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Epilepsy

  • Writer: Christie Roberts
    Christie Roberts
  • 3 days ago
  • 11 min read

Epilepsy is a neurological condition characterised by unprovoked seizures. Seizures are defined by transient episodes of abnormal excitable electrical activity spread throughout the brain, which can also be described as excessive firings of neurons in the cortex (the outer 2-3mm of the brain).


There are multiple different types of seizure, which can affect people at different ages, occur in different areas of the brain, and present differently- I think everyone knows the 'classic' seizure that you see on TV where someone falls to the ground and starts shaking, but there are other presentations, including non-convulsive seizures (Kammerman and Wasserman, 2001). Epilepsy will usually be diagnosed when you have had more than one seizure (NHS, 2025), as people may have a one off seizure for multiple reasons. It's estimated up to 10% of people will have one seizure during their lifetime (WHO, 2024). Epilepsy is more common in children as their nervous system is more immature, with many more neurons- making it an excitable environment where inappropriate signals can be sent more readily.


Epilepsy can be divided into primary and secondary depending on the aetiology.

Primary epilepsy is also known as idiopathic epilepsy, meaning we don't know the cause. It is thought to account for 50-75% of cases of epilepsy (Kammerman and Wasserman, 2001; WHO, 2024).

Secondary epilepsy occurs following a trigger event. This may be a traumatic brain injury, a CVA, meningitis or encaphalitis, to name a few examples. The important part to remember is that although there was a trigger event that affected the brain, the seizures are still unprovoked, making it a form of epilepsy.


Other causes of seizures unreated to epilepsy can include:

  • Stress and sleep deprivation

  • Drug interactions

  • Electrolyte imbalances

  • Infections

  • Tumours

  • Hypoglycaemia

  • Fever

  • Acute brain injuries- CVA, TIA etc

  • Hemiplegic migraine

  • PNES/NEAD (I will try to cover this later in this post, but it's not an area I know a lot about)


Epilepsy is further categorised depending on the area of the brain that is affected, which will determione the type of seizure.


Generalised seizures affect both hemispheres of the brain, and will lead to an altered conscious level. This includes tonic-clonic (grand mal) and absence (petit mal) seizures.

Comparatively, focal seizures are localised to one hemisphere, and 1 area within that hemisphere.



Types of seizure

The one you've all been waiting for...


Tonic Clonic

Tonic clonic seizures are what you think of when you think 'seizure'. It's a form of generalised seizure involving a tonic stage- muscle tensing and stiffening, and a clonic stage- muscle jerking (Epilepsy Foundation, 2022a). People may experience an aura prior to a seizure (an aura is a subjective experience that can indicate to a person that a seizure is oncoming; prevalence ranges from 22-83% (Capara et al., 2023)).

Tonic clonic seizures can present with loss of consciousness, tongue and cheek biting, urinary incontinence, goraning or abnormal sounds, and irregular breathing. In the tonic phase, there may be a groan as air rushes out past the vocal cords and breathing may be difficult whilst in the clonic phase (Epilepsy Foundation, 2022a).

After the seizure has stopped, you can expect a prolonged post-ictal phase ('ictal' referring to the time spent in the seizure). During this period, the person may be tired, confused and irritable. It can take 5-30 minutes for the person to return to baseline (Abood and Bandyopadhyay, 2023).


Focal

Also known as partial seizures, these affect an isolated area of the brain. The temporal lobe is the most common location for focal seizures, and these are typically also associated with aura before the seizure, and post ictal confusion (Chowdhury et al., 2021). Depending on the focus of the seizure (where it is located) will dictate what symptoms are present. There can be:

  • sensory changes, such as hallucinations (auditory, visual, tactile, olfactory and gustatory), a sense of deja vu, intense feelings of fear or joy and visual disturbances (Epilepsy Society, no date)

  • motor changes, with abonrmal movements such as lip smacking, limbs becoming stiff or floppy, and unilateral repetitive movements (Epilepsy Society, no date)

  • autonomic involvement, including tachycardia, bradycardia, altered respiration, epigastic sensations, and even erections (International League Against Epilepsy, no date).

Because we love to sub-categorise things here, focal seizures can be broken down once again:

Simple partial seizures mean a person is typically awake and aware throughout the seizure, so can also be known as focal aware seizures. The person will know that the seizure is happening, and remember it afterwards. Sometimes, focal aware seizures are considered a type of aura as it can be an indicator of a further seizure.

Complex partial seizures can lead to impaired consciousness and impaired awareness, and are sometimes referred to as focal impaired awareness seizures (Kuma, Ighodaro and Sharma, 2024).


Myoclonic

Myoclonic seizures are sudden and brief muscle contractions that lead to abnormal twitching or movements. These are distinct from myoclonic jerks, as the seizure activity leads to reapeated muscle contractions. Episodes last only a second or two, but people may have several episodes over a short period of time. The episodes are short enough that you do not lose consciousness, and the person will be aware of the seizure.

Myoclonic seizures can be generalised or focal, and this will dictate which muscles are affected (Epilepsy Action, 2025a).

Myoclonic seizures can form part of a syndrome known as Juvenile Myoclonic Epilepsy (JME). This typically starts between the ages of 12-18, and around 10% of people with epilepsy have JME.. All people with JME will have myoclonic seizures, but can also have tonic clonic (90% of cases) and absence seizures (30% of cases). Absence seizures will typically present before the myoclonic or tonic clonic seizures, meaning that many young people are initially diagnosed woth Juvenile Absence Epilepsy (JAE) instead (Epilepsy Action, 2024).


Tonic

As we discovered earlier, a tonic phase refers to muscle tending and stiffening. Therefore in a tonic seizure, the whole body stiffens due to an increase in muscle tone.

If a person is standing when this happens, they will fall, and this will usually be backwards (ouch). Fortunately, tonic seizures usually occur during sleep (Epilepsy Foundation, 2017).

It is a form of generalised seizure, using both sides of the brain, so all muscle can be affected, and typically will last for a matter of seconds.

Tonic seizures are more common in people with Lennox-Gastaut syndrome, which is a rare form of childhood-onset epilepsy, often refractory to many anti-epileptic drugs (AEDs) and considered a developmental and epileptic encephalopathy (DEE) where seizure activity leads to progressive cognitive dysfunction (National Organisation for Rare Disorders, 2024).


Atonic

Also known as 'drop attacks', atonic seizures involve a sudden loss of muscle tone. They tend to be brief in duration and the person is typically aware during the seizure. They can be focal or generalised, but generalised is more common (Epilepsy Foundation, no date). Depending on what someone is doing when the seizure starts, injuries can occur so protectoive equipment such as helmets may need to be considered.

Episodes are usually short, and the person may or may not be confised following the seizure. As with tonic seizures, atonic seizures are often seen in Lennox-Gastaut syndrome, and also in Dravet syndrome (a rare genetic epileptic encephalopathy that begins in the first year of life) (Epilepsy Foundation, 2020a).


Absence

Absence seizures are also known as petit mal seizures. They most commonly occur in children, but can continue into adulthood (Epilepsy Foundation, 2022b). It is a generalised seizure where the person will lose awareness of their surroundings (NHS, 2025). This may present as appearing blank, staring into space, and then returning to normal, with episodes lasting 10-30 seconds. There may also be signs such as eyes turning upwards, eyelid fluttering, lip smacking and excessive blinking (Epilepsy Foundation, 2022b). People will be unaware of their surroundings but consciousness will not be affected. The seizure cannot be interruped by external stimuli, such as calling their name or touching them, which marks a distinction from daydreaming which it is often mistaken for, expecially in children. For this reason, it is often teachers who pick up on absence seizures in school and can escalate to relevant professionals.


Infantile spasms

Also known as West Syndrome, this is classed as a rare form of epilepsy affecting 1 in 3000 children in the UK (Young Epilepsy, 2023). It is usually diagnosed between 4-8 months of age, and can stop by around 4-5 years. It presents with clusters of full body spasms and can be associated with delayed development or developmental regression.


The characteristic electroencephaolgram (EEG) finding is hypsarrythmias.

(for the love of god, do NOT ask me to interpret what any of these squiggles mean, but I've been assured that they are 'very high voltage polyspike and slow wave discharges interspersed with multifocal spikes and slow waves' (Hancock, Osborne and Milner, 2001)).



Seizures that are not epilepsy

As previously mentioned, people can have seizures for lots of different reasons without it being epilepsy. From the above list of potential seizure triggers, I wanted to hone in on 2 real quick.


Febrile convulsions

Typically seen in babies and children between 6 months and 6 years old, febrile convulsions aer tonic clonic seizures caused by high temperatures. The seizure will usually last 2-3 minutes, but emergency care should be considered if it lasts more than 5 minutes (NHS, 2023). Febrile convulsions are not caused by epilepsy or any other pathology, although there is some evidence that links febrile convulsions with epilepsy later in life (NHS Inform, 2024).


PNES/NEAD

Psychogenic Non Epileptic Seizures, and Non Epileptic Attack Disorder (apologies, I don't know if there is a preferred term?) are conditions that cause seizures without any abnormal electrical activity in the brain as seen on EEG. The seizures arise from psychogenic causes, and can co-exist with epilepsy (Huff, Liu, Murr, 2024). Another term can be 'dissociative seizures' where the brain responds with seizure activity in response to a overwhelming stress (Mind, 2023). There's probably a lot more I can say about these types of seizures, but this would require significant further research on my part to do it justice.


Triggers for seizures

Triggers for seizures are multifactorial and cover a range of physical and emotional states. Common triggers include:

  • Missed medication

  • Illness- either with diarrhoea and vomiting, which may reduced absorption of medications, or with a fever which can contribute to febrile seizures

  • Hormonal changes, including with menstrual cycles or menopause

  • Sleep depreivation

  • Stress, or extreme emotions (anxiety, excitement)

  • Flashing/flicking lights- around 3-5% of people with epilepsy have photosensitivity (Epilepsy Action, 2025b)


Investigations and diagnosis

Patient history will be key. Knowing what type of seizure occurred, and how long it lasted for, can be crucial information in determining next steps.

An electroencephalogram (EEG) is a test that measures the electrical activity of the brain. Each type of seizure will have different wave patterns which can help determine the type of epilepsy.


Other tests can be used to rule out non-epileptic causes of seizures, such as MRIs to diagnose structural pathology (such as tumours) and ECGs to rule out cardiac involvement.


Blood tests similarly can rule out other organic causes- blood glucose levels, and serum electrolytes (abnormalities that can cause seizures are helpfully summarised in this table!)


Blood and urine cultures, and lumbar punctures, can also be used to rule out differential diagnoses such as sepsis, meningitis and encephalitis.




Management

The aim of epilepsy management is to be seizure free on the minimum amount of AEDs- ideally on a monotherapy. There are a range of different AEDs available including:

  • Levitiracetam (or Keppra, if you're one of many who can't pronounce the drug name)

  • Lamotrigine

  • Sodium valporate

  • Ethosuximide

  • Phenobarbitol

  • Phenytoin

  • Topiramate

  • Carbamazapine

  • Pregabalin


(Please consult the BNF/NICE for specific first line treatments for specific types of seizure)


The choice of medication will depend on factors including seizure type, epilepsy syndrome, risks and benefits of treatment, concurrent medications, age, sex, and personal circumstances (eg concordance with medication, likelihood of pregnancy).

One big warning is the use of sodium valporate in women of childbearing age, due to teratogenic effects. Topiramate should ideally also be avaided unless conditions of a pregnancy prevention programme are met (NICE, 2022).


The pharmacology of many AEDs is the impact on GABA in the brain. GABA has an inhibitory function, therefore introducing drugs that increase GABA will help to suppress excitable neuronal signals that are responsible for seizures. Additionally, medications may help to block sodium and calcium channels in neurons to prevent excitatory neuronal transmission.



Surgical intervention is also an option for epilepsy that does not respond to medication, through implanting a vagus nerve stimulator. This is a device implanted into the chest and connected to the vagus nerve, which sends mild electrical impulses to the brain to calm excitable activity (Epilepsy Society, 2023). I was lucky enough to watch this surgery when I was a student nurse- it really is an amazing piece of technology.


Thermal ablation is another option, for focal epilepsy. Here, a laser is guided to the focus of the seizure activity under MRI guidance and uses heat to ablate the target area (Epilepsy Foundation, 2020b). It is considered a minimally invasive surgical option, with an efficacy of around 50% after single treatment (Winslow, Himstead and Vadera, 2025).


There are also supportive measures in managing epilepsy, such as recognising, recording and reporting seizure activity to measure drug efficacy, and reporting seizures to the DVLA (which may require you to surrender your license, sorry).


There is some evidence that following a ketogenic diet can help to reduce seizure frequency in drug resistant, or refractory, epilepsy. The Keto diet is has high fat and low carbohydrates to promote the production of ketones (GOSH, 2020). The ketones are thoughts to disrupt cellular metabolism and homeostasis and impact on resting membrane potential that play a role in excitable neuronal activity to reduce seizure activity (Mishra, Singh, Ramadass, 2024).


Status epilepticus

Status epilepticus is a medical emergency characterised by a seizure lasting over 5 minutes, or multiple seizures without regaining consciousness in between. Status epilepticus can be convulsive or non-convulsive, and can become refractory to appropriate AEDs. It can be associated with significant morbidity and mortality from neurological injury if not corrected rapidly and appropriately.

Management requires an A-E approach:

  • Maintain airway patency

  • Administer high flow oxygen

  • Cardiac monitoring

  • Obtain IV access

  • Check blood glucose levels

The aim of treatment is to stop the seizure as fast as possible, as seizures become harder to stop the longer they go on (NICE, 2022).

The first line treatment is benzodiazepines, with the aim of opening channels for chloride ions to enter neurons and bring the threshold down to inhibit excitatory firings. This would be buccal midazolam, rectal diazepam or IV lorazepam. If there is no response after 5-10 minutes, a second dose should be given (NICE, 2022).

If ineffective, second line treatment could include levitiracetam, phenytoin, sodium valporate or phenobarbitol. If status continues despite this, general anaesthesia may be considered (NICE, 2022).




I hope you have found this post informative. As always, information is correct to the best of my knowledge and as to what is published at the time of writing. Please let me know if you have any questions!



Love,

Christie x



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