eMedicine Specialties > Neurology > Pediatric Neurology
Shuddering Attacks
Updated: Sep 11, 2008
Introduction
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.1 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
History
- Parents describe the paroxysmal episodes of shuddering attacks 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 neurologic 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.
Differential Diagnoses
| Absence Seizures | Frontal Lobe Epilepsy |
| Benign Childhood Epilepsy | Psychogenic Nonepileptic Seizures |
| Complex Partial Seizures | Seizures and Epilepsy: Overview and
Classification |
| Dizziness, Vertigo, and Imbalance | Simple Partial Seizures |
| Epilepsy, Juvenile Myoclonic | Syncope and Related Paroxysmal Spells |
| Essential Tremor | Tonic-Clonic Seizures |
| Febrile Seizures |
Other Problems to Be Considered
Benign epilepsy syndromes
Tonic seizures
For more information on epilepsy, see Medscape's Epilepsy Resource Center.
Workup
Laboratory Studies
No laboratory studies are helpful for the diagnosis of shuddering attacks.
Imaging Studies
Brain CT scan or MRI may be performed because epileptic seizures are in the differential diagnosis. However, the results of these studies are normal.
Procedures
- Reviewing the appearance of a typical episode as captured on video camera by the parents is helpful in suggesting the diagnosis; however, prolonged electroencephalography (EEG) video monitoring to record a typical episode definitively differentiates shuddering attacks from epileptic seizures.2
- 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 EEG3 without video recording is useful for diagnosis but does not record the clinical event.
- Routine EEG results are typically normal.
Treatment
Medical Care
In most cases, no treatment is necessary for shuddering attacks.
- 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
Medications are rarely used for shuddering attacks. However, propranolol may have some efficacy.
Beta-adrenergic blockers
These agents compete with beta-adrenergic agonists for available beta-receptor sites.
Propranolol (Inderal)
Has membrane-stabilizing activity and decreases automaticity of contractions.
Dosing
Adult
40 mg PO bid initially; increase as tolerated; not to exceed 240-320 mg/d divided bid/tid
Pediatric
Not established
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
Contraindications
Documented hypersensitivity; uncompensated congestive heart failure; bradycardia, cardiogenic shock; A-V conduction abnormalities
Precautions
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
Follow-up
Prognosis
Shuddering attack 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
Medicolegal Pitfalls
Shuddering attacks should not be mistakenly diagnosed as epileptic seizures. The diagnosis should always be confirmed by EEG-video monitoring.4
References
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].
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].
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].
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].
Keywords
shuddering attacks, benign paroxysmal spells of childhood, mimic epileptic seizure, shiver-like movement, tremor, electroencephalography, EEG, seizures
Contributor Information and Disclosures
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, MD 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
Disclosure: Nothing to disclose.
Medical Editor
Raj D Sheth, MD, Division Chief, Division of Pediatric Neurology, Department of Pediatrics, Nemours Alfred I duPont Hospital for Children
Raj D Sheth, MD is a member of the following medical societies: American Academy of Neurology, American Academy of Pediatrics, American Epilepsy Society, American Neurological Association, and Child Neurology Society
Disclosure: Nothing to disclose.
Pharmacy Editor
Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.
Managing Editor
Kenneth J Mack, MD, PhD, Senior Associate Consultant, Department of Child and Adolescent Neurology, Mayo Clinic
Kenneth J Mack, MD, PhD is a member of the following medical societies: American Academy of Neurology, Child Neurology Society, Phi Beta Kappa, and Society for Neuroscience
Disclosure: Nothing to disclose.
CME Editor
Paul E Barkhaus, MD, Professor, Department of Neurology, Medical College of Wisconsin; Director of Neuromuscular Diseases, Milwaukee Veterans Administration Medical Center
Paul E Barkhaus, MD is a member of the following medical societies: American Academy of Neurology, American Association of Neuromuscular and Electrodiagnostic Medicine, and American Neurological Association
Disclosure: Nothing to disclose.
Chief Editor
Amy Kao, MD, Assistant Professor, Department of Neurology, Department of Pediatrics, Division of Pediatrics, Oregon Health and Science University; Consulting Staff, Shriners Hospital
Amy Kao, MD is a member of the following medical societies: American Academy of Neurology, American Academy of Pediatrics, American Epilepsy Society, and Child Neurology Society
Disclosure: Nothing to disclose.