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Highlights • Tilt-induced syncope is associated with changes in several quantitative EEG (QEEG) parameters. • QEEG changes include a shift in power from higher to lower frequency ranges. • Laterality of QEEG changes is not different from a probability of 0.5. Abstract Objective To characterize the quantitative electroencephalographic (QEEG) patterns associated with tilt-induced syncope in youth. Methods Several QEEG parameters were analyzed. Data were calculated for peak or nadir changes with syncope for amplitude-EEG, fast Fourier transform (FFT) power in several frequency ranges, 8–13 Hz/1–4 Hz frequency ratio, and FFT edge. Results Changes in QEEG parameters were present among all patients with tilt-induced syncope (n = 76). These changes included increases in the low frequency FFT power (1–4 Hz range), decreases in the power ratio (8–13 Hz/1–4 Hz) and decreases in the FFT edge (95%, 1–18 Hz). All patients had suppression of EEG amplitudes that closely followed loss of consciousness. Asymmetry indices demonstrated cerebral hemisphere lateralization at multiple periods during the evolution of syncope, but the side of lateralization did not differ from 0.5 probability. Conclusions QEEG parameters can be used to characterize EEG changes associated with tilt-induced, neurally-mediated syncope. Significance QEEG may serve as a useful tool for the study of syncope neurophysiology, and the modeling of changes with syncope may improve our understanding of other neurologic disorders caused by defects in cerebral perfusion. [ABSTRACT FROM AUTHOR]

Abstract Background A previous study of electroencephalography (EEG) changes with syncope led to a finding that some young patients develop prolonged periods of tilt-induced hypotension, but they do not lose consciousness. The present study aim was to compare patterns of hemodynamic changes, measures of duration, and sweating between these patients and patients with tilt-induced vasovagal syncope. Methods In an observational study, qualitative changes in hemodynamic parameters were compared between patients with prolonged hypotension (n = 30) and with syncope (n = 30). To demonstrate that periods of hypotension far-exceed the typical presyncope period, several parameters were used to compare the durations of events between groups. Differences in sweating patterns were explored. Results Parallels in hemodynamic changes were present in both groups suggesting similar vasovagal mechanisms. Patients with prolonged hypotension had longer durations of hypotension (165 ± 44 versus 57 ± 13 s, p < 0.001), diminished cardiac output (109 ± 38 versus 32 ± 9 s, p < 0.001), and EEG slowing (85 ± 31 versus 9 ± 4 s, p < 0.001) compared to patients with syncope. While all patients generated an increase in sweat rate, those with hypotension only developed a robust sweat response that always preceded the plateau in hypotension compared to 14 (47%) patients with syncope who developed an increase in sweating prior to syncope, p < 0.001. Conclusions Similarities are present among hemodynamic changes with prolonged hypotension and with tilt-induced vasovagal syncope, suggesting a possible vasovagal mechanism for prolonged hypotension. If true, understanding why some individuals develop a vasovagal response that does not culminate in rapid syncope may help to elucidate the physiologic underpinnings of the vasovagal reflex. [ABSTRACT FROM AUTHOR]

Objective: To characterize the presence and degree of postconcussion lightheadedness in relation to postconcussion vertigo and dizziness, and to determine whether lightheadedness influences overall symptom duration. Design: Prospective, cohort design. Setting: Nationwide Children's Hospital, Sports Concussion Clinic. Participants: Five hundred ten patients (9-19 years of age) within 30 days of concussion injury. Main Outcome Measures: Patient ratings (scale 0-6) of multiple postconcussion symptoms including lightheadedness, vertigo, and dizziness, reported from the day of clinic evaluation and recalled from the day of concussion. Results: Postconcussion lightheadedness occurred commonly relative to vertigo. Lightheadedness was recalled more than vertigo (70.8% vs 48.6%, P < 0.001) on concussion day and reported more than vertigo (47.1% vs 24.1%, P < 0.001) on the day of clinic evaluation. Principal component analysis demonstrated strong correlations among lightheadedness, vertigo, balance difficulties, difficulty concentrating, mental fogginess, and difficulty remembering, relative to other postconcussion symptoms. When present on the day of clinic evaluation, these highly correlated symptoms predicted prolonged concussion recovery [P = 0.028; Hazard Ratio (HR) = 1.2]. Female sex (P = 0.04; HR = 1.23), emotional symptoms recalled from the day of concussion (P = 0.007; HR = 1.23), and cephalalgic symptoms (P < 0.001; HR = 1.34) reported on the day of clinic evaluation also predicted prolonged concussion recovery. Conclusions: Not all postconcussion dizziness is vertigo. Postconcussion lightheadedness is common and, when present at the time of clinic evaluation, can influence concussion recovery. Clinical Relevance: Distinguishing postconcussion lightheadedness from vertigo may help to inform clinical treatment and concussion research design. This study adds to the growing body of evidence that supports an association between concussion and autonomic dysfunction. [ABSTRACT FROM AUTHOR]

Background: Little is known about somatic and psychiatric symptoms and perceived peer relationships of patients with psychogenic nonsyncopal collapse.Objective: This study aimed to compare somatic and psychiatric symptoms and other elements potentially related to functional neurological symptom disorders between youth with psychogenic nonsyncopal collapse and those with neurally mediated syncope.Methods: Before testing, patients completed a structured interview and questionnaire addressing current symptoms, previous psychiatric diagnoses, referrals, diagnostic testing, prescribed medications, and patient self-ratings of anxiety, depression, and perceived peer relationships.Results: Compared with patients with syncope (n = 60), patients with psychogenic nonsyncopal collapse (n = 60) had higher ratings for lightheadedness and vertigo, more abdominal pain, more chronic headaches, more fatigue, more sleep disturbances, more prescriptions for antidepressant medicines, more encephalograms performed, more referrals to psychiatry, and more psychiatric diagnoses including anxiety, depression, posttraumatic stress disorder, previous nonfainting conversion disorders, and eating disorders (all p < 0.05). Patients with psychogenic nonsyncopal collapse rated their anxiety (10.5 ± 7.7 versus 5.9 ± 5.8, p < 0.001) and depression (8.7 ± 8.3 versus 3.1 ± 5, p < 0.001) symptoms higher and their peer relationships (37 ± 12.3 versus 47.6 ± 7.9, p < 0.001) lower than patients with syncope. Peer relationships remained significantly lower (p = 0.001) when analyzed with anxiety and depression.Conclusion: Patients with psychogenic nonsyncopal collapse have more symptom complaints and perceptions of poorer peer social interactions than patients with syncope. These results broaden our understanding of the biopsychosocial profile that increases an individual's vulnerability to psychogenic nonsyncopal collapse specifically and to functional neurological symptom disorders in general. [ABSTRACT FROM AUTHOR]

Background: The aim of the study was to characterize the clinical and electroencephalographic (EEG) patterns associated with tilt-induced reflex syncope and delayed orthostatic hypotension without syncope in youth.Methods: We conducted a prospective observational study of 95 patients referred to a pediatric neurology clinic for head-upright tilt testing. Clinical signs, symptoms, video EEG, and continuous blood pressure and heart rate were monitored.Results: Eighty patients had reflex syncope, and 15 had delayed-onset hypotension without syncope. The mean age was 15.3 (standard deviation ±2.3) years; 75 (78.9%) were female. All patients with hypotension only had corresponding signs and symptoms; 13 (86.7%) had corresponding EEG slowing. The duration of EEG slowing with hypotension far exceeded the presyncope interval from onset of slowing to loss of consciousness among patients with syncope (P < 0.001). Although prior near-syncope and presyncope episodes were reported commonly in both groups, patients with delayed hypotension without syncope were less likely to have experienced loss of consciousness during episodes of orthostatic intolerance (P < 0.001). Patients with syncope had either slow-flat-slow (n = 23) or slow-only (n = 57) EEG patterns. Compared to those with slow-only EEG patterns, patients with the slow-flat-slow pattern had greater rates of asystole (P < 0.001), myoclonic movements (P < 0.001), facial grimace (P = 0.003), vocalizations (P = 0.002), and arm flexion (P < 0.001) or extension (P = 0.006) during tilt-induced syncope.Conclusions: Among otherwise healthy youth, orthostatic signs and symptoms vary across the spectrum of tilt-induced reflex syncope and delayed hypotension without syncope. Delayed hypotension without syncope may represent the poorly defined phenomenon of "near syncope" in some patients. [ABSTRACT FROM AUTHOR]

Objective: The term "post-traumatic migraine" (PTM) has been used to describe post-traumatic headaches (PTHs) that have associated migraine features, but studies of this relationship are lacking. The objective of the present study was to determine whether PTH correlates strongly with migraine symptoms among youth with concussion.Methods: Twenty-three symptoms were analyzed from a retrospective cohort of 1953 pediatric patients with concussion. A principal component analysis (PCA) with oblique Promax rotation was conducted to explore underlying symptom relationships in the full cohort and in subcohorts stratified by the presence (n = 414) or absence (n = 1526) of premorbid headache.Results: The mean patient age was 14.1 years; 63% were male. Headache was the most common postconcussion symptom, acknowledged by 69.4% of patients. When considering the full cohort, the PCA demonstrated clustering of headache with photophobia, phonophobia, nausea, dizziness, and neck pain. Similar clustering was present among patients without premorbid headaches. Repeating the analysis in the patients with preconcussion headaches led to elimination of neck pain from the cluster.Conclusions: PTH correlates strongly with other migraine symptoms among youth with concussion, regardless of premorbid headaches. This clustering of migraine symptoms supports the existence of PTM as a distinct clinical entity in some patients. [ABSTRACT FROM AUTHOR]

PHACE (posterior fossa brain malformation, hemangiomas, arterial anomalies, coarctation of the aorta and cardiac defects, and eye abnormalities) syndrome is a neurocutaneous disorder often involving the cerebral vasculature. PHACE patients appear to have early-onset and severe headaches more commonly than children without PHACE. The objective of this study was to characterize the clinical features and prevalence of headache by conducting a cross-sectional survey of families in 2 large PHACE registries. Sixty-six percent of eligible families completed the survey in which 62.7% of respondents reported headaches. Average age of headache onset was 48.8 months. Females were more likely to have headaches (68.6% vs 30.8%, P = .014). Families reported associated migrainous features including nausea (62.5%), vomiting (37.5%), photophobia (75%), and phonophobia (75%). Headaches occurred at least weekly in 29.4%, lasted ≥1 hour in 85.4%, and led to ≥1 hospital admission in 15.7%. Three respondents with headaches had at least 1 ischemic stroke. We demonstrated that headaches are common among PHACE patients, develop at an early age, and have migrainous features. [ABSTRACT FROM AUTHOR]

Objective: To explore head-upright tilt table (HUT) signs of autonomic dysfunction in a cohort of youth with persistent postconcussion symptoms (PCSs) that include light-headedness and to correlate repeat tilt table results with symptom improvements for those patients found to have postural tachycardia syndrome (POTS) on initial testing. Design: Prospective cohort design. Setting: Nationwide Children's Hospital, Neurology Clinic. Participants: Thirty-four patients (13-18 years of age) with persistent PCSs. Main Outcome Measures: All patients underwent at least 1 tilt table test. The PCS Interview (PCS-I) and patient ratings of light-headedness and vertigo were used to measure symptom burden. Patients found to have POTS were asked to repeat tilt table testing when PCSs improved or 3 to 6 months after the initial test if symptoms persisted. Results: Twenty-four of the 34 (70.6%) patients had abnormal tilt table results with patients categorized as normal (n = 10), isolated syncope (n = 10), and POTS (n = 14). Patients with POTS had higher PCS-I scores than normal patients (P < 0.001) and higher ratings of light-headedness than both normal patients (P = 0.015) and syncope patients (P = 0.04). Twelve POTS patients underwent repeat tilt table testing, and 9 of 12 (75%) no longer met POTS diagnostic criteria. All patients with resolution of POTS had corresponding improvements in PCSs, including light-headedness and vertigo. Conclusions: Our study demonstrates a high rate of tilt table abnormalities among youth with persistent PCSs. Several patients with POTS had normalization of tilt table testing when PCSs improved. These findings warrant further research of autonomic dysfunction related to concussion. Clinical Relevance: Our study is the first to prospectively characterize autonomic dysfunction in patients with persistent PCSs using HUT testing and to show that the tilt test abnormalities normalize in some patients as PCSs improve. [ABSTRACT FROM AUTHOR]

Background There is a paucity of pediatric data addressing the complex relationship between primary headaches and sleep disturbances. Our study objective was to explore headache-related factors that predict sleep disturbance and to compare sleep complaints with other forms of headache-related disability among youth with migraines. Methods A prospective cohort study was conducted in patients 10-18 years old with migraine or probable migraine and without daily sleep complaints. The patients completed a 90-day internet-based headache diary. On headache days, patients rated headache intensity, answered Pediatric Migraine Disability Assessment-based questions modified for daily scoring, and reported sleep disturbances that resulted as a direct effect of proximate headaches. Results Fifty-two patients generated 4680 diary entries, 984 patients (21%) involved headaches. Headache intensity ( P = 0.009) and timing of headache onset ( P < 0.001) were predictive of sleep disturbances. Three Pediatric Migraine Disability Assessment-based items were also associated with sleep disturbances: partial school-day absence ( P = 0.04), recreational activities prevented ( P < 0.001), and decreased functioning during recreational activities ( P < 0.001). Sleep disturbances correlated positively and significantly with daily headache disability scores ( r pb = 0.35; P < 0.01). Conclusion We conclude that specific headache factors predict sleep disturbances among youth with primary headaches. [ABSTRACT FROM AUTHOR]

Objective The aim of this study is to compare daily Pediatric Migraine Disability Assessment ( PedMIDAS)-based scores for headaches occurring on school days vs non-school days and during the school year vs the summer holiday. Background The PedMIDAS is the only instrument validated to assess migraine disability among school-aged children. However, the PedMIDAS may underestimate disability during prolonged school holidays. Methods In a prospective cohort study, migraine patients aged 10-18 years completed a 90-day Internet-based headache diary. For each headache day, they answered PedMIDAS-based questions and rated their headache intensity (scale 1-10). PedMIDAS-based scores, headache intensity ratings, and relative headache frequencies were compared for school days vs non-school days and for the school year vs the summer holiday. Results Fifty-two patients completed 4680 diary entries comprising 984 headache days. The headache frequencies and intensity ratings did not differ between time periods. However, the mean headache disability scores (as measured from PedMIDAS-based questions) were significantly different for school days (0.85) compared to non-school days (0.45), P < .001, and for the school year (0.73) compared to the summer holiday (0.46), P < .016. Conclusion Given similar headache intensities and frequencies, daily PedMIDAS-based scores significantly underestimate headache disability on non-school days. Accordingly, PedMIDAS scoring during the school year may not be comparable to assessments done during the summer holiday. These potential differences must be considered when using the instrument as an outcome measure for clinical trials. [ABSTRACT FROM AUTHOR]

Abstract: Background: The causes of persistent headache following concussion are poorly understood. The objective of this study is to explore analgesic overuse as a potential cause of chronic post-traumatic headache among adolescents referred to a headache clinic following concussion. Methods: A retrospective chart review was conducted of all adolescent concussion patients referred to our pediatric headache clinic over the 16-month period between August 1, 2011, and November 30, 2012. Those patients with chronic post-traumatic headaches of 3-12 months' duration who also met International Headache Society criteria for probable medication-overuse headache were identified. Demographic data, concussion symptoms, and headache features were characterized from the initial evaluation and from follow-up visits. Results: Of 104 adolescent concussion patients referred during the study period, 77 had chronic post-traumatic headache of 3-12 months' duration. Fifty-four of 77 (70.1%) met criteria for probable medication-overuse headache. Only simple analgesics were overused. Thirty-seven patients (68.5%) had resolution of headaches or improvements to preconcussion headache patterns after discontinuing analgesics; seven (13%) had no change in headaches or worsening of headaches after discontinuing analgesics and 10 (18.5%) did not discontinue analgesics or were lost to follow-up. Conclusion: Excessive use of analgesics postconcussion may contribute to chronic post-traumatic headaches in some adolescents. Management of patients with chronic post-traumatic headache should include analgesic detoxification when medication overuse is suspected. [Copyright &y& Elsevier]

Aim: The aim of this article is to compare 90-day and 30-day recall of Pediatric Migraine Disability Assessment (PedMIDAS) elements and headache frequency against daily entries from an Internet headache diary among pediatric patients and their parents. Methods: In a prospective cohort study, patients aged 10-18 years with episodic migraine or probable migraine completed a 90-day Internet-based headache diary that incorporated PedMIDAS questions. Following the 90-day diary period, patients and parents completed modified PedMIDAS instruments to assess 90-day and 30-day recall. Intraclass correlation coefficients (ICC) were calculated to measure recall reliability. The Kruskal-Wallis and Jonckheere-Terpstra tests were used to explore recall accuracy as it relates to each participant's self-reported confidence in recall and to patient age. Results: Fifty-two subjects completed 90 consecutive diary entries. Comparing 30-day to 90-day recall of PedMIDAS elements, ICC scores improved by 26.2% (patients) and 17.5% (parents). Patients had better recall than their parents for all study measures. Self-reported confidence in recall and patient age had limited and inconsistent effects on recall accuracy. Conclusion: The optimal recall interval to assess migraine disability must balance recall accuracy with generalizability across a range of headache frequencies. When compared to daily diary entries, recall accuracy of PedMIDAS elements and headache frequency improves at 30 days compared to 90 days. Parent report of migraine disability should not be used as a replacement for patient report. [ABSTRACT FROM AUTHOR]

Objective To identify symptoms that may predict postural tachycardia syndrome ( POTS) among adolescent patients with headache and lightheadedness referred for tilt table testing. Background Individuals with POTS can have a variety of symptoms that impair quality of life. The specific symptoms that help to distinguish the POTS patient in an adolescent headache population have not been determined. Methods A group of symptoms was compared among 70 adolescent patients with headache and lightheadedness referred to a pediatric headache clinic for tilt table testing. Every patient completed a symptom questionnaire prior to the tilt table test. The chi-square test was used to compare questionnaire responses between patients found to have POTS and those who did not have POTS. Thirteen symptoms were analyzed. Symptoms that differed statistically between groups were further assessed for sensitivity, specificity, and diagnostic predictive values. Results Thirty-seven (53%) patients met diagnostic criteria for POTS. Several symptoms differed between the patients found to have POTS and those without POTS. Headache type was not predictive. Vertigo and evening exacerbation of headaches had P values <.05 but did not meet significance after a statistical correction for multiple variables, P ≤ .004 (0.05/13). New-onset motion sickness, dizziness as a headache trigger, and orthostatic headaches had P values <.004 and were relatively sensitive and/or specific for the POTS diagnosis. Conclusions While no single clinical symptom or headache type reliably establishes the POTS diagnosis, several symptoms can help to distinguish the POTS patient in an adolescent headache population. [ABSTRACT FROM AUTHOR]

Objective: To identify the clinical factors that influence the duration of postconcussion symptoms among youth referred to a sports concussion clinic.Study Design: A retrospective cohort study was conducted to evaluate several potential predictors of symptom duration via a Cox proportional hazards analyses. The individual postconcussion symptom scores were highly correlated, so these symptoms were analyzed in the statistical model as coefficients derived from principal component analyses.Results: Among 1953 youth with concussion, 1755 (89.9%) had dates of reported symptom resolution. The remainder (10.1%) were lost to follow-up and censored. The median time to recovery was 18 days (range 1-353 days). By 30 days, 72.6% had recovered; by 60 days, 91.4% had recovered; and by 90 days, 96.8% had recovered. Several variables in a multivariate Cox model predicted postconcussion symptom duration: female sex (P < .001, hazard ratio [HR] = 1.28), continued activity participation (P = .02, HR = 1.13), loss of consciousness (P = .03, HR = 1.18), anterograde amnesia (P = .04, HR = 1.15), premorbid headaches (P = .03, HR = 1.15), symptom components from the day of concussion (emotion, P = .03, HR = 1.08), and the day of clinic evaluation (cognitive-fatigue, P < .001, HR = 1.22; cephalalgic, P < .001, HR = 1.27; emotional, P = .05, HR = 1.08; arousal-stimulation, P = .003, HR = 1.1). In univariate analyses, greater symptom scores generally predicted longer symptom durations. Worsening of symptoms from the day of concussion to the day of clinic evaluation also predicted longer recovery (P < .001, HR = 1.59).Conclusions: Several factors help to predict protracted postconcussion symptom durations among youth referred to a sports concussion clinic. [ABSTRACT FROM AUTHOR]

Background Concussion is a complex brain injury that results in more than 100,000 emergency department visits for school-aged children each year in the United States. All 50 US states have passed concussion legislation designed to promote safety in youth sports. Most of these laws require medical clearance by a licensed health care provider before returning to sport, which may have contributed to an increase in pediatric subspecialty referrals, particularly referrals to the child neurologist. Methods We reviewed the literature on pediatric concussion. Results This review summarizes the current knowledge and recommendations for concussion diagnosis and management in children and adolescents, athletes and nonathletes. It highlights concussion epidemiology, pathophysiology, advances in neuroimaging, and potential health risks including second impact syndrome and chronic traumatic encephalopathy. It also underscores clinical areas where evidence is lacking. Conclusions The diagnosis and management of concussion requires specific considerations in children. Further concussion research must be done to minimize injury risk and to optimize medical care for this common problem. [ABSTRACT FROM AUTHOR]