Benign paroxysmal torticollis in infancy

Benign paroxysmal torticollis

Benign paroxysmal torticollis is a rare, usually benign, condition classified as an episodic syndrome. It is characterized by episodes of paroxysmal head tilt and associated symptoms, some of which are shared with migraine. It is likely to be the migraine equivalent with the earliest age of onset, starting in some cases in the neonatal period but resolving typically by the age of three or four. It may evolve into other episodic syndromes, migraine, or hemiplegic migraine, and an antecedent history or family history should be sought from migraineurs. Its prevalence and under-recognition has made it difficult to study. There are emerging associations with genes implicated in other paroxysmal syndromes, including hemiplegic migraine and episodic ataxia. Treatment currently centers on supportive care and environmental modification.

Pediatric migraine variants: a review of epidemiology, diagnosis, treatment, and outcome

Pediatric migraine variants, previously known as childhood periodic syndromes, migraine equivalents, or migraine precursors, are a group of periodic or paroxysmal disorders occurring in patients who also have migraine with or without aura, or who have an increased likelihood of developing migraine. They have common key clinical features including periodic or paroxysmal character, normal neurological examination between attacks, family history of migraine, and clinical evolution to classic types of migraine. This article aims to review the pathophysiology, evaluation, and management of the pediatric migraine variants including abdominal migraine, benign paroxysmal vertigo, cyclic vomiting syndrome, and benign paroxysmal torticollis as well as the episodic syndromes that may lead to migraine, infantile colic, alternating hemiplegia of childhood, and vestibular migraine.

The Efficacy of Topiramate in Benign Paroxysmal Torticollis of Infancy: Report of Four Cases

Benign paroxysmal torticollis (BPT) is a rare paroxysmal dyskinesia and 1 of the childhood periodic syndromes presenting with recurrent stereotypic episodes of torticollis, usually accompanied with some of the nonheadache features of migraine such as vomiting and ataxia. Although the nature of BPT may seem benign, its recurrent episodes can mimic attacks of epilepsy and expose the infant to unnecessary hospitalization and adverse effects of inappropriate medications. There is no approved medication for the disease, but a few studies have suggested that cyproheptadine is useful. However, use of this agent has not been confirmed as effective for these patients, and the safe dosage for children aged <2 years has not yet been established. We report 4 patients who exhibited a successful response to treatment with topiramate (their episodes of BPT stopped). Considering the underlying relation of BPT with migraine, the satisfactory response of our patients to topiramate, and the safety of this medication in neonates and children, topiramate seems to be an effective and safe medication for the reduction and elimination of BPT episodes. In addition, 1 of our case subjects (patient 4) confirmed this finding by exhibiting an explicit dependence in the regularity and duration of her attacks with topiramate. Topiramate seems to be an effective medication for the prophylaxis of BPT episodes. Further studies and clinical trials are recommended.

Migraine equivalents in childhood

Migraine equivalents are a group of periodic and paroxysmal neurologic diseases. Because headache is not a prominent symptom, the diagnosis might be challenging. The objective of the study was to evaluate the frequency and outcome of migraine equivalents. This was a retrospective study. We included benign paroxysmal torticollis of infancy, benign paroxysmal vertigo of infancy, abdominal migraine, cyclic vomiting, aura without migraine, and confusional migraine. We evaluated the frequency of events, treatment, and outcome. Out of 674 children with headache, 38 (5.6%) presented with migraine equivalents. Twenty-one were boys and the mean age was 6.1 years. Fifteen had abdominal migraine, 12 benign paroxysmal vertigo, 5 confusional migraine, 3 aura without migraine, 2 paroxysmal torticollis, and 1 cyclic vomiting. Prophylactic treatment was introduced in 23 patients; 4 lost follow-up and 19 had significant improvement. We conclude that the correct diagnosis of migraine equivalents enables an effective treatment with an excellent outcome.

Episodic movement disorders: from phenotype to genotype and back

Episodic dyskinetic movement disorders are a heterogeneous group of rare conditions. Paroxysmal dyskinesias constitute the core of this group and usually exhibit normal interepisodic neurologic findings. Contrariwise, episodic dyskinesias occur as a particular feature of complex chronic neurologic disorders. Conjunction of accurate phenotyping with up-to-date methods of molecular genetics recently provided remarkable new insights concerning the genetic causes of episodic dyskinesia. The identification of heterozygous mutations in the PRRT2 gene in paroxysmal kinesigenic dyskinesia as well as in benign familial infantile seizures linked episodic movement disorders with epilepsy. Alternating hemiplegia of childhood, the prototype of a chronic multisystem disease with episodic dyskinesia as a clinical hallmark, was recently found to be caused by heterozygous de novo mutations in the ATP1A3 gene. The clinical spectra of PRRT2 as well as of ATP1A3 mutations are still expanding. This review summarizes new genetic findings and clinical aspects in episodic dyskinesias.

The neurology of benign paroxysmal torticollis of infancy: report of 10 new cases and review of the literature

Benign paroxysmal torticollis is an under-recognized cause of torticollis of early infancy. The attacks usually last for less than 1 week, recur from every few days to every few months, improve by age 2 years, and end by age 3. There very frequently is a family history of migraine. We did a detailed analysis of 10 cases of benign paroxysmal torticollis, seen over 5 years, and compared our findings with those in the 103 cases in the literature. Detailed neurodevelopmental assessments, available only in our cases, showed accompanying gross motor delays in 5/10 children, with additional fine motor delays in 3/5. As the benign paroxysmal torticollis improved, so did the gross motor delays in 3/5, and the fine motor delays in 1/3. In all of our cases, at least 2 other family members had migraine. Benign paroxysmal torticollis is likely an age-sensitive, migraine-related disorder, commonly accompanied by delayed motor development.

Limited value of plain radiographs in infant torticollis

OBJECTIVE

The purpose of this work was to assess the frequency of clinically relevant findings from plain films of infants evaluated for torticollis.

PATIENTS AND METHODS

After institutional review board approval, radiology records were searched for infants 0 to 12 months of age who underwent plain film study for torticollis or "head tilt." Infants evaluated for trauma or Down syndrome were excluded. All of the studies were reviewed, demographic data was recorded, and any additional imaging studies were examined.

RESULTS

A total of 502 patients (189 girls and 313 boys) were identified with an average age of 0.37 +/- 0.2 years. Head tilt was to the left in two thirds of patients. Ten patients had abnormal findings reported. Six of these proved normal on subsequent studies (3 suspected occipital-C1 fusions, 2 suspected cervical fusions, and 1 suspected hemivertebra). Four patients had true bony vertebral abnormalities including absent left C7 pedicle, multiple fusion anomalies from C4 to T2, C3 hemivertebra and thoracic spine anomalies, and C4 hypoplasia. This last patient had abnormal kyphosis on physical examination and demonstrated instability with dynamic testing. Twenty-five additional patients with normal plain films underwent spine computed tomography or magnetic resonance imaging; all were normal.

CONCLUSIONS

The true-positive yield of plain films in nontraumatic infant torticollis was low (4 of 502). There were more false-positive than true-positive results. A common rationale for imaging is to exclude craniocervical or other unstable abnormalities that might contraindicate physical therapy, seen in only 1 of the 502 cases. Close physical examination could safely eliminate most patients sent for radiography.

Torcicolo paroxístico benigno da infância: diagnóstico e evolução clínica de seis pacientes

O torcicolo paroxístico benigno da infância é distúrbio que ocorre de modo súbito e espontâneo nos primeiros meses de vida. A cabeça do paciente desvia-se para um dos lados, mantendo-se assim por horas a dias; outros sintomas podem ocorrer associadamente como vômitos, sudorese, palidez, irritabilidade, cefaléia e marcha instável. Relatamos seis pacientes com torcicolo paroxístico benigno da infância, cujos sintomas e sinais surgiram nos primeiros seis meses de vida e desapareceram até os cinco anos de idade. É importante que o médico possa reconhecer este distúrbio benigno, para oferecer um prognóstico apropriado e não realizar exames desnecessários, que vão gerar apenas custos e ansiedade para as crianças e os seus pais.

Benign paroxysmal torticollis in infancy

Background. Benign paroxysmal torticollis (BPT) is an episodic functional disorder of unknown etiology, characterized by the periods of torticollic posturing of the head, that occurs in the early months of life in healthy children. Case report. We reported two patients with BPT. In the first patient the symptoms were observed at the age of day 20, and disappeared at the age of 3 years. There were 10 episodes, of which 2 were followed by vomiting, pallor, irritability and the abnormal trunk posture. In the second patient, a 12-month-old girl, BPT started from day 15. She had 4 episodes followed by vomiting in the first year. Both girls had the normal psychomotor development. All diagnostical tests were normal. Conclusion. The recognition of BPT, as well as its clinical course may help to avoid not only unnecessary tests and the treatment, but also the anxiety of the parents.

Complicated migraine and migraine variants

This article reviews the less frequently encountered varieties of migraine. It is suggested that these disorders be approached by evaluating possible underlying etiologies before positively diagnosing migraine. This decreases the likelihood of "missing" structural or metabolic disorders. The classification, diagnostic evaluation, differential diagnosis, and treatment options of these disorders is reviewed and a selection of references appended for additional information.

Pediatric migraine equivalents: occurrence and clinical features in practice

Migraine equivalents of infancy, childhood, and adolescence are recognized periodic, paroxysmal syndromes without associated headache that are thought to be migrainous in etiology. Five such equivalents are presently recognized. Their clinical features and relative frequency in ambulatory pediatric neurology practice have not been well documented. Utilizing a comprehensive, standardized computer database, the occurrence of these migraine equivalents in a single pediatric neurology practice together with their observed clinical features were documented over an 8-year period. Of a total of 5,848 patients in the database, of whom 1,106 were migraineurs, 108 patients (1.8% of total, 9.8% of migraineurs) were identified to have migraine equivalents. The following distribution among migraine equivalents was observed: benign paroxysmal torticollis 11 (10.2% of patients with migraine equivalents), benign paroxysmal vertigo 41 (38%), abdominal migraine/cyclical vomiting 20 (18.5%), acephalgic migraine 31 (28.7%), and acute confusional migraine 5 (4.6%). In each type, with the exception of benign paroxysmal torticollis and acute confusional migraine, females clearly predominated, and in all types a strong positive family history of migraine was elicited (68%-100%). There was variation in the age of onset of a particular equivalent with considerable overlap observed. Coexisting more typical migraines were observed in from 10% (benign paroxysmal torticollis) to 70% (abdominal migraines/cyclical vomiting) of the cases. In conclusion, pediatric migraine equivalents occur with relative frequency in ambulatory practice, possessing discrete clinical features that have a clear relationship to more typical migrainous phenomena.

Benign paroxysmal torticollis of infancy

Benign paroxysmal torticollis is an episodic functional disorder of unknown etiology that occurs in the early months of life in healthy individuals. The child's head tilts to one side for a few hours or days, usually without any associated symptoms. The disorder, which disappears within the first few years of life, is often misinterpreted and the patient pointlessly undergoes numerous tests. We present our series of 22 patients observed at the pediatric neurology outpatients clinic in Padova with a view to refreshing the pediatrician's memory on this frequent, benign pathology.

Paroxysmal torticollis

An infant with recurrent episodes of torticollis lasting several hours at a time is presented. The diagnosis is primarily one of pattern recognition and exclusion of alternative diagnoses.