How to manage seizures manifesting as panic attacks?

Management of Seizures Manifesting as Panic Attacks

When seizures present with panic attack symptoms, the critical first step is distinguishing true epileptic seizures from panic disorder through video-EEG monitoring, as these conditions require fundamentally different treatments and misdiagnosis leads to ineffective antiepileptic drug therapy and delayed appropriate care.

Diagnostic Approach

Recognition of the Clinical Challenge

The overlap between panic attacks and partial seizures creates significant diagnostic difficulty, particularly with temporal lobe epilepsy:

• Right temporal lobe seizures frequently present with panic attack semiology including feelings of panic, impending doom, hyperventilation, palpitations, diaphoresis, shortness of breath, and generalized paresthesias 1
• Panic attacks are the most frequent type of pseudoepileptic seizures in patients with epilepsy history and occur more commonly in epilepsy patients than the general population 2
• This misdiagnosis leads to "pseudosevere epilepsy" with unnecessary antiepileptic drug escalation 2

Key Distinguishing Features to Assess

Temporal characteristics:

• Epileptic anxiety typically lasts seconds to 1-2 minutes, while panic attacks usually last longer (peak within 10 minutes per DSM-V criteria) 3, 1
• Focal seizures may be followed by a postictal period with tiredness and confusion for several minutes 4

Associated symptoms:

• Look for focal neurological signs: jerking of one extremity, abnormal facial movements, small repetitive movements, or staring spells that suggest focal seizures 4
• Urinary incontinence during the episode suggests seizure over panic attack 4
• Right mesial temporal involvement specifically correlates with ictal panic symptoms 1

Response pattern:

• Seizures after long remission misdiagnosed as relapse when actually representing new-onset panic disorder 2
• Lack of response to standard panic disorder pharmacotherapy may suggest epileptic etiology 5

Definitive Diagnostic Testing

Video-EEG monitoring is essential when the diagnosis is unclear:

• Standard scalp EEG may miss deep limbic discharges, making video-EEG monitoring critical for diagnosis 6, 7
• Temporal lobe EEG abnormalities have been documented in patients with panic-like symptoms who respond to anticonvulsants 5
• EEG-EKG recording can document ictal tachycardia or bradycardia patterns 1

Brain imaging:

• MRI may reveal right mesial temporal sclerosis or other structural lesions in patients with ictal panic symptoms 1

Management Based on Diagnosis

If True Epileptic Seizures (Focal Seizures with Panic Symptoms)

Acute seizure management:

• Follow standard first aid protocols: help person to ground, place in recovery position on their side, clear area, stay with patient 4
• Activate EMS for: first-time seizure, seizures >5 minutes, multiple seizures without return to baseline, seizures with difficulty breathing, or failure to return to baseline within 5-10 minutes after seizure stops 4
• Never restrain the person or put anything in their mouth 4

Chronic seizure management:

• Standard antiepileptic drugs are appropriate: carbamazepam, phenobarbital, phenytoin, or valproic acid as monotherapy 4
• Valproic acid has shown particular efficacy in some refractory cases 7
• For patients with established epilepsy and new panic-like symptoms, reevaluate the epileptic syndrome rather than escalating AEDs 2

If True Panic Disorder (Not Epileptic)

Benzodiazepines for panic disorder:

• Clonazepam is FDA-indicated for panic disorder with or without agoraphobia 3
• However, use cautiously in patients with seizure history, as benzodiazepines can cause problems and SSRIs should be used cautiously in patients with seizure disorders 4, 3

Psychological interventions:

• Cognitive behavioral therapy (CBT) principles should be considered as primary treatment 4
• Problem-solving approaches for patients in distress 4
• Sensory grounding techniques to prevent dissociation if panic attacks have dissociative features 4

Avoid inappropriate AED escalation:

• Do not increase or add antiepileptic medications for panic attacks misdiagnosed as seizure relapse 2
• Obtain accurate retrospective diagnosis of prior epileptic syndrome before assuming relapse 2

If Diagnostic Uncertainty Persists

Consider anticonvulsant trial in refractory cases:

• Patients with panic attacks and temporal lobe EEG abnormalities who fail conventional panic treatment may respond to anticonvulsants 5
• Valproic acid has shown best results in this subset 7
• This approach is reasonable after nonresponse to standard pharmacotherapy 7

Critical Pitfalls to Avoid

• Do not assume seizure relapse in patients with long-remission epilepsy presenting with panic symptoms without video-EEG confirmation 2
• Do not use antipyretics (acetaminophen, ibuprofen) to stop or prevent seizures, even febrile seizures—they are ineffective 4
• Do not give oral medications during or immediately after a seizure when consciousness is impaired 4
• Recognize that scalp EEG may be falsely negative for deep limbic seizures; video-EEG monitoring is superior 6, 7
• Be aware that ictal panic from right temporal seizures can present identically to DSM-defined panic disorder 1