18.2 Seizures, Headache & Concussion

Neurology is clinical category #12. Domain II is whether the spell is a simple febrile seizure, absence, breath-holding, a concussion, or West syndrome. Domain III is who gets imaging, who gets neurology, and who does not leave with a primary-care phenobarbital prescription. Sports-chapter concussion rules still apply; this section expands return-to-learn.

Quick Answer: A simple febrile seizure in a well-appearing 6-month to 5-year-old typically needs no CT or LP after the first event; counsel recurrence. An unprovoked seizure goes to neurology — do not start a chronic AED in primary care without a specialist. Absence is brief uninterruptible staring; ADHD staring is interruptible. Image headache for red flags (worst, morning vomiting, papilledema, focal, thunderclap). Concussion: out the same day, then a return-to-learn ladder before full return-to-play. Breath-holding is not epilepsy. Infantile spasms are refer NOW.

Febrile seizures: simple versus complex

A febrile seizure occurs with fever in a developmentally typical child, classically 6 months to 5 years, without a central-nervous-system infection. It is the most common childhood seizure.

After a first simple febrile seizure, if the child is well-appearing, the exam shows a typical viral source or no meningitis signs, and immunization status is not a special meningococcal/Hib problem, routine CT and lumbar puncture are not indicated. AAP teaching: LP is indicated when meningitis or encephalitis is suspected (ill appearance, nuchal rigidity, petechiae, prolonged focal seizure). LP is an option in infants 6–12 months who are unimmunized or whose immunization status is unknown, and in children already given antibiotics, because meningeal signs can be unreliable. Do not CT a recovered, playful toddler “to rule out a tumor” after a 3-minute generalized febrile seizure.

Counsel recurrence. Roughly one in three children will have another febrile seizure; risk is higher with younger age at the first event, family history, and a relatively low fever at the time of the seizure. Recurrence is frightening and usually still benign. Teach fever recognition, rescue positioning, when to call EMS (seizure ≥5 minutes, focal, repeated, or incomplete recovery), and that chronic daily antiepileptic drugs are not indicated in primary care for simple febrile seizures. Abortive rectal diazepam or nasal midazolam is a neurology/ED decision for selected recurrent or prolonged cases, not a reflex after one brief simple event.

Complex febrile seizures, abnormal neurodevelopment, and a child who is not well-appearing need a harder look — including infection workup and neurology — not automatic home acetaminophen as the only plan.

Unprovoked seizure, AEDs, absence versus ADHD staring

A first unprovoked seizure (no fever, no acute metabolic trigger you have already treated) is a pediatric neurology referral. Obtain glucose in the acute setting, consider electrolytes when indicated, and get an ECG if the “seizure” might have been arrhythmic syncope. Imaging decisions for a first unprovoked seizure belong with the acute-care and neurology teams; a well child who fully recovered may not need an emergency CT in the office. Do not start a chronic antiepileptic drug in primary care without a specialist. Choice of levetiracetam versus oxcarbazepine versus ethosuximide is not a CPNP-PC sample-closet skill. You may give rescue counseling and safety teaching (water, heights, driving for adolescents per state law) while the referral is in motion.

Absence epilepsy is typical in school-age children: dozens of brief (seconds) staring spells per day, unresponsive during the spell, no postictal sleepiness, sometimes eyelid flutter or automatisms, and often provoked by hyperventilation in clinic. EEG shows 3-Hz spike-and-wave. Teachers report the child “blanks out” during lessons.

ADHD staring is inattentive drifting that can be interrupted by calling the name, touching a shoulder, or a novel stimulus. It is not a 10-second freeze with unresponsiveness and immediate return. Do not start ethosuximide from a Vanderbilt form. Do not start a stimulant as the only plan for uninterruptible daily staring — that child needs an absence evaluation.

Headache: migraine, tension, secondary red flags

Primary migraine in children is often bifrontal (not always unilateral), with photophobia or phonophobia, nausea, a desire to lie down, and a family history. Attacks last hours; the child looks miserable and then is well between episodes. Tension-type headache is a pressing, band-like, milder pain without vomiting or severe photophobia, often with stress or screen load.

Secondary headache is the imaging question. Red flags:

• Worst headache of life or a sudden thunderclap
• Morning vomiting or headache that wakes the child from sleep
• Papilledema, diplopia, or a new focal neurologic finding
• Progressive worsening, personality or school collapse, ataxia, or a young child with an atypical first severe headache
• Known VP shunt, immunosuppression, or head trauma with red-flag signs

Image if red flags are present. Emergent CT is for thunderclap, acute trauma with deterioration, or a child who is not safe to wait. MRI (often with neurology guidance) is preferred for subacute concerning features when the child is otherwise stable. Do not CT every tension headache. Treat migraine with early ibuprofen or acetaminophen, rest, hydration, and a trigger/sleep plan; frequent or disabling migraine and any red-flag case need a tighter follow-up or neurology path. Opioids are not pediatric headache care (see 15.3).

Concussion: same-day removal, then return-to-learn

Section 15.2 already locked the field rule: a sport-related concussion is a clinical diagnosis; remove from play the same day; no same-day return; CT is for intracranial-injury red flags, not to prove concussion. This section adds return-to-learn (RTL).

Cognitive rest is relative, not a week in a dark room as a default. After 24–48 hours of reduced load if symptoms are prominent, start a graded school plan:

1. Symptom-limited activity at home (light reading, short walks)
2. Schoolwork at home in brief blocks
3. Partial school day, extra time, no tests, reduced screen and noise, rest breaks
4. Full days with accommodations
5. Full academics without concussion accommodations

Advance a step when symptoms stay stable or improve. Return-to-learn generally precedes full return-to-play. An athlete is not cleared for contact while still needing a half-day and test waivers because of headache and fog. Return-to-play remains a stepwise progression (light aerobic → sport-specific → noncontact drills → full-contact practice → game) with written clearance. Worsening at a step means drop back. Second-impact danger is why same-day return is forbidden.

School nurses and teachers need a written RTL note. Persistent symptoms beyond a couple of weeks, especially with migraine history or inadequate rest/overstimulation, need a structured concussion clinic or neurology path — not endless light duty without a plan.

Breath-holding spells and infantile spasms

Breath-holding spells occur in toddlers (often 6 months to 6 years). Cyanotic spells follow crying or frustration: a long cry, apnea, cyanosis, brief loss of consciousness, sometimes a few jerks, then rapid recovery. Pallid spells follow a startle or minor bump: pallor, limpness, brief asystole-range reflex. The child is well afterward. This is not epilepsy. EEG is unnecessary when the history is classic. Check iron status — iron deficiency is associated, and treatment can reduce spells. Do not start a chronic AED. Teach that the spell is involuntary, protect the airway during it, and avoid reinforcing prolonged tantrums as the only strategy without also treating iron if deficient.

Infantile spasms (West syndrome) are an emergency. Typical age is about 3–12 months (often 4–8). Clusters of sudden flexor or extensor spasms (jackknife, salaam) especially around sleep transitions; a developmental plateau or regression; EEG hypsarrhythmia at neurology. Caregivers may call them colic, a startle, or reflux. Refer NOW — same-day pediatric neurology or ED that can obtain an urgent EEG — because delayed treatment worsens developmental outcome. You do not trial GER medication for a week while waiting to see if the clusters fade.

Exam traps

• CT after every simple febrile seizure in a recovered, well child.
• Starting a chronic AED from primary care after one unprovoked seizure.
• Calling absence “ADHD” because the teacher mentioned staring.
• Imaging every tension headache — or not imaging thunderclap, papilledema, or morning vomiting.
• Same-day sport return, or full contact before return-to-learn is complete.
• AEDs for breath-holding.
• Watchful waiting on infantile spasms.

Counsel the simple febrile seizure, refer the unprovoked one, interrupt the ADHD stare on purpose, image the red-flag headache, write the school ladder after concussion, reassure true breath-holding, and move West syndrome out of the office today.