Neurology · PANCE / PANRE

Seizures and Epilepsy

Written & clinically reviewed by Ryan Busch, PA-C · Updated August 2026 · Report an error

Paroxysmal neurologic events from abnormal hypersynchronous cortical discharge.

Also known as: seizure, epilepsy, focal seizure, generalized seizure, tonic-clonic, grand mal, absence

Overview

A seizure is a transient occurrence of signs and/or symptoms due to abnormal, excessive, or synchronous neuronal activity in the brain. Epilepsy is a disease characterized by an enduring predisposition to seizures, defined by ILAE 2014 as: (1) ≥2 unprovoked seizures >24 h apart, OR (2) one unprovoked seizure plus ≥60% recurrence risk over next 10 years, OR (3) diagnosis of an epilepsy syndrome.

Epidemiology

Lifetime risk of a seizure ~10%; epilepsy prevalence ~1%. Bimodal age distribution — peaks in childhood and after age 65.

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Question 1NeurologyEasy
A 19-year-old man is evaluated after his first unprovoked generalized tonic-clonic seizure, which lasted 3 minutes and was followed by return to baseline mental status. MRI of the brain and electroencephalogram (EEG) are normal, and there are no provoking factors. Which of the following is the most appropriate next step in management?
  • AStart scheduled antiseizure medication now
  • BAdmit for continuous video EEG monitoring
  • CDiscuss the risks and benefits of treatment
  • DReassure that no further workup is needed
Reveal answer & full explanation
Correct answer: C — Discuss the risks and benefits of treatment
  • AStart scheduled antiseizure medication now
  • BAdmit for continuous video EEG monitoring
  • CDiscuss the risks and benefits of treatment✓
  • DReassure that no further workup is needed

Why discussing the risks and benefits of treatment is correct

  • Epilepsy is defined as two unprovoked seizures, or one unprovoked seizure with a high recurrence risk (>60% over 10 years), which requires an abnormal MRI, abnormal electroencephalogram (EEG), or prior brain injury.
  • This patient has a normal MRI and normal EEG, predicting roughly 40-50% recurrence, which is below the threshold that mandates treatment.
  • After a first unprovoked seizure, an antiseizure medication roughly halves short-term recurrence but does not improve long-term seizure freedom, so the decision is individualized through shared decision-making (per current American Academy of Neurology guidance).
  • The discussion should weigh driving restrictions, occupation, and patient preference.

Why the others are wrong

  • Start scheduled antiseizure medication now — Reflexively starting a drug ignores the low recurrence risk after a single seizure with a normal workup; premature-treatment trap.
  • Admit for continuous video EEG monitoring — The patient returned to baseline and the routine EEG is already normal; inpatient video EEG is for diagnostic uncertainty or status epilepticus, not a resolved first seizure; over-investigation trap.
  • Reassure that no further workup is needed — Dismisses the real recurrence risk and the need to counsel on driving and safety; under-management trap.

Teaching point

  • After a first unprovoked seizure with a normal MRI and EEG, treatment is not mandatory; individualize the decision through shared decision-making.
Question 2NeurologyMedium
A 24-year-old female has had two unprovoked seizures 3 months apart. EEG shows generalized epileptiform discharges and MRI of the brain is normal. She uses no contraception and may want to become pregnant. Which of the following is the most appropriate first-line antiepileptic drug?
  • AValproate
  • BPhenytoin
  • CLamotrigine
  • DCarbamazepine
Reveal answer & full explanation
Correct answer: C — Lamotrigine
  • AValproate
  • BPhenytoin
  • CLamotrigine✓
  • DCarbamazepine

Why Lamotrigine is correct

  • Epilepsy diagnosis per International League Against Epilepsy (ILAE) 2014: two unprovoked seizures more than 24 hours apart, OR one unprovoked seizure with a high recurrence risk (abnormal EEG, structural lesion, prior brain injury, nocturnal seizure); treatment is therefore indicated here
  • For generalized epilepsy in a woman of childbearing age, lamotrigine (broad spectrum, favorable pregnancy profile with folic acid supplementation) and levetiracetam are preferred

Why the others are wrong

  • Valproate — the most effective generalized antiepileptic drug but highly teratogenic (neural tube defects, neurocognitive impairment) and avoided in this population unless no alternative exists (confused-with best-efficacy choice)
  • Phenytoin — not a preferred agent for generalized epilepsy in a woman of childbearing age due to teratogenicity and its narrow-spectrum profile (right-concept-wrong-drug)
  • Carbamazepine — also teratogenic and not preferred for generalized epilepsy in women who may become pregnant (anchoring on a familiar AED)

Additional high-yield points

  • Ethosuximide is indicated for absence seizures only and would not be appropriate here
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Risk factors

  • Provoked (acute symptomatic) seizures: hypoglycemia, hyponatremia, hypocalcemia, alcohol/benzodiazepine withdrawal, fever (children), drugs (cocaine, tramadol, bupropion), eclampsia, acute stroke, head trauma, CNS infection, hypoxia
  • Unprovoked (epilepsy): prior stroke, traumatic brain injury, CNS infection, brain tumor, neurodegenerative disease, cortical malformations, genetic epilepsy syndromes, perinatal injury
  • Family history of epilepsy
  • Sleep deprivation, photic stimulation (triggers in susceptible patients)

Pathophysiology

Excessive excitation (glutamate-driven) and/or insufficient inhibition (GABA-driven) at the cortical level produces hypersynchronous neuronal firing. Focal seizures begin in a discrete area and may remain focal or evolve to bilateral involvement. Generalized seizures involve both hemispheres from the outset, often via thalamocortical circuits.

Clinical presentation

Symptoms

  • Focal (formerly partial) — aware: motor (clonic jerking), sensory (paresthesia), autonomic, psychic (déjà vu, fear)
  • Focal — impaired awareness: behavioral arrest, automatisms (lip smacking, picking), postictal confusion
  • Focal to bilateral tonic-clonic (formerly secondary generalization)
  • Generalized tonic-clonic: sudden LOC, tonic stiffening 10-20 s, clonic jerking 1-2 min, postictal confusion, tongue bite (lateral), urinary incontinence
  • Absence (typical childhood): brief staring spells with 3 Hz spike-wave on EEG, no postictal state
  • Myoclonic: brief shock-like jerks (juvenile myoclonic epilepsy classically morning jerks)
  • Atonic ('drop attacks'): sudden loss of tone, falls

Signs / physical exam

  • During seizure: rhythmic movements, gaze deviation, automatisms, postictal Todd paralysis (focal weakness lasting minutes-hours)
  • Postictal confusion, somnolence (after generalized seizure)
  • Lateral tongue bite (highly specific for seizure vs syncope)
  • Skin: incontinence, abrasions

Classic findings

Witnessed rhythmic convulsions + postictal confusion + lateral tongue bite + urinary incontinence.

Differential diagnosis

  • Syncope — Brief LOC, pallor, diaphoresis, rapid recovery; convulsive syncope can mimic seizure but lacks prolonged postictal state
  • Psychogenic non-epileptic seizures (PNES) — Asynchronous limb movements, eyes closed, pelvic thrusting, side-to-side head movement, lack of postictal confusion; video-EEG diagnostic
  • TIA / stroke — Typically negative symptoms (weakness, sensory loss); seizures usually positive (movements, paresthesias)
  • Migraine with aura — Slower march of symptoms over minutes; visual scintillations, headache follows
  • Cataplexy / narcolepsy — Sudden loss of muscle tone with preserved consciousness, triggered by emotion
  • Movement disorders (tics, tremor) — Stereotyped movements with retained awareness
  • Sleep disorders (REM behavior disorder, parasomnias) — Occur during sleep, video-EEG distinguishes

Diagnostic workup

Diagnostic criteria

Clinical event + EEG abnormality (interictal spikes or ictal pattern) supports epilepsy. ILAE definition of epilepsy: ≥2 unprovoked seizures >24 h apart OR ≥1 with ≥60% recurrence risk.

Labs

  • Fingerstick glucose, BMP (sodium, calcium, magnesium), CBC, LFTs
  • Toxicology screen, ethanol level
  • Pregnancy test in women of childbearing age
  • Prolactin elevated 10-20 min after generalized seizure (not absence or PNES) — limited utility now
  • Lumbar puncture if fever or meningitis suspected (after imaging)

Imaging

  • Non-contrast head CT in ED (acute structural lesion: hemorrhage, mass, stroke)
  • MRI brain with epilepsy protocol (thin coronal cuts through hippocampus) — for new-onset unprovoked seizures, focal features, or refractory epilepsy
  • EEG — standard initial (within 24-48 h boosts yield); sleep-deprived or prolonged EEG, video-EEG monitoring for diagnostic uncertainty or surgical workup

Diagnostic algorithm

Seizure TypeAwarenessClassic FeaturesFirst-Line AED
Focal awarePreservedMotor, sensory, autonomic, psychic symptomsLevetiracetam, lamotrigine
Focal impaired awarenessImpairedAutomatisms, behavioral arrestLevetiracetam, oxcarbazepine
Generalized tonic-clonicLostTonic stiffen → clonic jerks → postictalValproate, levetiracetam, lamotrigine
AbsenceBrief loss3 Hz spike-wave EEG, staring, no postictalEthosuximide, valproate
MyoclonicPreservedBrief shock-like jerks (JME morning jerks)Valproate, levetiracetam
AtonicMay be impairedSudden tone loss, fallsValproate, lamotrigine
ILAE 2017 seizure classification and first-line treatment.

Treatment

First-line

  • Acute single seizure: ensure airway, position on side, do NOT restrain or place objects in mouth; time the seizure
  • Antiepileptic — levetiracetam (1500-3000 mg/day) is broad-spectrum first-line for focal and generalized, lamotrigine (titrate slowly), valproate (avoid in women of childbearing potential — neural tube defects, reduced offspring IQ, autism risk)
  • Focal seizures: levetiracetam, lacosamide, oxcarbazepine, carbamazepine, lamotrigine
  • Generalized tonic-clonic: levetiracetam, valproate, lamotrigine, topiramate
  • Absence seizures: ethosuximide (first-line), valproate, lamotrigine
  • Myoclonic: valproate, levetiracetam, lamotrigine (can worsen myoclonus in some patients)
  • Treat reversible cause if provoked seizure — typically no chronic AED needed

Second-line / adjunct

  • If breakthrough seizures: optimize first AED dose, then switch or add second agent
  • Refractory epilepsy (failure of 2 appropriate AEDs at adequate dose): refer to epilepsy center
  • Surgical options: temporal lobectomy (for mesial temporal sclerosis), focal cortical resection, laser ablation, corpus callosotomy for drop attacks
  • Neuromodulation: vagus nerve stimulator, responsive neurostimulation (RNS), deep brain stimulation
  • Ketogenic diet (especially pediatric refractory epilepsy)
  • Counseling: driving restrictions (state-specific; typically 3-12 months seizure-free), safety (no swimming alone, careful with heights/machinery), SUDEP awareness

Complications

  • Status epilepticus (see separate entry)
  • Injury: tongue bite, falls, fractures, burns
  • Sudden Unexpected Death in Epilepsy (SUDEP) — risk ~1/1000 patient-years, higher in poorly controlled epilepsy and during sleep
  • Cognitive impairment, depression, anxiety (epilepsy comorbidities)
  • Driving restrictions, vocational impact
  • Medication side effects: valproate (weight gain, alopecia, hepatotoxicity, teratogenicity), lamotrigine (Stevens-Johnson syndrome), phenytoin (gingival hyperplasia, ataxia)
  • Pregnancy: valproate is the most teratogenic; lamotrigine and levetiracetam preferred

PANCE pearls

  • First unprovoked seizure does not automatically equal epilepsy — recurrence risk after first seizure ~30-50% over 2 years.
  • Lateral tongue bite is highly specific for generalized tonic-clonic seizure (tip-of-tongue bite occurs in syncope).
  • Postictal Todd paralysis can mimic stroke — resolves over minutes to hours; check old records and consider imaging if first event.
  • Ethosuximide treats absence ONLY (not generalized tonic-clonic). Valproate covers both.
  • Avoid valproate in women of childbearing potential when possible — neural tube defects, autism, IQ reduction. Folic acid 1-5 mg/day for women on any AED.

References

  • ILAE 2014 — ILAE Official Report: A Practical Clinical Definition of Epilepsy (Fisher et al., Epilepsia 2014)
  • ILAE 2017 — Operational Classification of Seizure Types and Epilepsies (Fisher, Cross, French et al., Epilepsia 2017)
  • AAN 2018 — Evidence-Based Guideline: Management of an Unprovoked First Seizure in Adults (Krumholz et al., Neurology 2015) — reaffirmed
  • AES 2016 — Evidence-Based Guideline: Treatment of Convulsive Status Epilepticus (Glauser et al., Epilepsy Currents 2016)

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Ischemic StrokeHemorrhagic (Intracerebral) StrokeTransient Ischemic Attack (TIA)Subarachnoid Hemorrhage (SAH)Subdural Hematoma (SDH)Epidural Hematoma (EDH)Concussion / Mild Traumatic Brain InjuryMigraineTension-Type HeadacheCluster HeadacheStatus EpilepticusMultiple SclerosisGuillain-Barré SyndromeMyasthenia Gravis

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