A 9-year-old Arabic male with a 5 year history of recurrent episodes of severe vomiting and unusual frightened behavior, was eventually diagnosed with ictal vomiting, in a report from Schneider Children’s Medical Center of Israel, Petah Tiqva, and Sackler Faculty of Medicine, Tel Aviv University, Israel. Multiple interictal EEGs were all normal, but an EEG obtained at the time of an attack at age 6 years showed left frontotemporal and bilateral sharp waves followed by delta activity postictally. Symptoms during the ictal recording included vomiting, staring ahead, and chewing movements. MRI and laboratory tests for metabolic and systemic disorders were negative. Treatment with propranolol for possible migraine was successful for 7 months, and a trial of carbamazepine was effective for 1 year, followed by relapse. Topiramate was effective in controlling attacks for 1 year when vomiting recurred, and an interictal EEG showed irregular sharp and slow waves of left temporal origin and bursts of bilateral spike-wave discharges. Seizures were subsequently controlled with topiramate and valproate. The child is attending school but has attention and learning disabilities. [1]

COMMENT. That cyclic or periodic attacks of vomiting may represent a form of epilepsy in children was proposed almost 50 years ago in a report of 33 cases studied at the Seizure Unit, Children’s Medical Center, Boston [2]. A history of generalized tonic-clonic or complex partial seizures in addition to vomiting attacks was found in 7 (21%), and 25 (76%) had seizure discharges in the interictal EEGs. Single spike discharges, usually focal and predominantly in the temporal lobe, were seen in 16 (48%). Antiepileptic drug therapy, especially phenytoin, was partially successful in preventing vomiting attacks. Apart from one case with periodic vomiting occasionally culminating in convulsion and coma, confirmatory ictal EEGs were not obtained and, in retrospect, some of our cases may have represented attacks of atypical migraine. (see Progress in Pediatric Neurology I and III, Chicago, PNB Publ, 1991;pp46-47; and 1997;51-53).

Reports of ictal vomiting recorded electrographically are scarce and most cases published have right temporal lobe involvement [3]. Kramer RE et al. [4] report 4 patients who underwent temporal lobectomy; and the pathology showed gliosis and neuronal heterotopia. Vomiting represented a late ictal manifestation in 3 children with occipitotemporal seizures induced by intermittent photic stimulation. [5]