multiple attacks) the clinical symptoms were associated with focal paroxysmal EEG changes. However, even in those who on some occasions had abnormal EEG changes associated with a panic attack, this only occurred in a proportion (with an average of 35 ) of their recorded attacks. However, as the authors acknowledge, first, their results may not be applicable to those with panic...

Figure 234

Multifocal Epilepsy

Because of the prolonged nature of seizures in Pan-ayiotopoulos syndrome, many children present with it to emergency departments while they are still in an ictal state. However, if the main features of this are impaired consciousness and vomiting, an epileptic state may not even come into the differential diagnosis. Conditions such as encephalitis and meningitis are often considered. If the ictus terminates in a hemi- or generalized convulsion, this may merely strengthen the presumptive (but erroneous) diagnosis. Many such children end up intubated and treated in pediatric intensive care units with antibiotics and antiviral agents. The prolonged seizures of Panayioto-poulos syndrome may also be confused with acute confu-sional migraine and, if vomiting is particularly prominent, with cyclical vomiting syndrome or gastroenteritis. Some seizures may simply be dismissed as travel sickness. There is a particularly strong association between seizures in these epilepsies and headache. This...

Safety

Figure Four Epilepsy

Adverse events reported with VNS therapy are generally transient and mild, and are often related to the duration and intensity of stimulation . Serious adverse events have not been reported with standard therapy, and no patients have died or had a higher mortality risk as a result of VNS therapy.4 The most common adverse events reported during the clinical trials were mild hoarseness or voice alterations, coughing, and paresthesia (primarily at the implant site and decreasing over time) and were not considered clinically significant . Other side effects reported less frequently during these studies include dyspnea, pain, headache, pharyngitis, dyspepsia, nausea, vomiting, fever, infection, depression, and accidental injury. Not all of these side effects were related to VNS therapy Outside the clinical trials, occasional reports of additional adverse events such as shortness of breath and vocal cord paresis have been reported, but did not result in discontinuation of therapy. Moreover,...

Figure 233

Seizure Diary

Other autonomic features may occur concurrently with or follow the emetic features. Pallor is very common cyanosis and flushing are less common (50). Pupillary abnormalities, especially mydriasis but also miosis, are frequently noticed by eyewitnesses, but will usually require prompting to obtain a report of them. Urinary and occasionally fecal incontinence may occur. A raised temperature may be suspected or measured during or immediately after a seizure and may represent a true ictal symptom, rather than being a precipitant of the seizure. Rarer ictal symptoms that have been reported include headache and other cephalic sensations, hypersaliva-tion, and coughing (50, 59).

Visual Seizures

Migraine is associated with visual scotoma that may resemble the elementary visual hallucinations as seen in occipital lobe seizures. It has been suggested that epileptic visual hallucinations are colored and migraine scotoma are black and white (111). However, because occipital epilepsy can be accompanied by vomiting and headaches, clinical distinction between epilepsy and migraine can be difficult without additional testing (refer to Chapter 9).

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