Letter to the editorNew daily persistent headache (NDPH), according to the International Classification of Headache Disorders-3 (ICHD-3), is a primary head-1 www.annchildneurol.org

Munchausen syndrome is a rare factitious disorder, characterized by either the intentional manifestation of physical symptoms or repeated self-injuries in order to achieve health care attention, complemented by pathological lying and a restless wandering from hospital to hospital for medical and/or surgical interventions [1]. Along with wounds and psychic symptoms, one of the commonest presenting complaint is seizures [2]. Here, we document an interesting case, presenting as factitious psychogenic nonepileptic paroxysmal episodes and limb paralysis. An 18-year-old male visited the emergency room (ER) with postictal limbs paralysis. Witnesses reported that he suffered a generalized tonic seizure-like event, followed by paraplegia or quadriplegia on resumption of consciousness. Social history revealed that his parents divorced when he was 8 years old and he was subsequently raised by his grandmother. From 9 years of age, he frequently visited ER for varying complaints, including lower extremity arthralgia, chest palpitation, and dyspnea. However, investigations did not show any abnormality. Past surgical history consisted of three episodes of orthopedic surgery and an appendectomy with a grossly normal appendix. He developed his first paroxysmal behavior at the age of 13. While the clinical semiology was bizarre, with brief tremulous movements and the absence of drooling or lip cyanosis, his brain magnetic resonance imag

Dear Editor, More than one-third of females of reproductive age with epilepsy experience cyclic exacerbation of seizures that are associated with periodic changes in the serum progesterone level (antiseizure activity) and the serum estrogen level (proseizure activity) during the menstrual cycle. 1,2 This condition is known as catamenial epilepsy (CE), and is mainly related to progesterone withdrawal during inadequate luteal phase cycles, which can impair GABAergic inhibition. 3,4 It has been proposed that maintaining high progesterone levels during the perimenstrual period would ameliorate seizure exacerbation (Fig. 1A). 5 We describe two patients with CE who received adjuvant therapy with cyclic progesterone supplementation during the luteal phase. The first patient was a 22-year-old female diagnosed with idiopathic generalized epilepsy who had normal brain MRI findings and occasional generalized high-voltage spike-and-wave discharges on EEG. Her symptoms were controlled with levetiracetam, which maintained the seizure frequency at once or twice a year. Her menstrual cycle had been relatively regular since menarche at the age of 14 years. While at high school she had experienced generalized tonic or brief absence seizures once or twice a month, which responded poorly to treatment with topiramate and clobazam in that order. The patient had experienced nine seizures during the previous year. It was particularly notable that she complained of more frequent seizure attacks 2-3 days after the initiation of her menstrual cycle that continued during the first week of the cycle. She was prescribed medroxyprogesterone acetate (MPA) tablets (10 mg, once daily) from day 14 to day 28 of her cycle, which was associated with the resolution of CE 12 months later; however, the habitual seizure frequency did not change significantly (Fig. 1B). She was generally satisfied with this treatment, because it allayed her fear of seizures and had made her menstrual cycle regular, despite complaints of slight weight gain and mild headache. The second patient was an 18-year-old female diagnosed with juvenile myoclonic epilepsy. Her brain MRI findings were normal, but EEG revealed occasional generalized bursts of highvoltage spike-and-wave discharges. Her menstrual cycle had been relatively regular since menarche at the age of 11 years. Generalized tonic-clonic seizures were resolved after administering levetiracetam and sodium valproate, but she experienced perimenstrual myoclonus exacerbations from 3 days before to 3 days after the start of her menstrual cycle. She received cyclic progesterone supplementation using the same protocol as applied to the first patient. Follow-up assessments performed after 12 months revealed a decrease in perimenstrual clustered myoclonus (Fig. 1B). She experienced slight mood instability, which was tolerable, and was satisfied with regular menstruation and milder symptoms. CE treatment has traditionally focused on the intermittent administration of cyclic medications such as acetazolamide, clobazam, and lev...

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