Although rare, narcolepsy is an important cause of daytime sleepiness because it can affect personal safety and school performance but is readily treatable. Normally, REM sleep only occurs when a person has been asleep for 60 to 90 minutes and follows all four stages of non-REM sleep. Narcolep-tic patients, on the other hand, experience sudden episodes of REM sleep in the middle of a wakeful state or immediately after falling asleep.

The key feature of narcolepsy is recurrent sleep attacks: sudden, unintentional, irresistible bouts of sleep that occur in inappropriate situations, such as during conversations or while driving. Other common findings include cataplexy (sudden bilateral loss of muscle tone without loss of consciousness), hypnagogic hallucinations (vivid dreamlike imagery just before falling asleep), and sleep paralysis (inability to move or speak just after morning awakening). Any child or adolescent with unexplained daytime sleepiness who does not respond to initial management with good sleep hygiene, or who has a family history of narcolepsy, should be considered for evaluation. A sleep study is required to make the diagnosis.

Narcolepsy treatment combines behavioral approaches with medications. The patient should adhere to good sleep hygiene. Therapeutic naps enhance daytime alertness and reduce the necessary dose of stimulants. Stimulant medications, such as methylphenidate, dextroamphetamine, or modafinil are very helpful for daytime sleepiness (Vgontzas and Kale, 1999) (SOR: A). The antidepressants are REM suppressants that help prevent cataplexy or hypnagogic hallucinations. The nonsedating antidepressants, especially the selective serotonin reuptake inhibitors (SSRIs), work syn-ergistically when combined with stimulants (Vgontzas and Kale, 1999) (SOR: B).

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