Management of Post-Concussion Seizures
For post-concussion seizures, treat active seizures immediately with standard antiepileptic medications including levetiracetam, sodium valproate, phenytoin, benzodiazepines, propofol, or barbiturates, but do NOT use routine prophylactic antiepileptics unless the patient has high-risk features such as intracranial hemorrhage, depressed skull fracture, or loss of consciousness >24 hours. 1, 2
Acute Seizure Management
When a seizure occurs after concussion, immediate treatment is required:
- First-line treatment: Administer benzodiazepines (such as lorazepam) for active seizures 2
- Second-line agents if seizures persist despite benzodiazepines: Use levetiracetam, sodium valproate, phenytoin, propofol, or barbiturates 3, 1
- For myoclonic seizures specifically: Propofol is particularly effective, along with clonazepam, sodium valproate, or levetiracetam (note that phenytoin is often ineffective for myoclonus) 3, 1
Levetiracetam (Keppra) Dosing for Active Seizures
When using levetiracetam for refractory status epilepticus after benzodiazepine failure, administer 30 mg/kg IV loading dose at 5 mg/kg per minute. 3
For ongoing seizure management:
- Loading dose: 1000-1500 mg IV 2
- Maintenance: 500-1500 mg IV/PO twice daily 2
- The FDA-approved dosing for adults starts at 1000 mg/day (500 mg BID), with increments up to 3000 mg/day maximum 4
Seizure Prophylaxis Decision Algorithm
Prophylaxis is indicated ONLY for high-risk traumatic brain injury patients, not for all concussions. 2
High-Risk Features Requiring Prophylaxis:
- Intracranial hemorrhage 2
- Depressed skull fracture 2
- Loss of consciousness or amnesia >24 hours 2, 5
- Age >65 years 2, 5
- Chronic subdural hematoma 2
- Past history of epilepsy 2
Prophylaxis Protocol When Indicated:
- First-line agent: Levetiracetam is preferred over phenytoin due to better tolerability, lack of significant drug interactions, and comparable efficacy 2
- Dosing: 1000-1500 mg IV loading, then 500-1500 mg IV/PO twice daily 2
- Duration: Maximum 7 days only—prolonged prophylactic use is not supported by evidence and may worsen neurological outcomes 2
- Alternative: Phenytoin (18-20 mg/kg IV at maximum 50 mg/min) remains acceptable when rapid CSF penetration is prioritized 2
Critical Caveat - Avoid Valproate:
Valproate should be avoided for traumatic brain injury prophylaxis due to increased mortality in this population. 2
Monitoring and Diagnostic Approach
- Imaging: Head CT is the preferred initial modality to identify acute intracranial hemorrhage or mass effect requiring urgent intervention (identifies 100% of acutely treatable lesions, with ~7% requiring urgent surgery) 5
- EEG monitoring: Consider continuous EEG in patients with depressed mental status disproportionate to brain injury severity to detect nonconvulsive seizures 2, 5
- Seizure detection: Use intermittent EEG to detect epileptic activity in patients with clinical seizure manifestations 3
Important Clinical Pitfalls
Do not use routine prophylaxis for all concussions: Overall prevention of post-traumatic seizures with antiepileptics cannot be broadly recommended based on analysis of over 2,700 patients across 11 clinical trials 2
Do not exceed 7 days of prophylaxis: Unless actual seizures occur, prolonged prophylactic use lacks evidence and may harm outcomes 2
Do not use high-dose glucocorticoids: The Brain Trauma Foundation explicitly states these should NOT be used after severe traumatic brain injury (Grade 1-, Strong Agreement) due to association with higher mortality 1, 2
Recognize myoclonus may be non-epileptic: Clinical seizures including myoclonus may not be of epileptic origin, and other motor manifestations could be mistaken for seizures 3
Evidence Quality Note
The Neurocritical Care Society recommends levetiracetam, valproate, or phenobarbital (in addition to phenytoin/fosphenytoin) for urgent seizure control based on high-level evidence 3. However, for traumatic brain injury specifically, levetiracetam is preferred and valproate should be avoided due to mortality concerns 2.