et al154 described such nodding attacks in a 2-year-old boy whose nodding disappeared immediately following surgical resection of a right temporal astrocytoma.

movements tend to be slow and rhythmical with boredom and fatigue and become faster and irregular with stress or excitement.117,118

Congenital Ocular Motor Apraxia

We have observed infants with congenital ocular motor apraxia who, in addition to head thrusting, show intermittent head nodding during fixation of a nonmoving object. This nodding may persist at an age when the head thrusting has resolved. We assume it somehow serves to fine-tune or recalibrate the fixation mechanism in this disorder.

Opsoclonus/Myoclonus

Severe myoclonus associated with opsoclonus can cause incessant, rapid, irregular head movements. Kinsbourne126 described wobbling, titubation, and rapid, irregular jerking movements of the head in three of six young children with acute postviral myoclonic encephalopathy associated with opsoclonus. The associated myoclonus distinguishes this disorder from other causes of head nodding. In the absence of an underlying neuroblastoma, the illness may resolve over weeks to months, although the course is protracted and recovery incomplete in some children.140

Intermittent Esotropia

Neurologically normal children have been described as having intermittent esotropia without nystagmus and intermittent head nodding that manifested only when the eyes were straight.125,181 The head movements cease with the spontaneous onset of esotropia or with the occlusion of either eye. “During head stabilization by the examiner, affected children often develop a manifest esotropia.” These reports suggest that the head nodding can somehow facilitate horizontal ocular alignment.

Infantile esotropia is rarely associated with head nodding and nystagmus. Brodsky and Wright30 described three patients with infantile esotropia, fine torsional nystagmus, and head oscillations that varied from shaking to nodding during periods of visual attention. Strabismus surgery restored ocular alignment and eliminated the head oscillations. It was unclear whether the head oscillations were casually related to the infantile esotropia, to the associated nystagmus, or both. Other infants with infantile esotropia may exhibit features of spasmus nutans that do not appear to be compensatory for binocular alignment.179

Visual Disorders

Blindness

Jan118 has reviewed the numerous abnormal head movements in visually impaired children. Head oscillations are among the sophisticated adaptations that blind children develop to interact more effectively with their physical surroundings. Head oscillations in the visually impaired child may appear as stereotyped, purposeless movements to the examiner, if their numerous adaptive functions go unrecognized. Children with tunnel vision may make side-to-side oscillating head movements when walking in order to scan the environment. Many blind children use their hearing to avoid obstacles with surprising efficiency.86 Jan118 has noted that, in the corridors of schools for the blind, it is not uncommon to see children walking with their heads slowly turning from side to side, while making clicking or chirping noises, in order to use their “radar systems.” The rhythmical front-to-back or side- to-side rocking movements of the head or trunk seen in blind children may start as a response to understimulation or overstimulation and later become a habit. These self-stimulating

Otological Abnormalities

Labyrinthine Fistula

“Head nystagmus” was alluded to in the older literature as a sign of labyrinthine fistula.60 Despite the recent flurry of interest in this controversial condition, its association with head shaking seems to have disappeared.15,35,109,130

Systemic Disorders

Aortic Regurgitation

Patients with severe aortic regurgitation may display a bobbing motion of the head and a jarring motion of the body with each systole due to a widened arterial pulse pressure (de Musset sign).194 The head bobbing of aortic regurgitation is accompanied by a high-pitched, decrescendo, diastolic murmur along the left sternal border. Originally considered a