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Home | Articles | Neurology | The First Seizure

The First Seizure

Last updated 4th March 2025

Was it a Seizure?

  1. Witness account essential.  If no witness, use the telephone.
  2. Differential includes:
    – simple faint
    – cardiac dysrhythmia
    – hypoglycaemia
    – intoxication
    – non epileptic attack disorder (pseudo-seizure)
    – hyperventilation and panic attacks.

Seizure Type

  1. Determine seizure type by assessing conscious level, motor and sensory symptoms
    Seizure Classification 2017

    Adapted From: Instruction manual for the ILAE 2017 operational classification of seizure types. Epilepsia 2017 Apr;58(4):531-542 (from PubMed)
  2. Focal seizures – may be motor or sensory with or without affected awareness, distortion of time or reality and unconscious behaviour (automatisms)
  3. Focal seizures evolving to generalised tonic/clonic convulsions (so-called secondary generalised seizure).
  4. Primary generalised seizures – see below.

Seizure Cause

  1. Causes of epilepsy are classified as idiopathic/genetic or sypmtomatic/secondary
  2. Idiopathic means epilepsy likely due to a genetic tendency
  3. Symptomatic means secondary to previously known or suspected CNS disorder known to increase risk of developing epilepsy – see table
    Always Consider
    Signs of other CNS disorder, CNS infection, Stroke, Head Injury, Haemorrhage
    Metabolic or toxic insult, Drug or alcohol toxicity or withdrawal
    Pre-existing epilepsy, low drug compliance, alcohol, sleep deprivation etc.

Primary Generalised Seizures

  1. Classically tonic/clonic but may also be absence, tonic, myoclonic, clonic and atonic.
  2. Most common form in adolescents is juvenile myoclonic epilesy – likely if onset below 25, early morning tonic/clonic seizures or myoclonic jerks, or typical absence seizures, photoparoxysmal response on EEG, generalised 3/sec spike & wave, or polyspike & wave on EEG. May be triggered by sleep deprivation & alcohol (true of other forms of epilepsy).
  3. Primary generalised seizures occur without warning. A tonic/clonic seizure with well defined “aura” is really partial seizure that then becomes secondary generalised.

History and Examination

  1. In tonic/clonic seizure, patient goes rigid rather than limp (tonic phase); followed by jerking movements (clonic phase) when may bite tongue or be incontinent; then period of confusion/drowsiness (post ictal).
  2. Simple faints usually have precipitating factors eg pain, prodrome (feeling of blacking out), pallor, pulse (usually slow) & physical weakness (may be prolonged).
  3. Occasional faints may involve rigidity and some shaking, esp if patient is propped up while fainting (convulsive faint/syncope).
  4. History of tongue biting and post ictal confusion/drowsiness is suggestive of generalised tonic/clonic seizure. Incontinence is a very unreliable sign.
  5. Examine for focal neuro signs – motor weakness, cerebellar signs, papilloedema suggestive of secondary epilepsy.

Routine Tests

  1. Routine tests will usually be normal, but check FBC, U&E, BG, LFTs, calcium, CXR. An ECG is essential.
  2. Levels of currently used anti-epileptic drug (AED) – to check efficacy and compliance

Indications for EEG

  1. To support the diagnosis & determine the type of epilepsy in patients in whom the clinical history indicates a significant probability of epilepsy.
  2. Always discuss request with neurologist, EEG cannot be used to exclude epilepsy

Indications for Brain Imaging

  1. Indicated unless there is a confident diagnosis of IGE with response to anti-epileptic drug (AED).
  2. MRI is the modality of choice to identify structural disease.
  3. CT has role in urgent assessmenteg trauma, coma with intubation, progressive deterioration or if MRI contraindicated.
  4. Not usually necessary to repeat imaging if patient has seizure shortly after a significant head injury with skull fracture, or a stroke and previous imaging was done.

Management

  1. Most tonic/clonic fits resolve spontaneously.
  2. Don’t treat patient with benzodiazepines AFTER a single fit.
  3. Give IV benzodiazepines to patients who have a series of fits
  4. AEDs should be offered after a seizure if:
    • Previous known epilepsy – seizures in the past
    • EEG shows unequivocal epileptic discharges.
    • Patient has a congenital neurological deficit – suggestive of resistant epilepsy.
    • Patient considers the risk of recurrence unacceptable.
    • Risk of symptomatic epilepsy eg brain tumour, brain injury or encephalitis, drug or alcohol withdrawal (short term).
  5. Tell patient not to drive, to let DVLA know, & not to work with dangerous machinery or in dangerous places. Click here for draft letter patient might want to send to DVLA.

Choice of First Line Anti-Epileptic Drug

  1. Primary generalised seizures – lamotrigine, levetiracetam,
  2. Partial and secondary generalised – carbamazepine, lamotrigine, levetiracetam
  3. Uncertain seizure types – lamotrigine, levetiracetam,

Valproate

  1. The Medicines and Healthcare products Regulatory Agency (MHRA) have recently published a Drug Safety Update. This states a requirement for review by two specialists for patients initiating valproate under 55 years of age.
  2. Valproate can seriously harm an unborn baby when taken by women during pregnancy and may lead to permanent disability in the offspring – click here for advice on prescribing valproate to women under 55.
  3. Valproate may potentially cause male infertility in patients and neurodevelopmental disorders in children born to men treated with valproate in the 3 months before conception –  click here for advice on prescribing valproate to men under 55.
  4. For men and women over 55 years of age – click here for latest advice from MHRA

Follow Up

  1. Patients not admitted to hospital should have routine tests including ECG as soon as possible.
  2. Patients with recurrent fits should have regular follow up (at least yearly).
  3. All patients with suspected or newly diagnosed epilepsy should be referred to neurology.

Links

  • SIGN 70 2003 Updated 2005
  • NICE CG 137 Jan 2012
  • UK Government Valproate Safety Measures
  • MHRA Collected Resources on Valproate

    Content by Ondrej Dolezal & Wendy Ackroyd