18 Y/o Female With Convulsions After Getting Hit In Head By Volleyball. - Page #4
 

Working Diagnosis:
Psychogenic paroxysmal non epileptic event sparked by migraine

Treatment:
Given rizatriptan with resolution of seizures within fifteen minutes. Held from physical activity until further evaluation by neuropsychiatry and neurology. Celexa and vyvanse were continued.

Outcome:
Re-evaluated by neurology, as well as neuropsychiatry, confirming underlying medical history of migraines and acute psychogenic seizure. Symptoms were not thought to be due to new/repeat concussion. Rather, the symptoms were thought to be due to patient fearing return of concussion-like syndrome after being hit in the head and experiencing mild headache. She was continued on treatment for underlying ADHD and depression. In addition, rizatriptan was continued as needed for migraine headaches. Patient returned to full physical activity following standard return-to-play protocol.

Author's Comments:
Management of concussions can be very difficult, especially when suffering from neurocognitive symptoms. It is important that providers be aware of alternate diagnoses that may be masked by underlying symptoms.

Editor's Comments:
Identified in the DSMV under “conversion disorder/functional neurologic symptom disorder,” psychogenic paroxysmal nonepileptic events (PNEs) can be classified as physiologic or psychological. There are many different etiologies of PNEs in the pediatric population, including migraine, important to the patient in this case who had symptoms similar to the typical aura of a migraine.

Correctly distinguishing PNEs from epileptic seizures is a diagnostic challenge. The history and event observation are frequently insufficient to make a definitive diagnosis and further evaluation with EEG may be necessary. Video EEG while capturing an event is very helpful in the diagnosis, of which did not occur in this case as the patient had no subsequent events. I would urge caution in making a definitive diagnosis of a PNE in this patient. While migraines are one etiology of PNEs, the presentation of tonic-clonic movements after head trauma is not the typical presentation of a migraine. Additionally, the patient had no prior history of migraine headaches. Furthermore, head trauma as an etiology of PNEs is not described in the literature.

Nevertheless, failure to recognize PNEs can lead to unnecessary polypharmacy and drug toxicity, hazardous interventions such as intubation, school absence, and lack of treatment of the underlying psychological problems (47,17). Individuals with PNEs typically experience other psychogenic disorders, including depression, anxiety and ADHD, all of which are present in this case (3). Once the diagnosis of PNEs is established, workup and treatment of comorbidities is crucial.

References:
1. Benbadis SR. How many patients with pseudoseizures receive antiepileptic drigs prior to diagnosis. Eur Neurol. 1999;41:114-115.
2. Krumholz A, Niedermeyer E. Psychogenic seizures: a clinical study with follow-up data. Neurology. 1983;33:498-502.
3. Gokce NS, Haydar AT, Hulya I. Semiological and psychiatric characteristics of children with psychogenic nonepileptic seizures: Gender-related differences. Seizure. 2015;31:144-148.

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