What are the symptoms and treatment options for a seizure?

Symptoms and Treatment of Seizures

Seizures are uncontrolled electrical discharges of neurons in the brain that can manifest through various symptoms and require specific management approaches based on seizure type and duration. 1

Symptoms of Seizures

Generalized Tonic-Clonic Seizures

• Full-body rhythmic jerking movements
• Loss of consciousness
• Possible urinary incontinence
• Post-seizure confusion and fatigue (postictal period) lasting several minutes 1

Focal Seizures

• Jerking of only one extremity or one side of the body
• Abnormal facial movements
• Small repetitive movements
• Staring spells (focal impaired awareness)
• May or may not involve changes in consciousness
• Can progress to generalized seizures 1

Other Common Seizure Symptoms

• Tonic posturing (stiffening) that may cause the patient to fall 1
• Tongue biting 1
• Blue facial discoloration during seizure 1
• Aura (sensory warning such as funny smell) before seizure onset 1
• Muscle aches after seizure 1
• Prolonged confusion after seizure 1

Seizure Causes

Seizures can occur due to:

• Infections
• Trauma
• Poisonings
• Lack of oxygen
• Metabolic abnormalities (e.g., hypoglycemia)
• Fevers (especially in children between 6 months and 2 years)
• Underlying neurological conditions like epilepsy
• Electrolyte imbalances
• Medication effects or withdrawal 1, 2

First Aid for Seizures

Do's:

• Help the person to the ground
• Place the person on their side in the recovery position
• Clear the area around them to prevent injury
• Stay with the person having a seizure 1, 3

Don'ts:

• Do not restrain the person
• Do not put anything in the mouth
• Do not give food, liquids, or oral medicines during or immediately after a seizure 1, 3

When to Seek Emergency Medical Care

Activate emergency medical services for:

• First-time seizure
• Seizures lasting >5 minutes
• Multiple seizures without return to baseline mental status between episodes
• Seizures occurring in water
• Seizures with traumatic injuries or difficulty breathing
• Seizure in an infant <6 months of age
• Seizure in pregnant individuals
• When the person doesn't return to baseline within 5-10 minutes after seizure activity stops 1

Treatment Approaches

Acute Seizure Management

1. First-line treatment: Benzodiazepines (preferably lorazepam IV or diazepam if IV access unavailable) 3

   • Rapid onset of action
   • Efficacy decreases if treatment is delayed
   • May cause sedation, respiratory depression, and hypotension

2. Second-line treatment (if seizures persist):

   • Phenytoin/fosphenytoin (requires cardiac monitoring due to potential hypotension)
   • Valproate (20-30 mg/kg IV loading dose, preferred due to fewer cardiovascular side effects)
   • Levetiracetam 3

3. Status epilepticus (seizures lasting >5 minutes or multiple seizures without return to baseline):

   • Life-threatening emergency with 5-22% mortality rate
   • May require third-line agents (propofol, midazolam, or barbiturates) if refractory to initial treatment 3

Long-term Management

For first unprovoked seizure:

• Prophylactic anticonvulsants generally not recommended unless specific risk factors are present:
  • History of previous brain disease/injury
  • Abnormal EEG
  • Abnormal neuroimaging findings
  • Focal onset of seizure 3

For recurrent unprovoked seizures (epilepsy):

• Antiepileptic drug therapy based on:
  • Seizure type and epilepsy syndrome
  • Patient age and comorbidities
  • Drug side effect profile
  • Dosing schedule and cost considerations 3

Common antiepileptic medications:

• Levetiracetam: May cause behavioral symptoms (agitation, anxiety, depression) 4
• Topiramate: Effective for partial onset seizures and primary generalized tonic-clonic seizures 5
• Valproate, lamotrigine: Particularly effective for generalized seizures 2

Diagnostic Evaluation

Essential laboratory tests:

• Serum glucose and sodium for all patients
• Pregnancy test for women of childbearing age
• Complete metabolic panel for altered mental status
• Toxicology screen if substance use suspected
• CBC, blood cultures, lumbar puncture if fever present
• Antiepileptic drug levels for patients on seizure medications 3

Imaging:

• MRI preferred for detailed evaluation
• CT may be performed initially in emergency settings for focal deficits, persistent altered mental status, or history of trauma/malignancy 3

Seizure Prevention Strategies

• Identify and avoid personal seizure triggers
• Maintain regular sleep patterns (avoid sleep deprivation)
• Manage stress levels
• Avoid alcohol and recreational drugs
• Take medications as prescribed
• Regular monitoring of antiepileptic drug levels 6, 3

Prognosis

The three major determinants of prognosis are:

• Duration of status epilepticus
• Patient age
• Underlying cause 3

Potential complications include neuronal damage, aspiration pneumonia, cardiac arrhythmias, respiratory failure, metabolic acidosis, hyperthermia, and rhabdomyolysis 3.