Abstracts

Rationale: PNES clinic was established to address unmet need of newly diagnosed PNES patients who was often lost in the gap between traditional neurology and behavioral healthcare. We encountered overwhelming complaints of headache in our PNES cohort. We evaluated the frequency, severity, and temporal relationship of headache to PNES. Methods: Retrospective chart review of consecutive patients referred and evaluated in the monthly PNES clinic at Children’s Healthcare of Atlanta from 7/24/2018 to 5/29/2019. Results: There were 76 patients referred to PNES clinic. The sources of referrals were (1) other neurology colleagues (N = 32, 42%), (2) emergency department (ED, N = 21, 28%), (3) primary care providers (N =12, 16%), (4) inpatient follow up (N=9, 12%), and other (N=2, 3%). We were able to see and evaluate 41/76 (54%) patients. Majority (24, 59%) were African American and 14 (34%), Caucasian. Vast majority (37/41, 90%) were girls. The average age of symptoms onset was 13.3 (± 2.7) years and age at the first clinic visit, 14.4 (± 2.4) years. Among 41 patients, 35 (85%) had headaches and 27 (77%) used either abortive or prophylactic antimigraine medications. Many (15, 43%) complained of daily headaches and 10 (26%) visited ED for headaches. A majority (18, 51%) of patients suffered from headache months to years prior to the onset and diagnosis of PNES while 7 (20%) patients presented with headache and PNES concurrently, and in 6 (17%) headache occurred after PNES or replaced PNES. For remaining 4 (11%), it was unclear or unknown when headache was present in relation to the diagnosis of PNES. A temporal correlation between headache and episodes of PNES were found in 24 patients (69%). For majority (18/24, 67%) headache preceded PNES, while 2 (7%) had headache immediately before and during PNES, and 7 (26%) complained of headache after PNES. Comorbid anxiety, depression, and post-traumatic stress disorder were present in 33 of 35 (94%) PNES patients with headache, and in 3 of 6 (50%) PNES patients without headache. Conclusions: We found very common occurrence of significant migraine–like headaches in our new onset PNES patients. Majority of PNES patients experienced headaches before the onset of PNES. Also, often headache preceded and was a warning sign before an episode of PNES in more than half of the PNES patients with headache. This temporal relationship is in contrast to epilepsy patients who commonly has post-ictal headaches. Most PNES patients with headache also had other comordid neuropsychiatric disorders whereas about half of PNES patients without headache was free of neuropsychiatric condition. Headache may be linked to underlying pathophysiology of PNES and may provide a diagnostic clue to PNES. Our finding underscores the role of a PNES clinic within neurology department to allow comprehensive evaluation and management of various accompanying neurologic symptoms such as headaches. Funding: Goizueta Family Foundation