Andrea Pelliccia

Melatonin to prevent migraine or tension-type headache in children

We designed a 3-month open label trial of melatonin prophylaxis in children with primary headache. After a one month baseline period without receiving preventive drugs, all children received a 3-month course of melatonin, 3 mg, administered orally, at bedtime. A total of 22 children were enrolled (10 boys, mean age 12.2±2.6 years, age range 6–16 years), 13 had recurrent migraine without aura, 1 with aura and 8 had chronic tension-type headache. When the trial ended, 14 of the 21 subjects reported that the headache attacks had decreased by more than 50% in respect to baseline and 4 of them reported having no headache attacks. After receiving melatonin for one month one subject dropped out because of excessive daytime sleepiness. Our promising results warrant randomized placebo-controlled trials in children to assess the real effectiveness of melatonin in preventing primary headache.

A case with atypical childhood occipital epilepsy "Gastaut type": an ictal migraine manifestation with a good response to intravenous diazepam.

We report the history of a 14‐year‐old girl with atypical childhood occipital epilepsy “Gastaut type” whose first generalized tonic–clonic seizure was preceded by migraine without aura and followed by a status migrainosus. This status lasted for 3 days despite standard analgesic therapy. An EEG recording revealed an occipital status epilepticus during her migraine complaints. Seven minutes after intravenous administration of 10 mg diazepam under continuous EEG recording, a suppression of the epileptiform discharges over the right occipital was seen, while the headache subsided 3 min later. After precise questioning about the circumstances that possibly could have led to these events, it appeared that she had played for hours with a play station on the new color TV and she had visited an exhibition of Matisse and Bonnard with bright colors and contrast‐rich text. Standardized extensive intermittent photic stimulation (IPS), 2 days after the status migrainosus, evoked besides asymmetrical right‐sided driving, green spots in her left visual field, while in the EEG sharp waves were recorded over the right parietotemporal region. After further IPS with 20 Hz (eye closure), she started complaining of a light pulsating headache right occipitally and in the EEG right parietotemporal sharp‐waves were seen. This lasted for about 10 min. Later, an interictal routine EEG was normal except for some theta over the right temporooccipital area. The most likely diagnosis is an atypical form of occipital epilepsy “Gastaut type.” We would therefore advocate recording EEGs with photic stimulation in patients with atypical migraneous features.

Levetiracetam during 1-year follow-up in children, adolescents, and young adults with refractory epilepsy.

PURPOSE To evaluate the efficacy and safety of levetiracetam (LEV) in refractory crypto/symptomatic, partial or generalised epilepsy in children, adolescents and young adults. METHODS We performed a prospective open label add-on study in 99 patients (age 12 months to 32 years, mean 14 years) with partial or generalised, crypto/symptomatic seizures. Levetiracetam was added to no more than two baseline AEDs and the efficacy was rated according to seizure type and frequency. RESULTS LEV was initiated at the starting dose of 10mg/kg/day with 5-day increments up to 50 mg/kg/day, unless it was not tolerated. Concomitant therapy was generally not modified throughout the study. After a mean follow-up period of 6.7 months (range 3 weeks to 29 months), 11 patients (11.1%) were free of seizures (cryptogenic partial epilepsy, 5; symptomatic partial epilepsy, 6). A more than 75% seizure decrease was found in 14 patients (14.1%) and >50% in 8 (8.1%). Seizures were unchanged in 38 (38.4%), and worsened in 23 (23.2%). Mild and transient adverse side effects were found in 17 patients (17.2%), mostly represented by irritability and drowsiness. CONCLUSION LEV appears to be well tolerated in children and adolescents with severe epilepsy and seems to be a broad spectrum AED, though in our experience, it was more effective against partial seizures with or without secondarily generalisation. LEV efficacy in other epilepsy syndrome should be evaluated further in homogeneous, more selected patients.

High prevalence of epilepsy in a village in the Littoral Province of Cameroon

PURPOSE In the Littoral Province of Cameroon, in the Sanaga River Valley, a door-to-door epidemiological study was carried out in order to evaluate the prevalence of epilepsy in a small village located in a geographically isolated area, hyper-endemic for onchocerciasis. It was followed by an electro-clinical evaluation of patients and a case-control study. METHODS The study involved a three-phases design: in phase I, a screening questionnaire was administered, in phase II, the presence of epilepsy was confirmed with electro-clinical evaluation, and in phase III, risk factors for epilepsy, socio-economical factors and life habits were evaluated in patients and two matched controls for the age (+/-1 year) residents in the same village. Endemicity level of onchocerciasis was assessed in the village by measuring the prevalence of nodules in adult males aged >or=20 years (PNAM). RESULTS One hundred eighty-one subjects (100 male and 81 female) were examined (91.9% of the overall population). The crude prevalence rate of active epilepsy was 105 per 1000 pop (CI 95% 60-150) while the age-adjusted prevalence rate was 134.5 cases per 1000 pop (CI 95% 90-178). Seizures were classified as generalized in 10 patients (52.6%) and partial in nine (47.4%). In 17 patients EEG was recorded. Afterward the electro-clinical classification this distribution was inverted: generalized seizures occurred in 35.3% of cases and partial seizures in 64.7% of cases. The PNAM was 62.5%. The surveyed village was classified as hyper-endemic for onchocerciasis. Among risk factors, only positive family history for epilepsy was found (p=0.031). A sample pedigree of a family with 10 epileptic cases (4 included in the epidemiological study) was showed. CONCLUSIONS To our knowledge, this is the first door-to-door study that produce an adjusted prevalence rate on epilepsy in Cameroon. In according to studies done in Tanzania, Liberia, Uganda, and Ethiopia, our results (i.e., the high prevalence rate in a restricted area, the clinical characteristics of epileptic seizures, the positive family history for epilepsy and the type of pedigree of a family with epileptic patients) may be accounted for by the presence of an strong interaction between environmental and genetic factors in some circumscribed areas.

Cyclic vomiting syndrome and food allergy/intolerance in seven children: a possible association

Abstract Cyclic vomiting syndrome (CVS) is characterized by repeated unpredictable, explosive and unexplained bouts of vomiting. The episodes have a rapid onset, persist over a number of hours or days, and are separated by symptom-free intervals. Despite the recent interest in this disorder, its aetiology, pathogenesis and even its target organ remain unknown. The purpose of this study is to investigate the role played by food allergy in CVS. The report concerns eight children (five male, three female), mean age 8 years (3–13 years), suffering from CVS for 2 years at least. The diagnosis of CVS was based on characteristic history, normal physical examination and negative laboratory, radiographic, neurological and endoscopic studies. Despite the absence of clinical signs typical of food allergy, skin prick tests were positive in six of the eight patients (75%). Specific IgE were present in 4/8 (50%) of the patients. Skin tests and specific IgE were positive for cows milk proteins, egg white and soya. IgE levels were higher than the mean + 2SD in 5/8 (63%) of the patients. A double blind placebo controlled food challenge (DBPCFC) was carried out on seven of the eight patients who displayed clinical improvement after an elimination diet for cows milk (and other foodstuffs indicated by positive skin tests). The DBPCFC was positive in all seven children. Clinical follow-up revealed a state of well-being over the 6 months of observation. Conclusion It appears reasonable to suggest that food allergy plays a role in cyclic vomiting syndrome.

Zonisamide in children and young adults with refractory epilepsy : An open label, multicenter Italian study

PURPOSE To report on the first multicenter Italian experience with zonisamide as an add-on drug for refractory generalised or partial epilepsy in children, adolescents and young adults. METHODS The patients were enrolled in a prospective, add-on, open-label treatment study from eight Italian centres for children and adolescent epilepsy care. Eighty-two young patients (45 males, 37 females), aged between 3 and 34 years (mean 13.1 years), all affected by partial (47) or generalised (35) refractory epilepsy, were enrolled in the study. ZNS was added to the baseline therapy at a starting dose of 1 mg/kg/day twice daily. This dose was increased by 2 mg/kg every 1-2 weeks over a period of up 3 months, according to the patients response and tolerability, up to a maximum dose of 12 mg/kg. ZNS was given at the mean daily dose of 5.7/mg/kg/24 h (range 1-12 mg/kg). RESULTS After a mean follow-up period of 11.9 months (range 2-64 months), 9 patients (10.9%) were seizure-free. The number of seizures decreased by 50-99% in 31 cases (37.8%), by 25-49% in 5 cases (6.1%), remained the same in 29 cases (35.4%) and increased in 8 cases (9.7%). After 15 months of follow-up, 61 patients (74.4%) were still taking ZNS, while the remaining 21 (25.6%) had stopped. Twenty-two patients (26.8%) reported adverse effects while taking ZNS. They generally appeared during the first weeks of treatment, and were mild to moderate. The most frequent adverse effects were irritability and a reduced appetite. CONCLUSION ZNS effectively reduced seizure frequency in this pediatric population with both partial and generalised crypto/symptomatic refractory epilepsy. Its overall tolerability was good.

Pattern Sensitivity and Photosensitivity in Epileptic Children with Visually Induced Seizures

Summary: We evaluated photosensitivity and pattern sensitivity in 74 epileptic children (38 males, 36 females aged 4 4–19 years; mean age 11.9 years) with reflex seizures induced by environmental visual stimuli and analyzed clinical and EEG characteristics of patients according to type of sensitivity. Standard procedures of visual stimulation were used in all cases. Seven children were excluded because of poor cooperation (3) or no activation (4).Fifty‐one percent of the remaining 67 patients showed sensitivity to both light and pattern, whereas 33% showed photosensitivity and 16% showed pattern sensitivity. Generalized abnormalities were more frequently elicited by intermittent light stimulation than by pattern (73 vs. 36%, p < 0.001). Significant differences in clinical and EEG findings were noted among patients according to their sensitivity to light or/and pattern. In particular, pattern‐sensitivity patients without photosensitivity had a higher occurrence of localization‐related symptomatic epilepsies, neurologic abnormalities, and epileptiform EEG abnormalities, mainly focal, at rest.

Allergy and childhood epilepsy: a close relationship?

Objectives – The possibility that certain foods or allergens may induce convulsions has already been reported in the literature. None of the relevant studies has, however, shown a close correlation between allergy and epilepsy, most reports being anecdotal and open to various causal hypotheses. The case–control study reported here was undertaken to test the hypothesis that epilepsy is linked to allergy. Material and methods– Seventy‐two epileptic children and a group of 202 controls in the same age bracket were investigated for allergy together with their immediate families. Results– The study revealed significantly higher rates of eczema in the mothers and rhinitis in the siblings of the patients studied as well as generally higher incidence of allergic pathologies in both of these groups with respect to the relevant controls. A significantly higher incidence of allergy to cows milk and asthma was also documented in the epileptic children with respect to the control group. Prick tests gave a significantly higher rate of positive results for cows milk proteins in the cases examined with respect to the controls. The total serum IgE of a random sample of cases and controls showed no difference in mean values. Conclusion– The study appears to bear out the hypothesis of a higher incidence of allergy in the children with epilepsy and their immediate families than in the controls and their families.

Pattern-sensitive epilepsy : genetic aspects in two families

Summary: We report two families in which five members (three in one and two in the other) suffer from patternsensitive epilepsy. In all affected members seizures were induced by environmental visual patterned stimuli. Diagnosis was confirmed by neurophysiological studies, including EEG with pattern and intermittent light stimulation and visual evoked potentials. The role of genetic aspects and the relationship between this form of reflex seizures and photosensitive epilepsy are emphasized.

Role of Continuous Positive Airway Pressure Therapy on the Pathogenesis of Sleep-Related Frontal Lobe Epilepsy in a Child With Obstructive Sleep Apnea Syndrome

We describe an obese child with severe obstructive sleep apnea syndrome in whom nocturnal frontal lobe seizures developed within a week after therapy was started with continuous positive airway pressure. The video polysomnographic study after the onset of nocturnal episodes showed 3 seizures: 2 starting from slow-wave sleep when he was sleeping with continuous positive airway pressure, and 1 from stage 2 non—rapid eye movement sleep when he was sleeping without continuous positive airway pressure. Cyclic alternating pattern analysis during the video polysomnography recorded after the onset of nocturnal seizures disclosed a high cyclic alternating pattern rate during slow-wave sleep, and the recording obtained after antiepileptic therapy began showed a low cyclic pattern analysis rate. In this child, we describe the non—rapid eye movement sleep instability induced by continuous positive airway pressure therapy might have had a role in triggering the nocturnal seizures.