William Matuja and Erich Schmutzhard contributed equally to the conceptual work of the manuscript.
The head nodding syndrome—Clinical classification and possible causes
Article first published online: 22 MAY 2008
Wiley Periodicals, Inc. © 2008 International League Against Epilepsy
Volume 49, Issue 12, pages 2008–2015, December 2008
How to Cite
Winkler, A. S., Friedrich, K., König, R., Meindl, M., Helbok, R., Unterberger, I., Gotwald, T., Dharsee, J., Velicheti, S., Kidunda, A., Jilek-Aall, L., Matuja, W. and Schmutzhard, E. (2008), The head nodding syndrome—Clinical classification and possible causes. Epilepsia, 49: 2008–2015. doi: 10.1111/j.1528-1167.2008.01671.x
- Issue published online: 1 DEC 2008
- Article first published online: 22 MAY 2008
- Accepted April 14, 2008; Early View publication May 22, 2008.
- Head nodding;
- Onchocerca volvulus;
Purpose: In the 1960s in Tanzania, L. Jilek-Aall observed a seizure disorder characterized by head nodding (HN). Decades later, “nodding disease,” reminiscent of what was seen in Tanzania, was reported from Sudan. To date this seizure disorder has not been classified and possible causes still remain obscure.
Methods: In a prospective study in southern Tanzania, we evaluated 62 patients with HN. Selected patients underwent blood (n = 51) and cerebrospinal fluid (CSF) (n = 48) analyses. Others were chosen for MRI (n = 12) and EEG (n = 10).
Results: Seizure type was classified as “head nodding only” and “head nodding plus,” the latter being combined with other types of seizure (n =34). During HN, consciousness was impaired in 11 patients (17.7%) and supportive signs of epileptic seizures were described by 15 (24.2%) patients. Precipitating factors were confirmed by 11 (17.7%) patients. Fifty-six (90.3%) patients had at least one relative with epilepsy. EEG confirmed interictal epileptic activity in two patients and unspecific changes in four patients. MRI showed hippocampus pathologies (n = 5) and gliotic changes (n = 5). Skin polymerase chain reaction (PCR) positivity for Onchocerca volvulus was significantly associated with lesions on MRI. However, PCR of the CSF was negative in all cases.
Conclusions: We present a comprehensive clinical description of the “HN syndrome,” possibly a new epilepsy disorder in sub-Saharan Africa. MRI lesions and their association with positive skin PCR for O. volvulus despite negative PCR of the CSF is intriguing and deserves attention. Furthermore, the high prevalence of hippocampus sclerosis and familial clustering of epilepsy may point toward other potential pathogenetic mechanisms.