AUTHOR AND EDITOR INFORMATION

Section 1 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

INTRODUCTION

Section 2 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Background

Shuddering 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.

Pathophysiology

The pathophysiology is unknown, although a relationship with essential tremor has been postulated. The origin is unclear, but shuddering attacks are not epileptic in nature.

Frequency

International

Incidence is unknown, but shuddering attacks are relatively uncommon.

Mortality/Morbidity

These episodes are usually benign and nondisabling. They are not associated with increased morbidity or mortality and tend to remit spontaneously.

Sex

No sex predilection is reported.

Age

The condition is seen in older infants and young children.

CLINICAL

Section 3 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

History

• Parents describe the paroxysmal episodes as a sudden flexion of the neck and trunk and adduction of the arms.
• A shiverlike movement of the trunk ("like a chill") occurs, and the body may stiffen.
• Consciousness does not seem to be altered, but this can be difficult to confirm.
• The episode usually lasts 5-15 seconds.
• Unlike epileptic seizures, shuddering attacks do not occur during sleep.

Physical

General and neurological examination findings are normal.

Causes

The 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.

DIFFERENTIALS

Section 4 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Other Problems to be Considered

Benign epilepsy syndromes
Tonic seizures

WORKUP

Section 5 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Lab Studies

• No laboratory studies are helpful for diagnosis.

Imaging Studies

• Brain CT scan or MRI may be performed because epileptic seizures are in the differential diagnosis. The results of these studies, however, are normal.

Procedures

• To help differentiate shuddering attacks from epileptic seizures, prolonged electroencephalography (EEG) video monitoring to record a typical episode is helpful.
• Recordings of the spells confirm that typical characteristics of an episode are 5-10 seconds of shiver-like movements of the trunk and limbs with no impairment of consciousness and no EEG discharge during the episode. A normal EEG result helps to rule out an epileptic origin.
• Ambulatory EEG without video recording is useful for diagnosis but does not record the clinical event.
• Routine EEG results are typically normal.

TREATMENT

Section 6 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Medical Care

In most cases, no treatment is necessary.

• Occasionally, if the episodes are unusually frequent or disabling, treatment may be attempted. However, there is no consistently effective treatment.
• Do not use antiepileptic drugs. They are ineffective.
• Propranolol can be helpful in isolated cases. However, it is used very rarely in the treatment of this condition.

Consultations

Infants and children with shuddering attacks are typically referred to a neurologist to check for possible seizures.

MEDICATION

Section 7 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Medications are rarely used. However, propranolol may have some efficacy.

Drug Category: Beta-adrenergic blockers

These agents compete with beta-adrenergic agonists for available beta-receptor sites.

FOLLOW-UP

Section 8 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Prognosis

• These episodes tend to remit. A relationship to essential tremor occurring later in life has not been established.

Patient Education

• Educate the family concerning the benign nature of this condition and the excellent long-term prognosis.

MISCELLANEOUS

Section 9 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Medical/Legal Pitfalls

• Shuddering attacks should not be mistakenly diagnosed as epileptic seizures. The diagnosis should always be confirmed by EEG-video monitoring.

REFERENCES

Section 10 of 10

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

• Benbadis SR. What can EEG-video monitoring do for you and your patients?. J Fla Med Assoc. Jun-Jul 1997;84(5):320-2. [Medline].
• Gilliam F, Kuzniecky R, Faught E. Ambulatory EEG monitoring. J Clin Neurophysiol. Mar 1999;16(2):111-5. [Medline].
• Holmes GL, Russman BS. Shuddering attacks. Evaluation using electroencephalographic frequency modulation radiotelemetry and videotape monitoring. Am J Dis Child. Jan 1986;140(1):72-3. [Medline].
• Vanasse M, Bedard P, Andermann F. Shuddering attacks in children: an early clinical manifestation of essential tremor. Neurology. Nov 1976;26(11):1027-30. [Medline].
• Watemberg N, Tziperman B, Dabby R, et al. Adding video recording increases the diagnostic yield of routine electroencephalograms in children with frequent paroxysmal events. Epilepsia. May 2005;46(5):716-9. [Medline].

Article Last Updated: Sep 28, 2006