What components should be included in a comprehensive template for history taking for convulsions?

Comprehensive History Taking Template for Convulsions

A thorough convulsion history must systematically capture the pre-ictal circumstances, ictal phenomenology with precise timing and movement characteristics, and post-ictal recovery pattern, while simultaneously identifying red flags for serious underlying pathology such as meningitis or cardiac arrhythmia.

Pre-Ictal Phase: Circumstances and Triggers

Immediate Precipitants

• Fever presence and magnitude: Document temperature, as febrile convulsions are common in pediatrics and require specific management protocols 1, 2
• Posture at onset: Standing/sitting suggests reflex syncope or cardiac causes; supine onset more consistent with epilepsy 1
• Specific triggers:
  • Prolonged standing, warm environment, or emotional stress (vasovagal syncope) 1
  • Flashing lights or visual patterns (photosensitive epilepsy) 1
  • Sleep deprivation (lowers seizure threshold) 1
  • Sudden loud noises/alarm clocks (long QT syndrome type 2 or startle epilepsy) 1
  • Strong emotions during argument (catecholaminergic polymorphic VT or cataplexy) 1

Prodromal Symptoms (Seconds to Minutes Before)

• Autonomic symptoms: Nausea, sweating, pallor (suggests reflex syncope) 1
• Visual changes: Dark spots, loss of color vision, tunnel vision (cerebral hypoperfusion in syncope) 1
• Auditory changes: Distant sounds, buzzing, tinnitus (syncope-related hypoperfusion) 1
• Epileptic aura features:
  • Rising epigastric sensation with unpleasant smell/taste (epileptic aura) 1
  • Déjà vu or jamais vu phenomena (pro-seizure) 1
  • Ictal cry or shout at attack onset (epilepsy) 1
• Cardiac symptoms: Palpitations preceding event (tachyarrhythmia) 1

Ictal Phase: Detailed Seizure Phenomenology

Loss of Consciousness Characteristics

• Duration of unconsciousness (critical discriminator):
  • <30 seconds strongly favors syncope 1

  • 1 minute suggests epileptic seizure (mean 74-90 seconds) or psychogenic non-epileptic seizures 1

  • 5 minutes indicates psychogenic pseudosyncope or psychogenic non-epileptic seizures 1

Nature of Fall

• Stiff, keeling over: Tonic phase epilepsy or occasionally syncope 1
• Flaccid collapse: Typical of all syncope variants or atonic epilepsy (rare, pediatric) 1

Movement Characteristics (Eyewitness Account Essential)

• Timing relative to fall:

  • Movements beginning before fall: epilepsy 1
  • Movements beginning after fall with delay (mean 20 seconds): syncope 1
  • Movements at onset of unconsciousness: epilepsy 1

• Movement pattern:

  • Symmetrical, synchronous movements: epilepsy 1, 3
  • Asymmetrical, asynchronous movements: syncope (rarely epilepsy) 1
  • Restricted to one limb or one-sided: epilepsy 1
  • Pelvic thrusting: psychogenic non-epileptic seizures or frontal lobe seizures 1
  • Repeated waxing/waning intensity with changing movement nature: psychogenic non-epileptic seizures 1

• Movement quantity:

  • Few movements (~10 countable): syncope far more likely 1
  • Many movements ("cannot count," "100+"): epilepsy or psychogenic non-epileptic seizures 1

Associated Features During Event

• Eye position: Open during unconsciousness (generalized seizures) versus closed (psychogenic non-epileptic seizures) 3
• Oral automatisms: Chewing, lip smacking, blinking (generalized seizures) 3
• Tongue biting: Especially lateral tongue (epilepsy more than syncope) 3
• Incontinence: Document urinary or fecal incontinence 4
• Cyanosis: Presence and duration 4

Post-Ictal Phase: Recovery Pattern

• Duration of confusion/drowsiness: Prolonged post-ictal state suggests epilepsy; brief or absent favors syncope 5
• Neurological deficits: Todd's paresis or focal weakness (epilepsy) 4
• Amnesia for event: Complete versus partial recall 4
• Headache, muscle soreness, or injuries sustained 4

Critical Background History

Seizure History

• Age at first seizure: Younger age increases febrile seizure recurrence risk 1, 2
• Previous seizure episodes: Frequency, characteristics, triggers 1
• Classification of prior events: Simple versus complex features 1, 2

Family History

• First-degree relatives with febrile convulsions: Increases recurrence risk to ~50% 1, 2
• Family history of epilepsy or sudden cardiac death: Suggests inherited channelopathies 1

Developmental and Neurological Status

• Baseline neurodevelopmental state: Document any pre-existing delays or abnormalities 1, 2
• Recent head trauma: Concussive convulsions occur within 2 seconds of impact with good prognosis 6, 5

Medical Context

• Current medications: Antiepileptic drugs, drug interactions, compliance 7
• Recent illness or infection: Meningitis risk assessment, especially in children <12-18 months 1, 2
• Metabolic factors: Hypoglycemia, electrolyte disturbances 1

Red Flags Requiring Urgent Investigation

• Age <12-18 months with fever: Lumbar puncture mandatory to exclude meningitis 1, 2
• Meningeal signs: Neck stiffness, photophobia, altered mental status 1, 2
• Complex convulsion features: Duration >20 minutes, focal features, incomplete recovery 1, 2
• Comatose state: Requires experienced physician assessment before lumbar puncture due to herniation risk 1, 2
• Cardiac symptoms with exercise or emotion: Consider channelopathies requiring cardiology evaluation 1

Common Pitfalls to Avoid

• Assuming all movements indicate epilepsy: Myoclonic jerks occur in syncope; focus on timing, symmetry, and quantity of movements 1
• Overlooking cardiac causes: Palpitations, exercise-related events, or family history of sudden death warrant ECG and cardiology referral 1
• Delaying lumbar puncture in young infants: Meningitis can present without obvious meningeal signs in children <18 months 1, 2
• Over-investigating simple febrile seizures: Routine EEG, electrolytes, and calcium are not indicated without specific clinical suspicion 1, 2