Seizures and epilepsy

Last updated: March 22, 2022

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A seizure is a transient manifestation of abnormal excessive or synchronous electrical brain activity that causes convulsions, loss of consciousness, and/or lapses of consciousness. The underlying cause of seizures is a state of neuronal hyperexcitability, which may be temporary (e.g, due to electrolyte imbalances) or long-lasting (e.g., due to inherited or acquired neural abnormalities). Provoked seizures occur as a result of various seizures triggers and underlying conditions (e.g., stroke, traumatic brain injury, alcohol withdrawal), while unprovoked seizures occur in the absence of an identifiable cause. Seizures can also be classified by onset and degree of CNS involvement, e.g., focal seizures, generalized seizures. Epilepsy is a chronic neurological disorder with diagnostic criteria that are based on seizure type, frequency, risk factors, and underlying conditions, e.g., epilepsy syndromes.

Acute complications of seizures include physical trauma and CNS tissue damage due to hyperthermia, cardiorespiratory deficits, or excitatory toxicity. Status epilepticus is a potentially life-threatening condition characterized by continuous seizure activity for more than 5 minutes that requires immediate management and stabilization. Acute seizures and status epilepticus in adults and children are most often treated with parenteral benzodiazepines first, followed by other parenteral antiepileptic drugs (e.g., fosphenytoin) if there is no resolution. Rapidly reversible causes of seizures, e.g., hypoglycemia, should also be managed concurrently. The underlying cause is investigated based on a combination of clinical evaluation (e.g., seizure classification, identifying seizure triggers), laboratory studies, and neuroimaging. Electroencephalography (EEG) can provide additional evidence to support the diagnosis, although a normal EEG between seizures does not rule out epilepsy. Important antiepileptic drugs for the long-term treatment of epilepsy include lamotrigine (first-line treatment in focal seizures), valproate (first-line treatment in generalized seizures), and ethosuximide (first-line treatment in absence seizures). Appropriate medical treatment allows the majority of patients to remain seizure‑free in the long term and prevents long-term complications such as psychiatric conditions (e.g., anxiety, depression, psychosis), sleep disorders, and sudden unexpected death in epilepsy (SUDEP); however, patients must be monitored for adverse effects of medications (e.g., bone disease).

For information on individual epilepsy syndromes, see “Generalized epilepsy in childhood.”

Seizures [1]

Epilepsy [1]

A single seizure or multiple provoked or triggered seizures (e.g., febrile seizures) without an underlying predisposition to seizures do not suffice for the diagnosis of epilepsy.

Epidemiological data refers to the US, unless otherwise specified.

Seizure triggers [9]

Seizure triggers are stimuli that can precipitate seizures both in people with and without epilepsy. [10]

Causes of acute symptomatic seizures [2]

Common causes of epilepsy [12]

Causes of epilepsy according to the age group [14]

Etiology of epilepsy in different age groups
Age group at manifestation Causes
Neonates and infants (< 6 months)
Older infants (> 6 months) and children (< 10 years)
Adolescents (10–18 years)
Adults (18–60 years)
Older adults (> 60 years)

Classification of seizures according to the ILAE 2017 classification [15]

Seizures are classified according to localization of abnormal neuronal activity and then further subcategorized based on symptoms and sometimes level of awareness.

Basic classification of seizures
Focal Generalized Unknown
Location of abnormal neuronal activity
  • Originates within the networks of a single hemisphere
  • Originates from both hemispheres
  • Determination of focal or generalized onset is not possible
Awareness
  • Aware
  • Impaired awareness
  • N/a
  • N/a
Symptoms
  • Motor onset
  • Nonmotor onset
Other
  • Focal to bilateral tonic-clonic: focal progresses to a tonic-clonic pattern (characteristic of bilateral brain involvement)
  • N/a
  • Unclassified [16]

* Note: An expanded version of the ILAE 2017 classification also considers further subtypes of motor and nonmotor categories.

Classification of epilepsy [12]

Focal seizures (formerly partial seizures) [10][15][17]

  • Originate in one brain hemisphere [18]
  • Usually caused by focal structural abnormalities
  • Symptoms depend on the anatomical location of the lesion or disturbance within the brain.
  • For more information about the etiology and symptoms of seizures originating from the cortex of particular brain lobes, see “Focal seizures and syndromes.”
Clinical features of focal seizures
Type Awareness Ictal Postictal
Focal
  • Residual transient neurologic deficits depending on the affected cerebral region
  • Todd paralysis: postictal weakness or paralysis of the involved limb or facial muscles (can last for minutes or up to hours)
Focal to bilateral tonic-clonic
  • Prodromal aura may be present.
  • Starts as unilateral, localized focal symptoms that then progress into a bilateral generalized phase: Initial focal symptoms may go unnoticed if the condition progresses rapidly, leading to a potential misdiagnosis of generalized-onset seizures and inappropriate therapy.
  • Bilateral generalized phase
  • Confusion
  • Drowsiness
  • Agitation
  • Fatigue
  • May not recall the focal onset

If focal to bilateral tonic-clonic type progresses rapidly to the bilateral generalized phase, initial focal symptoms may go unnoticed, leading to a potential misdiagnosis of generalized-onset seizures and inappropriate therapy.

Generalized-onset seizures [10][20][21]

Clinical features of generalized seizures
Type Ictal Postictal
Generalized motor seizure
Tonic-clonic seizure (grand mal)
Clonic seizure
Tonic seizure
  • Amnesia of the event
  • Drowsiness or confusion may occur
Myoclonic seizure
  • Positive myoclonus: sudden jerk-like muscle twitching
  • Negative myoclonus: a brief loss of muscle activity during tonic contraction of a muscle
  • Myoclonus can affect the entire body or only a part.
  • Myoclonic seizures are nonrhythmic (i.e., jerks occur at different intervals) and irregular (i.e., jerks are asymmetric and may change laterality)
Myoclonic-atonic seizure
Myoclonic-tonic seizure
  • Myoclonus followed by a brief increase in tone
Atonic seizure (also known as “drop seizure” or “drop attack”)
  • Sudden loss of muscle tone: sudden head drop or collapse (lasts < 15 seconds)
  • Frequently mistaken for syncope
Generalized nonmotor seizure (absence seizure)
Typical
  • Interrupted motion or activity, blank stare, unresponsiveness
  • Can occur several hundred times a day and usually lasts < 10 seconds
  • Subtle automatisms (often go unnoticed): lip-smacking, eye fluttering, or head nodding are common.
  • Sudden onset and stop
  • None
  • Consciousness returns rapidly, without any impairment
  • Amnesia is common
Atypical
  • Interrupted motion or activity, blank stare
  • Patients may be responsive
  • Automatisms: lip-smacking, eye fluttering, chewing
  • Small hand movements (e.g., rubbing of the fingers)
  • Longer than typical form (10–30 seconds)
  • Gradual onset and stop

It is important to distinguish between focal/bilateral tonic-clonic seizures and generalized tonic-clonic seizures, as they manifest similarly but are managed differently.

The following addresses evaluation following the resolution of an acute seizure. See “Management of acute seizures and status epilepticus” for actively seizing patients.

Approach

In patients with an epilepsy diagnosis who present with an acute seizure, evaluate for medication-related issues, e.g., adherence, changes in drug doses or formulations, medication interactions.

Obtain neuroimaging in patients with an epilepsy diagnosis if there is a change in seizure pattern or other concerning features are present (e.g., recent head injury, new neurological deficit, persistent headache). [23]

Confirmation of seizure

Nonconvulsive status epilepticus is diagnosed based on the clinical presentation (e.g., changes in behavior and/or mental status from baseline) and the demonstration of seizure activity on EEG.

Evaluation for underlying conditions

In adults, an isolated unprovoked focal or focal to bilateral tonic-clonic seizure typically indicates a structural or metabolic origin and should receive further evaluation.

Differential diagnosis of epilepsy
Condition Risk factors and triggers Clinical features Duration Diagnostics
Focal-onset seizure
  • Usually < 2 minutes

Generalized-onset motor seizure

  • Usually < 5 minutes
Febrile seizure
  • Young age (6 months to 5 years)
  • Genetic predisposition
  • High fever (> 40°C/104°F)
  • Viral infection (e.g., HHV-6, influenza)
  • Postimmunization fever
  • < 15 minutes
  • No more than 1 seizure per day
  • Simple (80% of cases)
    • < 15 minutes
    • < 1 seizure per 24 hours
  • Complex (20% of cases)
    • > 15 minutes
    • > 1 seizure per 24 hours
Psychogenic nonepileptic seizure (PNES)
  • Usually occur in presence of eyewitnesses [26][27]
  • Generalized asynchronous motor activity
  • Eyes are usually closed and resist being opened
  • Tongue-biting and other types of self-injury are rare.
  • Awareness is usually unimpaired
  • Individuals with PNES can recall the event
  • Typically > 5 minutes [28]
  • Video-EEG monitoring
Panic attack
  • Seconds to hours
  • History
Syncope
  • 1–2 minutes
  • History
  • ECG
  • Blood tests
  • Supine and orthostatic blood pressure measurements
Stroke/TIA
  • Symptoms variable, depending on the location of the stroke or TIA
  • Usually negative symptoms (e.g., weakness, visual loss)
  • Consciousness preserved
  • TIA: Minutes to hours
  • Stroke: Days to years, often permanent damage
Migraine aura
  • Genetic predisposition
  • Female sex
  • Hormonal changes
  • Life stress
  • Typically positive symptoms (e.g., hallucinations) followed by negative ones (e.g., anesthesia)
  • Gradual onset
  • Consciousness preserved
  • Auras followed by headache
  • ≤ 1 hour
  • History
Breath-holding spell
  • Young age (6 months to 6 years)
  • Iron deficiency anemia
  • Distress due to strong emotions (e.g., anger, frustration, tantrums) or injury
  • Episodes of prolonged expiratory apnea
  • Transient paroxysms of cyanosis or pallor
  • Possibly generalized stiffness and jerky movements of the limbs
  • Post-event syncope
  • Vigorous cry: < 15 seconds
  • Cessation of breathing: ≤ 1 minute
  • Recovery: ≤ 1 minute
  • History
Self-stimulatory behavior
  • Repetitive movements performed to stimulate one's own senses
  • Examples of behaviors include tapping on a desk, twirling a lock of hair, and/or rocking back and forth.
  • Variable
  • History
Masturbation in children [29]
  • Normal behavior in children 5 months to 8 years
  • Dystonic posturing with rocking, grunting, and sweating
  • Median frequency: 7/week
  • Median duration: 2.5 minutes
  • History

The differential diagnoses listed here are not exhaustive.

Acute management [30][31][32]

Acute seizures are often self-limited and may not require immediate pharmacological intervention.

Status epilepticus is a life‑threatening condition! If not interrupted, it can lead to cerebral edema, hyperthermia, rhabdomyolysis, and cardiovascular failure. If the time from seizure onset is unknown, begin management for status epilepticus.

Long-term management following a seizure [30][31][32]

Long-term medical therapy following a first unprovoked seizure is not required unless the patient meets the criteria for epilepsy or is at high risk of recurrence.

Disposition

  • Hospital admission and inpatient workup is recommended for patients with any of the following: [23][31][34]
    • Required > 1 dose of benzodiazepines to terminate the seizure
    • Failure to return to baseline clinical status after the seizure
    • Recurrent seizures
    • New-onset acute symptomatic seizures for which the immediate cause has not been definitively corrected
    • Acute illness (including isolated fever) or trauma
    • New neurological abnormalities preceding or following the seizure
    • Persistent headache
    • Concerns regarding adherence or inability to ensure follow-up
  • In patients who have returned to their baseline clinical status and do not require hospitalization:

Patients who have had a seizure or suffer from epilepsy typically cannot drive until a seizure-free interval of at least 6 months has passed. Check local guidance, as it may be the clinician's legal responsibility to inform the relevant licensing authorities!

Management steps are determined by the time from seizure onset. Steps include patient stabilization, identification and treatment of reversible acute causes of seizures, and pharmacotherapy to terminate the seizure. Treatment recommendations are consistent with the 2016 American Epilepsy Society (AES) guidelines on the treatment of convulsive status epilepticus in adults and children. [30]

Initial stabilization for acute seizures [33]

A severe but self-limited metabolic acidosis due to marked and transient hyperlactatemia commonly occurs immediately after a seizure and usually does not require specific intervention. [35][36]

When indicated in an actively seizing patient, a nasopharyngeal airway is preferred over an oropharyngeal airway to avoid damaging intraoral structures in the setting of muscle spasms.

Phase-based acute seizure management [30]

The following addresses acute seizure management in adults and children. For other patient groups see “Neonatal seizures”, “Eclampsia”, or “Febrile seizures.” If initial contact is ≥ 5 minutes from seizure onset or the time from seizure onset is unknown, implement interventions for early seizure and early status epilepticus simultaneously.

Overview of pharmacotherapy for acute seizures [30][33][37]
Pharmacotherapy
Seizure phase (time from seizure onset) Preferred agents Alternatives
Early seizure (0–5 minutes)
  • Often self-limited; pharmacotherapy is usually not indicated.

Early status epilepticus (5–20 minutes): first-line therapy

Administer push dose. Repeat every 5–10 minutes if no response.

Persistent status epilepticus (20–40 minutes): second-line therapy

Administer loading dose.

Refractory status epilepticus (40–60 minutes)

Expert guidance is required.

Concurrently manage rapidly reversible causes of seizures (e.g., hypoglycemia, hyponatremia, hypocalcemia) without delay.

Early seizure (0–5 minutes)

Early status epilepticus (5–20 minutes)

Initiate first-line pharmacotherapy with a benzodiazepine (IV route is preferred).

  • If IV access is available, administer:
  • If IV access is unavailable, administer one of the following:
  • If there is no response to the initial dose, repeat IV benzodiazepine after 5 minutes (after 10 minutes for other routes).
  • Monitor for benzodiazepine-induced hypotension and respiratory suppression.
  • Consider ICU consult if there is no response to the first dose of benzodiazepine.

Persistent status epilepticus (20–40 minutes)

If first-line pharmacotherapy is unsuccessful, initiate second-line pharmacotherapy.

Refractory status epilepticus (40–60 minutes)

If first and second-line pharmacotherapy are unsuccessful:

A recurrent seizure following full neurological recovery from a preceding seizure should be managed as a discrete episode: repeat first-line pharmacotherapy with benzodiazepines while carefully monitoring for respiratory depression.

Focal motor status epilepticus is often drug-resistant but rarely life-threatening. Phase-based management is similar to that of generalized motor seizures but general anesthesia is NOT typically required. [33]

Management of rapidly reversible causes of seizures

Management of rapidly reversible causes of seizures
Cause Recommended initial interventions
Hypoglycemia
  • Give IV dextrose ; consider IM/SQ glucagon if there is no IV access. [30]
  • Consider concurrent thiamine if there is evidence of significant chronic alcohol use and/or poor nutritional status. [30][33][39][40]
  • See also “Treatment of hypoglycemia.”
Electrolyte imbalance [41] Hyponatremia
Hypocalcemia [45]
Hypomagnesemia [46]
Hyperthermia
Eclampsia [47]
Hypertensive encephalopathy
Alcohol withdrawal [48]
Poisoning [34]

The following focuses on the chronic treatment of epilepsy. The management of acute seizures and status epilepticus and long-term management following an acute seizure are discussed separately.

Medical therapy [52]

  • Treatment regimen
    • Monotherapy should be maintained, if possible.
      • Increase the dosage of a single agent or switch drug if treatment proves ineffective before initiating combination therapy.
      • ∼ ⅔ of epilepsy patients become seizure-free with monotherapy [53]
    • Combination therapy should only be given if monotherapy fails. In this case, drugs from different classes and/or with different pharmacologic modes of action should be tried. [54]
  • Termination of treatment
    • To be evaluated on a case‑by‑case basis
    • May be considered if the patient has < 2 seizures/year, an inconspicuous provocation EEG, normal psychological findings, and no hereditary predisposition
    • Generally possible after 2–5 seizure‑free years with normal EEG results
    • Medications should be tapered with caution.

Nonpharmacological therapy

  • Indications: pharmacoresistant epilepsy
  • Surgery
    • Procedures
      • Resection (surgical removal of pathological lesions)
      • Disconnection (surgical section of neuronal circuits)
        • Callosotomy: section of the corpus callosum [55]
          • Initially, partial disconnection only (usually the anterior ⅔)
          • Complete disconnection if seizures persist
        • Hemispherotomy: disconnection of the cortex of one hemisphere from the ipsilateral subcortical structures and the cortex of the other hemisphere without removal of the affected hemisphere [56]
  • Stimulation techniques: vagus nerve stimulation, deep brain stimulation
  • Dietary measures: ketogenic diet [57]

Successful epilepsy therapy depends on determining whether the patient has focal or generalized seizures and prescribing medication accordingly.

Acute

Long term

Sudden unexpected death in epilepsy (SUDEP) [60]

  • The sudden death of a person with diagnosed epilepsy that cannot be attributed to trauma or drowning and occurs with or without evidence of preceding seizure in the absence of any underlying medical conditions that could explain the event
  • Usually occurs while the patient is asleep
  • Is more common in patients with intractable epilepsy, frequent seizures (especially tonic-clonic seizures), and early age of onset

We list the most important complications. The selection is not exhaustive.

Definition [30][61]

Etiology [62]

Classification [61]

  • With prominent motor features
  • Without prominent motor features: nonconvulsive status epilepticus (NCSE)
    • With coma
    • Without coma
      • Absence
      • Focal (e.g., aphasia, impaired consciousness, ongoing autonomic or sensory symptoms)

Management

Consider NCSE in patients with persistently altered mental status following a seizure or with otherwise unexplained altered mental status, bizarre behavior, autonomic dysfunction, or sensory symptoms.

Prognosis

  • Mortality is bimodal, with the highest risk in neonates (25–39%) and patients > 80 years of age (> 50%). [63][64]
  • Overall infant and child mortality: 3.6% [65]
  • Overall adult mortality: 15.9% [65]
  • Risk of seizure recurrence
    • After the first unprovoked seizure [66][67]
      • With no underlying brain insult (stroke, trauma, or CNS infection): ∼ 40–50% within 2 years
        • 80% of recurrences occur within 2 years of the initial seizure.
      • Occurring after at least 1 week after a brain insult: ∼ 65% over the next 10 years
    • After the second unprovoked seizure: 60% within 1 year
    • After an acute symptomatic seizure: ∼ 19% over the next 10 years
  • Treatment outcomes [68]
    • 60–70% of all treated patients become seizure-free at 10 years after first seizure
    • 60–90% of children and 35–57% of adults remain seizure-free after discontinuing medical therapy following a 2-year seizure-free period on antiepileptic drugs.
  • Legal regulations: State laws vary with regard to the requirements for individuals with epilepsy to operate vehicles and heavy machinery. [69]
  • Mortality [70]
    • Risk of all-cause mortality is 1.6–3 times higher in individuals with epilepsy than in the general population.
    • The worldwide incidence of SUDEP is 1.2–6.3 per 1,000 individuals with epilepsy.

Seizure disorders in pregnancy [71]

Epilepsy in pregnancy

Other seizure disorders in pregnancy

Seizures in neonates [74][75][76]

EEG screening and diagnostic confirmation are essential, as most seizures in neonates are subclinical and many other clinical entities can mimic true seizures.

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