Summary 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.

An epidemic illness characterized by head nodding associated with onchocerciasis has been described in eastern Africa since the early 1960s; we summarize published reports and recent studies. Onset of nodding occurs in previously healthy 5–15-year-old children and is often triggered by eating or cold temperatures and accompanied by cognitive impairment. Its incidence has increased in Uganda and South Sudan over the past 10 years. Four case–control studies identified modest and inconsistent associations. There were nonspecific lesions seen by magnetic resonance imaging, no cerebrospinal fluid inflammation, and markedly abnormal electroencephalography results. Nodding episodes are atonic seizures. Testing has failed to demonstrate associations with trypanosomiasis, cysticercosis, loiasis, lymphatic filariasis, cerebral malaria, measles, prion disease, or novel pathogens; or deficiencies of folate, cobalamin, pyridoxine, retinol, or zinc; or toxicity from mercury, copper, or homocysteine. There is a consistent enigmatic association with onchocerciasis detected by skin snip or serologic analysis. Nodding syndrome is an unexplained epidemic epilepsy.

A random cluster sample survey of approximately 18,000 people in 11 villages was performed in Ulanga, a Tanzanian district with a population of approximately 139,000 people. Well-instructed fourth-year medical students and neurologic and psychiatry nurses identified persons with epilepsy using a screening questionnaire and sent them to a neurologist for detailed evaluation. Identified were 207 subjects (88 male, 119 female) with epilepsy; of these, 185 (89.4%) (80 male, 105 female) had active epilepsy. The prevalence of active epilepsy was 10.2 in 1,000. Prevalence among villages varied, ranging from 5.1 to 37.1 in 1,000 (age-adjusted 5.8-37.0). In a 10-year period (1979-1988) 122 subjects living in the 11 villages developed epilepsy, with an annual incidence of 73.3 in 100,000. Generalized tonic-clonic seizures (GTCS) accounted for 58% and partial seizures accounted for 31.9%, whereas in 10.1% seizures were unclassifiable. Of the partial seizures, secondarily generalized seizures were the most common. Possible etiologic or associated factors were identifiable in only 25.3% of cases. Febrile convulsions were associated in 13.4 of cases. Other associated factors included unspecified encephalitis (4.7%), cerebral malaria (1.9%), birth injury (1.4%), and other (3%). In 38% of the cases, there was a positive family history of epilepsy.

SUMMARY Purpose Epilepsy is common in sub-Saharan Africa (SSA), but the clinical features and consequences are poorly characterized. Most studies are hospital-based and few studies have compared different ecological sites in SSA. We described active convulsive epilepsy (ACE) identified in cross-sectional community-based surveys in SSA, to understand the proximate causes, features, and consequences. Methods We performed a detailed clinical and neurophysiological description of ACE cases identified from a community survey of 584,586 people using medical history, neurological examination and electroencephalograph (EEG) data from five sites in Africa: South Africa; Tanzania; Uganda; Kenya and Ghana. The cases were examined by clinicians to discover risk factors, clinical features, and consequences of epilepsy. We used logistic regression to determine the epilepsy factors associated with medical comorbidities. Key findings Half (51%) of the 2,170 people with ACE were children and 69% of seizures began in childhood. Focal features (EEG, seizure types and neurological deficits) were present in 58% of ACE cases, and varied significantly with site. Status epilepticus occurred in 25% of people with ACE. Only 36% received antiepileptic drugs (phenobarbital was the commonest drug (95%)), and the proportion varied significantly with the site. Proximate causes of ACE were adverse perinatal events (11%) for onset of seizures before 18 years; acute encephalopathy (10%) and head injury prior to seizure-onset (3%). Important comorbidities were malnutrition (15%), cognitive impairment (23%) and neurological deficits (15%). The consequences of ACE were burns (16%), head injuries (post seizures) (1%), lack of education (43%) and being unmarried (67%) or unemployed (57%) in adults; all significantly more common than those without epilepsy. Significance There were significant differences in the co-morbidities across sites. Focal features are common in ACE suggesting identifiable and preventable causes. Malnutrition, cognitive and neurological deficits are common in people with ACE and should be integrated into the management of epilepsy in this region. Consequences of epilepsy such as burns, lack of education, poor marriage prospects and unemployment need to be addressed.