When to Refer a Patient with Seizures to a Specialist
Patients with features suggesting epilepsy should be referred for specialist neurologic assessment, while those with suspected cardiac causes or unexplained seizures after initial assessment require specialist cardiovascular evaluation. 1
Immediate Neurologist Referral (Within 24 Hours)
- Suspected acute encephalitis requires immediate neurological specialist opinion within 24 hours of referral 2
- Status epilepticus or refractory seizures in the emergency department, particularly those not responding to first-line benzodiazepines and phenytoin 1
- New focal neurologic deficits developing after seizure, as this suggests structural pathology requiring urgent evaluation 1, 2
Urgent Neurologist Referral (Within Days to Weeks)
First unprovoked seizure with high-risk features including:
Pediatric patients with intractable epilepsy being considered for seizure surgery should be referred to a neurosurgeon with expertise in seizure surgery 1
Worsening symptoms over time despite normal initial examination, as this pattern suggests evolving pathology 2
Rapid head growth, infantile spasms, neurologic examination changes, or regression of skills warrant brain MRI and neurologist consultation 4
Non-Urgent Specialist Referral
Failure of two antiepileptic drug trials to control seizures indicates the patient should be referred to an epilepsy center, as additional medications are unlikely to be effective and alternative treatments (epilepsy surgery, ketogenic diet, vagus nerve stimulators) should be considered 5, 6
Refractory seizures requiring multiple anticonvulsants, particularly in patients with velocardiofacial syndrome or other complex conditions requiring collaboration with epileptologists or movement disorder neurologists 4
Suspected epilepsy syndromes requiring accurate classification through detailed clinical history and EEG to guide medical management 4, 5
Cardiovascular Referral (Not Neurologist)
Suspected cardiac cause of transient loss of consciousness or unexplained events after initial assessment should receive specialist cardiovascular assessment rather than neurologic referral 1
Brief seizure-like activity during syncope is common and should not be regarded as indicating epilepsy; these patients need cardiovascular rather than neurologic evaluation 1
Patients Who Do NOT Require Specialist Referral
Uncomplicated faint, situational syncope, or orthostatic hypotension should receive electrocardiography but do not require immediate further investigation or specialist referral 1
Acute symptomatic (provoked) seizures secondary to correctable causes such as hypocalcemia, hypomagnesemia, fever, medication effects, or metabolic disturbances do not require neurologist referral if the underlying cause is identified and corrected 4, 7
Single unprovoked seizure without risk factors may be managed without immediate antiepileptic drugs or specialist referral, as delaying therapy until a second seizure does not affect remission rates 3
Critical Pitfalls to Avoid
Do not assume brief seizure-like movements indicate epilepsy during a syncopal event, as this is a common occurrence that leads to misdiagnosis and inappropriate neurologic referral 1
Do not overlook correctable metabolic causes such as hypocalcemia before attributing seizures to primary epilepsy, as correcting the underlying electrolyte disturbance should be the primary treatment 4, 7
Do not delay referral for patients failing two medication trials, as 60-70% of patients with temporal lobe epilepsy can become seizure-free with epilepsy surgery 5
Do not perform routine EEG on patients with syncope as the primary diagnosis, as it is not beneficial when syncope is the most likely cause of transient loss of consciousness 1
Do not continue indefinitely trying additional antiepileptic drugs in primary care once two appropriate medications have failed; this delays access to potentially curative surgical options 5, 6