Noninfectious · Common
Headaches
Migraine vs. tension vs. red flags — the approach is in knowing what to rule out first.
🚨 Red Flag Headaches — "SNOOP4"
Systemic symptoms/signs (fever, weight loss, immunocompromised) · Neurologic signs (focal deficits, altered MS, papilledema) · Onset sudden/severe ("thunderclap") · Older age (new pattern) · Postural component (worse lying flat) · Progressive worsening · Prior headache history change · Precipitated by Valsalva → neuroimaging required.
| Type | Character | Location | Associated Sx | Duration | Treatment |
|---|---|---|---|---|---|
| Migraine | Moderate-severe, throbbing/pulsating, worsened by activity | Unilateral (bilateral more common in children than adults) | Nausea/vomiting, photophobia, phonophobia; may have aura (visual, sensory, speech) | 2–72h (4–72h adults; 1–72h pediatric — shorter) | Acute: NSAIDs (ibuprofen ⭐), triptans (age ≥6–12); Preventive: amitriptyline, topiramate, propranolol, cyproheptadine (young children) |
| Tension-type | Mild-moderate, pressure/tightening, NOT throbbing; NOT worsened by activity | Bilateral; "band-like" around head | No nausea/vomiting; mild photo/phonophobia (not both) | 30min–7 days | NSAIDs, acetaminophen; stress reduction, sleep hygiene; amitriptyline for prevention |
| Cluster | Severe, stabbing, unilateral periorbital | Strictly unilateral, periorbital/temporal | Autonomic: lacrimation, rhinorrhea, ptosis, miosis, conjunctival injection; restless/agitated (not still like migraine) | 15–180 min; clusters over weeks-months | Acute: high-flow O₂ (100%) ⭐, sumatriptan; Prevention: verapamil |
Migraine — Pediatric Pearls
- Most common primary headache requiring treatment in children
- Bilateral in 60–70% of children (unlike adults who are unilateral)
- Duration shorter in children — can be as brief as 1 hour
- Abdominal migraine: recurrent periumbilical pain without headache — migraine equivalent in young children
- Cyclic vomiting syndrome — also a migraine equivalent
- Aura: typically visual (scotoma, zigzag lines), precedes headache by 20–60 min
- Triggers: sleep changes, stress, skipping meals, dehydration, hormonal changes, strong odors
Acute Migraine Treatment
1
NSAIDs — first-line ⭐
Ibuprofen 10 mg/kg at onset. Naproxen sodium also effective. Take early — most effective if given before headache peaks.
2
Triptans
Sumatriptan/naratriptan nasal spray (age ≥12); rizatriptan (age ≥6). For moderate-severe or NSAID failure. Vasoconstrict → avoid in hemiplegic migraine or basilar migraine.
3
Anti-emetics
Ondansetron, prochlorperazine — for nausea; prochlorperazine + diphenhydramine in ED setting.
4
Rest in dark quiet room
Supportive — reduce sensory stimulation.
Migraine Prevention
- Indicated if: ≥4 migraines/month, significant disability, acute meds overused
- Amitriptyline — most commonly used in pediatrics; also helps sleep + mood
- Topiramate — effective; SE: cognitive dulling ("dopamax"), kidney stones, teratogenic
- Propranolol — avoid in asthma, depression
- Cyproheptadine — preferred in young children; antihistamine with antiserotonin properties
- CGRP monoclonal antibodies (erenumab) — emerging in adolescents
- Lifestyle: regular sleep, meals, hydration, stress management
Noninfectious · Infant–Toddler
Breath Holding Spells
Terrifying to watch — but benign, self-limited, and never require treatment.
🎨 Analogy
Breath holding spells are like a brief circuit breaker trip in the brainstem. The child cries, exhales, and then — triggered by the vagal response to emotional upset or pain — the body briefly pauses breathing. The brain detects hypoxia and reboots with a brief loss of consciousness or seizure-like movement. The circuit resets in seconds, the child recovers completely, and nothing is damaged. The hardest part isn't the spell itself — it's convincing terrified parents that it's benign.
Cyanotic vs. Pallid
- Cyanotic (most common):
- Triggered by frustration, anger, or upset
- Child cries, exhales fully, turns blue, loses consciousness briefly
- May have brief tonic posturing or jerking (looks like seizure)
- Mechanism: vagal → apnea → hypoxia → brief LOC
- Pallid:
- Triggered by pain or sudden fright (even mild)
- Child cries little/not at all, turns pale/white, loses tone and consciousness
- Mechanism: vagal → cardiac pause → ↓ cerebral perfusion → LOC
Key Clinical Features
- Age: 6 months – 6 years (peak 1–2 years)
- Always triggered by stimulus (crying, pain, fright) ⭐
- Full recovery within seconds to minutes
- Child returns to normal behavior immediately after
- NO postictal state (distinguishes from epileptic seizure) ⭐
- EEG normal between and during spells
- Resolve spontaneously by age 5–6 in most cases
- Associated: iron deficiency anemia (increases frequency) — check CBC
Management
- Reassure parents — most important intervention
- No treatment needed for typical spells
- During spell: place child on side (recovery position), do not restrain
- Check CBC — treat iron deficiency if present (reduces spell frequency)
- Avoid reinforcing behavior — calm, consistent response
- EEG NOT routinely indicated unless atypical features
- Neuroimaging NOT needed for typical presentation
💡 Board Pearl — Seizure vs. BHS
Breath holding spell: always triggered → cyanosis/pallor → LOC → rapid recovery, NO postictal state. Epileptic seizure: may be unprovoked, postictal state (drowsy/confused after), EEG abnormal. BHS does not require anticonvulsants.
Noninfectious · Childhood
Tic Disorders
Simple tics · Tourette syndrome — repetitive, involuntary movements or sounds the child often can't suppress.
Definitions & Types
- Tic: sudden, rapid, recurrent, nonrhythmic motor movement or vocalization
- Simple motor tics: eye blinking, nose twitching, shoulder shrugging, head jerking ⭐
- Complex motor tics: facial grimacing, touching, jumping, obscene gestures (copropraxia)
- Simple vocal tics: throat clearing, sniffing, grunting ⭐ — most common!
- Complex vocal tics: echolalia (repeating others), palilalia (repeating self), coprolalia (obscene words — rare, in minority of Tourette's)
- Premonitory urge: uncomfortable sensation before tic that is relieved by performing it
Tourette Syndrome — DSM-5 Criteria
- ≥2 motor tics AND ≥1 vocal tic (not necessarily simultaneously)
- Present for >1 year
- Onset before age 18
- NOT due to substance or other medical condition
- Peak severity around age 10–12; often improves in adolescence/adulthood
- Male > Female (3–4:1)
- Coprolalia (obscene words) present in only ~10% — NOT required for diagnosis
- Comorbidities: ADHD (~50%), OCD (~40%), anxiety, learning disabilities
Management
- Education and reassurance — many tics mild and not requiring treatment
- CBIT (Comprehensive Behavioral Intervention for Tics) — first-line behavioral therapy ⭐; habit reversal training
- Alpha-2 agonists (guanfacine, clonidine) — first-line pharmacotherapy; also treat comorbid ADHD
- Antipsychotics (fluphenazine, haloperidol, aripiprazole, risperidone) — for severe/refractory tics
- Topiramate — moderate evidence for tic reduction
- Treat comorbid ADHD and OCD
- Tics worsen with stress, excitement, fatigue, illness — wax and wane
Infectious · Emergency
Meningitis
Inflammation of the meninges — bacterial is a true emergency, viral is usually self-limited.
🎨 Analogy
The meninges are the brain's three-layer protective wrapping — dura, arachnoid, and pia mater — with the CSF flowing in between like shock-absorbing fluid. When bacteria or viruses invade this space, the immune response generates massive inflammation inside a closed, rigid compartment. Pressure builds (↑ ICP), blood supply to the brain gets compromised, and the classic triad of fever + headache + stiff neck appears. In bacterial meningitis, this inflammation can progress within hours to herniation, hearing loss, and death — which is why this is a don't-wait-for-labs diagnosis.
Bacterial Meningitis — By Age
- Neonates (0–28 days): GBS (Group B Strep) ⭐, E. coli, Listeria monocytogenes
- 1–3 months: GBS, E. coli, S. pneumoniae, N. meningitidis
- 3 months–18 years: S. pneumoniae ⭐ (most common overall), N. meningitidis
- Adolescents (esp. college): N. meningitidis — vaccine-preventable!
- H. influenzae type b — now rare due to Hib vaccine
Clinical Presentation
- Classic triad: fever + headache + neck stiffness (nuchal rigidity) ⭐
- Photophobia, phonophobia
- Altered mental status, irritability
- Kernig's sign: hip flexed 90° → painful resistance to knee extension
- Brudzinski's sign: passive neck flexion → involuntary hip/knee flexion
- Bulging fontanelle in infants (classic sign in neonates)
- Petechial/purpuric rash → N. meningitidis ⭐ — meningococcemia → septic emboli
- Neonates: nonspecific — fever, poor feeding, irritability, bulging fontanelle, high-pitched cry
- Waterhouse-Friderichsen syndrome: bilateral adrenal hemorrhage → septic shock from meningococcemia
Diagnosis — CSF Analysis ⭐
| Finding | Normal | Bacterial | Viral | TB/Fungal |
|---|---|---|---|---|
| Appearance | Clear | Cloudy/turbid | Clear | Clear/xanthochromic |
| WBC | <5 | ↑↑↑ PMNs | ↑ lymphocytes | ↑ lymphocytes |
| Protein | 15–45 | ↑↑↑ | Normal/↑ | ↑↑ |
| Glucose | >60% serum | ↓↓ (<40) | Normal | ↓ |
| Gram stain | Negative | + (60–90%) | Negative | Negative |
Management
1
Blood cultures + LP → empiric antibiotics STAT
Do NOT delay antibiotics for imaging if LP is safe. If LP must wait → draw blood cultures then give antibiotics immediately.
2
Empiric antibiotics by age
Neonates: ampicillin + gentamicin (or cefotaxime). 1–3 months: ampicillin + cefotaxime/ceftriaxone. ≥3 months: vancomycin + ceftriaxone (covers resistant pneumococcus).
3
Dexamethasone (≥6 weeks, before or with first abx dose)
Reduces inflammation → ↓ hearing loss risk. Give BEFORE or with first antibiotic dose — not after. Benefit primarily for H. influenzae and S. pneumoniae.
4
Supportive care + ICP management
Seizure management, fluid balance, ↑ ICP treatment if herniation risk.
⚠️ Contraindications to LP Before CT
Get CT first if: papilledema, focal neurologic deficits, altered consciousness, immunocompromised, seizure within 1 week. But do NOT delay antibiotics — draw blood cultures and give antibiotics while waiting for CT.
💡 Viral (Aseptic) Meningitis
Most common cause: enteroviruses (especially in summer/fall). Also: HSV (treat empirically with acyclovir until ruled out), mumps, HIV. CSF: lymphocytic pleocytosis, normal glucose, mildly ↑ protein. Treatment: supportive (unless HSV → acyclovir). Generally self-limited.
Infectious · Brain Parenchyma
Encephalitis
Inflammation of the brain itself — altered mental status is the key distinguishing feature from meningitis.
Encephalitis vs. Meningitis
- Meningitis: inflammation of the meninges → meningeal signs (stiff neck, Kernig's, Brudzinski's); normal mental status in early/mild cases
- Encephalitis: inflammation of brain parenchyma → altered mental status/behavior ⭐ — confusion, personality change, psychosis, focal deficits, seizures
- Meningoencephalitis: both meningeal + brain signs — most common presentation
- Key distinction: altered mental status = encephalitis until proven otherwise
Etiology & Presentation
- Most common: HSV-1 (herpes simplex) — most important treatable cause ⭐
- Also: enteroviruses, arboviruses (West Nile, La Crosse, Eastern equine), CMV, EBV, VZV, rabies
- Autoimmune: anti-NMDA receptor encephalitis (young women, ovarian teratoma) — psychiatric prodrome + seizures + movement disorder
- Fever + headache + altered mental status + seizures + focal deficits
- HSV encephalitis: temporal lobe predilection → personality changes, memory deficits, olfactory hallucinations
Diagnosis & Management
- MRI brain (with contrast) — more sensitive than CT; temporal lobe changes = HSV ⭐
- LP: CSF — lymphocytic pleocytosis, ↑ protein, normal/↓ glucose; PCR for HSV, enteroviruses
- EEG — PLEDS (periodic lateralizing epileptiform discharges) in temporal lobe = HSV pattern
- Empiric acyclovir immediately — do NOT wait for PCR results if HSV encephalitis suspected ⭐
- Anti-NMDA: immunotherapy (IVIG, steroids, plasmapheresis) + remove teratoma
- Supportive: seizure management, ICP management, airway protection
Seizures · Febrile & Afebrile
Febrile Seizures
The most common seizure type in children — and usually the most benign.
🎨 Analogy
Think of the developing brain as an electrical system still being insulated. In young children, the insulation (myelin) isn't complete, and the temperature regulation circuits are still immature. When fever spikes rapidly, it's like a power surge hitting poorly insulated wiring — the circuit trips briefly, causing a seizure. The brain isn't damaged; the wiring just isn't ready for that much heat yet. As the child grows and the insulation completes, febrile seizures stop occurring — the system becomes more resilient to surges.
Simple vs. Complex Febrile Seizure
| Feature | Simple | Complex |
|---|---|---|
| Duration | <15 minutes ⭐ | ≥15 minutes |
| Recurrence | None in 24h | Recurs in 24h |
| Focality | Generalized | Focal component |
| Age | 6 months–5 years | Any febrile age |
| LP needed? | Only if meningitis suspected | Consider strongly |
| EEG needed? | No ⭐ | Consider |
| Epilepsy risk | 1–2% (same as general pop) | ↑↑ (up to 10%) |
| Treatment | Reassure; no prophylaxis | Workup + consider prophylaxis |
Febrile Seizure — Key Pearls
- Most common seizure type in children — 2–5% of children age 6 months–5 years
- Peak age: 18 months
- Simple febrile seizure: NO routine LP, EEG, neuroimaging, or antiepileptics ⭐
- LP if: child <12 months, signs of meningism, complex seizure, immunocompromised
- Recurrence risk: ~30% overall; higher if first seizure at young age, low fever at onset, family history
- Antipyretics do NOT prevent febrile seizures
- Rectal diazepam or intranasal midazolam for prolonged seizures at home
- Parent reassurance is the most important intervention
Status Epilepticus
- Seizure lasting ≥5 minutes OR ≥2 seizures without recovery between
- Step 1 (0–5 min): ABCs, O₂, IV/IO access, glucose check
- Step 2 (5–20 min): Benzodiazepine ⭐ — lorazepam IV (first-line); diazepam rectal/IV; midazolam IM/IN if no IV access
- Step 3 (20–40 min): 2nd-line antiepileptic — fosphenytoin, levetiracetam, or valproate IV
- Step 4 (>40 min — refractory): phenobarbital, propofol, or midazolam infusion; ICU intubation
- Check: glucose, electrolytes, Ca, Mg, toxic screen, antiepileptic levels
Epilepsy · Seizure Classification
Epilepsy
Two or more unprovoked seizures — know your seizure types, syndromes, and drugs.
| Seizure Type | Onset | Clinical Features | EEG | Drug of Choice |
|---|---|---|---|---|
| Absence (Petit Mal) | Generalized | Brief (5–30 sec) staring spells, eye blinking; abrupt onset/offset; NO postictal state; multiple per day; precipitated by hyperventilation ⭐ | 3 Hz spike-and-wave ⭐ | Ethosuximide ⭐ (pure absence); valproate (absence + other); lamotrigine. Avoid carbamazepine — worsens absence! |
| Tonic-Clonic (Grand Mal) | Generalized | Tonic (stiffening) → clonic (rhythmic jerking) → postictal confusion/sleep ⭐ | Generalized spike-wave during; diffuse slowing postictal | Valproate, levetiracetam, lamotrigine, carbamazepine (if focal onset) |
| Infantile Spasms (West Syndrome) | Generalized | Clusters of sudden flexion/extension spasms; onset 3–12 months ⭐; developmental regression | Hypsarrhythmia ⭐ (chaotic high-amplitude pattern) | ACTH ⭐ or vigabatrin (especially TSC); ketogenic diet |
| Focal (Partial) — Aware | Focal | Motor, sensory, autonomic, or psychic symptoms WITHOUT loss of consciousness; aura | Focal sharp waves | Carbamazepine ⭐, oxcarbazepine, levetiracetam, lamotrigine |
| Focal — Impaired Awareness | Focal | Loss of awareness; automatisms (lip smacking, hand movements); postictal confusion | Focal theta/sharp waves, temporal | Carbamazepine, oxcarbazepine, levetiracetam |
| Lennox-Gastaut Syndrome | Generalized | Multiple seizure types (tonic, atonic "drop attacks," absence); onset 2–8 years; severe ID; refractory | Slow spike-wave (<2.5 Hz) ⭐ | Valproate, lamotrigine, rufinamide, clobazam; VNS; corpus callosotomy for drop attacks |
| BECTS (Benign Rolandic Epilepsy) | Focal | Nocturnal facial/tongue tingling + twitching; drooling; speech arrest; normal development ⭐ | Centrotemporal spikes ⭐ | Often no treatment needed — outgrows by adolescence ⭐ |
Antiepileptic Drug Pearls ⭐
- Ethosuximide — ONLY for absence seizures; worsens tonic-clonic
- Valproate — broad spectrum; avoid in young women (teratogenic — neural tube defects, PCOS); monitor LFTs
- Carbamazepine — focal seizures; worsens absence + myoclonic; SIADH; SJS risk in HLA-B*1502
- Levetiracetam (Keppra) — broad spectrum; SE: behavioral/mood changes ("Keppra rage")
- Lamotrigine — broad spectrum; slow titration (SJS risk if titrated too fast); safe in pregnancy
- Phenobarbital — neonatal seizures first-line; SE: sedation, cognitive effects
- ACTH — infantile spasms; SE: hypertension, immunosuppression, Cushingoid
Neonatal Seizures
- Most common in first 1–3 days of life
- Causes: HIE ⭐ (most common), hypoglycemia, hypocalcemia, hyponatremia, meningitis, IVH, metabolic (pyridoxine deficiency)
- Presentations: subtle (apnea, eye deviation, lip smacking), clonic, tonic, myoclonic
- Treatment: phenobarbital first-line; fosphenytoin second; levetiracetam; treat underlying cause
- Check glucose immediately in any neonate with seizures
- Pyridoxine-dependent seizures: refractory neonatal seizures → trial of IV pyridoxine (B6)
Neurologic Injury
Closed Head Injury · Mild TBI (Concussion)
Concussion is a functional injury, not structural — symptoms are real, imaging is usually normal.
Concussion (mTBI) — Definition
- Traumatic brain injury caused by biomechanical force → transient neurologic dysfunction
- Structural imaging (CT/MRI) typically normal ⭐ — functional injury
- Symptoms develop within minutes to hours of injury:
- Physical: headache, dizziness, nausea, vomiting, visual changes, fatigue, light/noise sensitivity
- Cognitive: feeling foggy, slowed processing, difficulty concentrating, memory problems
- Emotional: irritability, sadness, anxiety, emotional lability
- Sleep: insomnia or hypersomnia
- LOC is NOT required for concussion diagnosis
CT Head — When to Image
- PECARN rules (Pediatric Emergency Care Applied Research Network) — validated tool
- High risk (CT recommended):
- GCS <15 at 2 hours post-injury
- Suspected skull fracture (bulging fontanelle, step-off, Battle's sign, raccoon eyes)
- Altered mental status (agitation, repetitive questioning, slowed response)
- LOC >5 seconds (<2 years) or any (≥2 years)
- Intermediate: observation vs. CT based on physician judgment
- CT NOT indicated for routine concussion with normal neuro exam
- Avoid unnecessary radiation — use clinical decision rules
Concussion Management
1
Physical + cognitive rest (48h)
Immediate: remove from play, no school if symptomatic. Brief rest (not prolonged isolation) — then gradual return to activity.
2
Gradual return to learn (RTL)
Step-wise school reintegration: rest → school partial day → full day with accommodations → full day.
3
Gradual return to play (RTP)
6-step protocol: rest → light aerobic → sport-specific → non-contact drills → full contact → return to play. Each step min 24h. Asymptomatic at each step required before advancing.
4
Symptom management
Acetaminophen for headache (avoid NSAIDs acutely — bleeding risk). Sleep hygiene. Amitriptyline for persistent headache. Vision therapy if visual symptoms persist.
Second Impact Syndrome & Red Flags
- Second impact syndrome: second concussion before full recovery from first → catastrophic cerebral edema → death or severe disability. VERY rare but catastrophic. Prevention = strict RTP protocol.
- Post-concussion syndrome: symptoms persist >4 weeks — headache, cognitive fog, mood changes, sleep disturbance; risk factors: female, prior concussion, anxiety/depression
- Red flags requiring emergent CT:
- Worsening headache
- Repeated vomiting (>2 episodes)
- Seizure
- Focal neurologic deficits
- Deteriorating mental status
- Signs of skull fracture
Board Quick Quiz · Flip to Reveal
Neurology Flash Cards
tap any card to flip ↓
What are the "SNOOP4" red flags for headache that require neuroimaging?
Systemic symptoms · Neurologic signs · Onset sudden/thunderclap · Older age new pattern · Postural component · Progressive worsening · Prior headache change · Precipitated by Valsalva.
First-line acute treatment for pediatric migraine?
Ibuprofen (NSAIDs) ⭐ — give early at headache onset. Triptans for moderate-severe or NSAID failure. Rest in dark quiet room. High-flow O₂ = cluster headache treatment.
2-year-old cries, turns blue, goes limp, and briefly loses consciousness. Recovers immediately, no confusion. Diagnosis?
Breath holding spell (cyanotic type). Key: triggered event → no postictal state → rapid full recovery. NO routine EEG, neuroimaging, or anticonvulsants needed. Check CBC for iron deficiency.
Most common organisms in bacterial meningitis in a 3-month-old? A 10-year-old?
3 months: GBS, E. coli, S. pneumoniae, N. meningitidis. 10 years: S. pneumoniae ⭐ (most common overall), N. meningitidis. Empiric tx ≥3 months: vancomycin + ceftriaxone.
CSF in bacterial vs. viral meningitis — what are the key differences?
Bacterial: cloudy, ↑↑ PMNs, ↑↑ protein, ↓↓ glucose. Viral: clear, ↑ lymphocytes, normal/↑ protein, normal glucose. Gram stain positive in bacterial (~60–90%).
When and with what do you give dexamethasone in bacterial meningitis?
Give dexamethasone BEFORE or WITH the first antibiotic dose (not after). Reduces inflammation → decreases hearing loss risk. Most benefit for H. influenzae and S. pneumoniae.
18-month-old has a 2-minute generalized tonic-clonic seizure with fever of 39.5°C. First time. What do you do?
Simple febrile seizure. No routine LP, EEG, neuroimaging, or antiepileptics needed. Reassure parents. Find and treat source of fever. Recurrence risk ~30%. Antipyretics don't prevent recurrence.
EEG shows 3 Hz spike-and-wave pattern. Child has staring spells triggered by hyperventilation. Diagnosis and drug of choice?
Absence epilepsy. Drug of choice: ethosuximide ⭐. If also tonic-clonic: valproate. Never use carbamazepine — it worsens absence seizures.
6-month-old with clusters of sudden arm-raising/flexion spasms, developmental regression, and chaotic EEG. Diagnosis and treatment?
Infantile spasms (West syndrome). EEG: hypsarrhythmia ⭐. Treatment: ACTH ⭐ or vigabatrin (especially if tuberous sclerosis). Urgently treat — prolonged spasms → severe developmental disability.
Child with nocturnal facial twitching, drooling, speech arrest, normal development, centrotemporal spikes on EEG. Diagnosis and treatment?
BECTS (Benign Rolandic Epilepsy). Often no treatment needed — outgrows by adolescence. Most evidence-based — reassure and observe unless seizures are frequent or disruptive.
Status epilepticus — what is the definition and first-line treatment?
Seizure ≥5 minutes OR ≥2 seizures without recovery. First-line: benzodiazepine ⭐ (lorazepam IV preferred; diazepam rectal; midazolam IM/IN if no IV). Then 2nd line: fosphenytoin, levetiracetam, or valproate.
Teen athlete takes a second hit before recovering from a concussion. What catastrophic syndrome can result?
Second Impact Syndrome — catastrophic cerebral edema from second concussion before full recovery. Can be fatal or cause severe permanent disability. Prevention: strict graduated return-to-play protocol. Never return same day.