You are in: eMedicine Specialties > Neurology > Pediatric Neurology Shuddering AttacksArticle Last Updated: Sep 11, 2008AUTHOR AND EDITOR INFORMATIONSection 1 of 11
  Author: Selim R Benbadis, MD, Professor, Director of Comprehensive Epilepsy Program, Departments of Neurology and Neurosurgery, University of South Florida School of Medicine, Tampa General Hospital Selim R Benbadis is a member of the following medical societies: American Academy of Neurology, American Academy of Sleep Medicine, American Clinical Neurophysiology Society, American Epilepsy Society, and American Medical Association Editors: Raj D Sheth, MD, Division Chief, Division of Pediatric Neurology, Department of Pediatrics, Nemours Alfred I duPont Hospital for Children; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; Kenneth J Mack, MD, PhD, Senior Associate Consultant, Department of Child and Adolescent Neurology, Mayo Clinic; Paul E Barkhaus, MD, Professor, Department of Neurology, Medical College of Wisconsin; Director of Neuromuscular Diseases, Milwaukee Veterans Administration Medical Center; Amy Kao, MD, Assistant Professor, Department of Neurology, Department of Pediatrics, Division of Pediatrics, Oregon Health and Science University; Consulting Staff, Shriners Hospital Author and Editor Disclosure Synonyms and related keywords: shuddering attacks, benign paroxysmal spells of childhood, mimic epileptic seizure, shiver-like movement, tremor, electroencephalography, EEG, seizures INTRODUCTIONSection 2 of 11
  BackgroundShuddering attacks are benign paroxysmal spells of childhood that can mimic epileptic seizures. They may superficially resemble several seizure types, including tonic, absence (typical and atypical), and myoclonic seizures. PathophysiologyThe pathophysiology is unknown, although a relationship with essential tremor has been postulated.1 The origin is unclear, but shuddering attacks are not epileptic in nature. FrequencyInternationalIncidence is unknown, but shuddering attacks are relatively uncommon. Mortality/MorbidityThese episodes are usually benign and nondisabling. They are not associated with increased morbidity or mortality and tend to remit spontaneously. SexNo sex predilection is reported. AgeThe condition is seen in older infants and young children. CLINICALSection 3 of 11
History
PhysicalGeneral and neurologic examination findings are normal. CausesThe cause is unknown. A relationship with essential tremor has been postulated because there may be an increased frequency of essential tremor in the families of these children. DIFFERENTIALSSection 4 of 11
Absence Seizures Benign Childhood Epilepsy Complex Partial Seizures Dizziness, Vertigo, and Imbalance Epilepsy, Juvenile Myoclonic Essential Tremor Febrile Seizures Frontal Lobe Epilepsy Psychogenic Nonepileptic Seizures Seizures and Epilepsy: Overview and Classification Simple Partial Seizures Syncope and Related Paroxysmal Spells Tonic-Clonic Seizures
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| Drug Name | Propranolol (Inderal) |
|---|---|
| Description | Has membrane-stabilizing activity and decreases automaticity of contractions. |
| Adult Dose | 40 mg PO bid initially; increase as tolerated; not to exceed 240-320 mg/d divided bid/tid |
| Pediatric Dose | Not established |
| Contraindications | Documented hypersensitivity; uncompensated congestive heart failure; bradycardia, cardiogenic shock; A-V conduction abnormalities |
| Interactions | Coadministration with aluminum salts, barbiturates, NSAIDs, penicillins, calcium salts, cholestyramine, and rifampin may decrease propranolol effects; calcium channel blockers, cimetidine, loop diuretics, and MAOIs may increase toxicity of propranolol; toxicity of hydralazine, haloperidol, benzodiazepines, and phenothiazines may increase with propranolol |
| Pregnancy | C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus |
| Precautions | Beta-adrenergic blockade may decrease signs of acute hypoglycemia and hyperthyroidism; abrupt withdrawal may exacerbate symptoms of hyperthyroidism, including thyroid storm; withdraw drug slowly and monitor closely |
Shuddering attack episodes tend to remit. A relationship to essential tremor occurring later in life has not been established.
Educate the family concerning the benign nature of this condition and the excellent long-term prognosis.
Shuddering attacks should not be mistakenly diagnosed as epileptic seizures. The diagnosis should always be confirmed by EEG-video monitoring.4
Tibussek D, Karenfort M, Mayatepek E, Assmann B. Clinical reasoning: shuddering attacks in infancy. Neurology. Mar 25 2008;70(13):e38-41. [Medline].
Article Last Updated: Sep 11, 2008
