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Seizures and Epilepsy – FAQ

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Contents

  • What
    is a seizure?

  • "Grand
    Mal" – Primary Generalized, Tonic-Clonic Seizures

  • "Temporal
    Lobe Epilepsy" – Complex Partial Seizures

  • "Focal
    Fits" – Simple Partial Seizures

  • Other
    Seizure Types

  • If
    I see someone having a convulsion, what can I do?

  • First,
    what NOT to do

    What TO do

    What is a seizure? If
    someone has a seizure, does that mean they suffer from epilepsy?

    A seizure is a change in behavioral
    state which results from abnormal electrical activity in the brain. Given the
    right set of circumstances (e.g. – blow to the head, intoxication, high fever)
    anyone can experience a seizure. The occurrence of a seizure in the presence of
    some acute precipitating physiological disturbance does not mean that it will
    ever happen after the precipitating cause has resolved. When seizures recur
    without any obvious precipitant or cause, then a person may be considered to
    have epilepsy.

    What happens during a seizure?

    "Grand
    Mal" – Primary Generalized, Tonic-Clonic Seizures

    The true generalized seizure is
    characterized by sudden loss of consciousness, usually without warning. At onset
    there is usually a general stiffening of the body, often with forceful
    expiration of air (and a peculiar sound as this air passes through the throat).
    If the person having the seizure is standing when this happens, there can be a
    hard fall to ground or floor. This "tonic" phase of the seizure is
    generally very brief but is responsible for a number of things which often
    frighten witnesses. Because virtually all skeletal muscles in the body are
    forcefully contracting at the same time, there may be biting of the tongue,
    passage of urine, (rarely) defecation or vomiting, and sometimes a change in
    color to a purplish-blue (due to muscles of respiration being stuck in the
    tightened state). This phase generally lasts about 30 seconds.

    Immediately following the ‘tonic’
    phase of a seizure, convulsing begins as forceful, rhythmic jerking of arms,
    legs, head and neck. This activity is variable in both its forcefulness and its
    duration, but it can last a couple of minutes, building up in intensity and then
    fading out while the frequency of shaking remains relatively constant.
    Skin/lip/nail bed color generally returns to normal during this period.

    After the convulsing ceases, there is
    usually a state of deep sleepiness. During this period, all the muscles that
    were convulsing are deeply relaxed. If a person in this state is in a position
    which makes it hard for them to breathe, they may NOT change their own position
    (see following section). The folklore about people with seizures
    "swallowing their tongue" actually relates to the possible airway
    obstruction which can occur in a person who is on their back with their head
    flexed forward during the very sleepy period after a major convulsion.

    As the sleepiness lightens, a person
    recovering from a seizure may initially be confused or even hard to engage in
    conversation beyond a few words. The confusion more often than not passes over
    minutes, but the desire for a retreat to bed to sleep for a while sometimes
    lasts for quite a while.

    If a generalized convulsion is
    prolonged (5 minutes or more) or if it is followed by a second seizure before
    complete recovery (person is awake and interactive), it is time to seek medical
    assistance.

    "Temporal Lobe
    Epilepsy" – Complex Partial Seizures (often erroneously labeled ‘petit
    mal’)

    The second most common form of seizure
    in adults is "partial" (i.e.-the electrical ‘storm’ involves some but
    not all of the brain) "complex" (i.e.- disturbance of consciousness).
    Usually the area of brain involved in the seizure activity is the temporal lobe.
    But other parts of the brain can give rise to seizures which fall under this
    heading. What most of these seizures have in common is:

    • Some form of warning or
      "aura" with an awareness that something is about to happen. This
      may take the form of a mental picture, a noxious odor, an unusual sensation
      in the stomach, the perception of a voice or music, even a particular
      recollection;

    • Loss of awareness without
      collapse/unconsciousness (as if ‘auto-pilot’ takes over);

    • Duration of minutes during which
      there may be automatisms — repetitive, non-purposeful acts — (eg.- lip
      smacking, swallowing, picking at things, garbled or semi-random speech,
      aimless walking or manipulation of objects);

    • A period of confusion lasting
      minutes after the episode, possibly with sleepiness (but not the profound
      somnolence that generally follows a major convulsion). The person in this
      state may walk around, as if with purpose. Rarely, aggression may be
      manifest during this phase – especially if someone is attempting to
      passively restrain/direct movement. This aggression, when manifest, is not
      well-focused, not ‘thought-out’ and can often be avoided by leaving the
      person alone for a few minutes.

    There is actually quite a bit of
    variety in the behavior individuals with this type of seizure exhibit. But once
    a seizure of this type has expressed itself in an individual, any subsequent
    episode generally has the same aura and outward behavioral appearance as the
    first one.

    There is total amnesia for the period
    of the seizure and variable amnesia for events just preceding and following it.
    Sometimes, in some persons, this type of seizure precedes a generalized
    convulsion (see above) as the electrical signal spreads out from one part of the
    brain to the entire brain.

    "Focal Fits"
    – Simple Partial Seizures

    Seizures which involve only part of
    the brain ("partial") without alteration of awareness
    ("simple") can occur in persons who have had injury to the brain (as
    from trauma, stroke, hemorrhage, malformation, tumor). Most commonly, they
    involve rhythmic (2-3 cycles/second) twitching of face, hand/arm, and/or leg on
    the side of the body opposite to the side of brain from which the seizure
    emanates. Generally, this type of seizure lasts minutes. In some individuals, it
    forms the prelude to a generalized convulsion. Occasionally, it can go on for a
    very long time (hours-days). The longer it lasts, the greater the associated
    fatigue. Extremely prolonged versions of this seizure type can interfere with
    sleep, cause muscle pain and lead to exhaustion.

    Other Seizure Types

    The true "petit mal" seizure
    type (also known as "Absence Attacks" or technically, "Primary
    Generalized Seizures – Absence Type") is observed almost exclusively in
    children. It is mentioned in this section only to assist in the campaign for
    accurate terminology.

    Absence seizures are characterized by
    abrupt and brief interruption of consciousness without convulsion. During the
    typical, seconds-long episode there is "loss of contact",
    "spacing out" rarely with chewing, swallowing, or blinking
    automatisms. Sometimes an individual continues doing whatever they were doing at
    seizure onset, though in an automatic way. During the episode, interaction is
    not possible. These episodes can be very brief, subtle and easily missed by a
    nearby observer. Normally, whatever activity a child was engaged in before the
    seizure is continued following it. Sometimes children with these seizure types
    are misdiagnosed with learning or behavioral problems.

    There are a host of seizure types
    which are seen only in children or infants.

    If I see someone having a convulsion, what
    can I do
    ?

    First, what NOT to do

    • DO NOT TRY TO PUT
      ANYTHING IN THE PERSONS MOUTH;

      • There is no place for the
        "tongue blade" at the bedside or in the home. In fact, it is
        dangerous. Many sticks, teeth, and other things have been broken by
        persons attempting to prevent "swallowing of the tongue". The
        same applies to fingers – never place anything in the mouth of a person
        who is actively seizing/convulsing.

      • It is sometimes appropriate to
        place an oral airway after the seizure has ended, but only if you’ve
        been trained in its use (and there happens to be one present). There is
        another way to deal with the airway during the profound sleepiness which
        sometimes follows a seizure — (read on).

    • DO NOT TRY TO
      RESTRAIN THE CONVULSING LIMBS;

      • Soften the surface, remove
        obstacles/furnishings, get the person to a safe spot, cushion head with
        your hands, YES. Restrain, NO.

    • IF A PERSON KNOWN
      TO HAVE ‘CONVULSIVE’ EPILEPSY SHOWS A COLOR CHANGE TOWARD BLUE IN FACE,
      LIPS, NAIL-BEDS AT THE ONSET OF A SEIZURE- COUNT TO 60;

      • The cyanosis (bluing of lips,
        nails, skin) that may accompany what in essence is a brief
        "respiratory arrest" at the beginning of a convulsion is
        caused by contracted and ‘stuck’ respiratory muscles. It is not
        something that can be altered by any bystander/caregiver. It should pass
        relatively quickly, with improvement in color as the convulsion
        proceeds.

      • If the above state lasts
        beyond a minute, OR if it is followed by relaxation (instead of
        convulsive movements) with persistent bluish color, it would probably be
        wise to assume that this IS a respiratory arrest and NOT a seizure. [In
        which case the proper response would be Basic Life Support].

    • DO NOT ATTEMPT TO
      GIVE THE PERSON MEDICATION/FLUIDS WHILE THEY ARE NON-INTERACTIVE;

      • The person should be talking
        before any attempt is made to give anything by mouth.

    Now, what TO do.
    (Sometimes the most important things are the simplest) –

    • Especially if this is the first
      seizure you’ve ever witnessed, or if you don’t know anything about the
      person’s medical history, feel for the carotid pulse. Feeling this should
      provide the necessary reassurance that the individual is not experiencing a
      cardiac arrest. Hopefully, you can relax enough to remember the following
      tips –

    • Create the safest possible
      environment for the seizure. Position away from objects which threaten
      injury. Provide a soft surface, if possible. Cushion head with hands to
      prevent banging of head against the ground/floor.

    • As the seizure ends and a state of
      deep relaxation ensues, place the person in the "recovery
      position" (as illustrated below).

      Recovery PositionRecovery Position - Head of bed view

      Never should the individual be left flat on their back – that position
      invites airway obstruction (by a relaxed/swollen tongue dropping to the back
      of the throat, blood from a bitten tongue, or vomitus). If, after
      positioning the person as illustrated there is any sign of ineffective
      breathing (loud snoring type sound, little/no air moving to/from
      mouth/nose), ensure that there is nothing in the mouth by sweeping your
      finger through, removing any debris as you do so [NOTE WELL- The seizure has
      stopped at this point and the person looks as if deeply asleep]. If there
      are dentures, this is the time to remove them. If after doing the foregoing
      there is still a loud snoring sound, try extending the neck a bit more.
      Other options to help open the airway include use of an oral airway or a
      performance of a "jaw thrust maneuver" (illustrated here).

    Jaw Thrust maneuver

    • Recovery should proceed over
      minutes, though significant fatigue is likely. If there has not been any
      injury (eg.- no significant cuts to skin or tongue or concern regarding
      injurious effects of a fall to ground/floor), the person should be allowed
      to fulfill their desire to rest.

    • Seek medical/hospital treatment if
      their is any concern about significant injury or if this is the individual’s
      first seizure.

    A couple of unusual
    situations-

    [Author’s note: I doubt that it would
    be possible to address every contingency pertaining to responses to seizure in
    any document – even in the ultimate hyperlinked Web-work. Hopefully, the most
    common scenarios will ultimately be well addressed in these pages.]

    There are a couple of unusual
    circumstances that are worth noting, especially because awareness can have a
    major impact upon outcome in particularly dangerous situations.

    • Seizure in water (e.g. –
      swimming). No one should swim alone. Persons known to have epilepsy of any
      type should not swim without their escort realizing that a seizure in water
      can be a particularly dangerous thing. During the forced expulsion of air at
      seizure onset, a seizing person would tend to sink quite rapidly. Then, with
      onset of the convulsive activity, water would tend to be drawn into the
      lungs. In non-convulsive seizure disorders, the impairment of awareness or
      movement control could pose some difficulty to a rescuer, but should not be
      dangerous as long as the head is kept above the water. Bottom-line? Consider
      the depth of water used during recreation as well as use of device which add
      some buoyancy.

    • Concern about possible neck injury
      in fall during a seizure. Fortunately, it seems to be remarkably rare for
      serious injuries to accompany seizures. Still, occasionally the fall at
      seizure onset is a hard drop to a hard surface. Especially in medical
      settings, such an occurrence tends to reflexively result in taking extra
      precautions with respect to possible neck injury. This means applying
      traction to the head in such a way as to minimize flexion/extension
      movements, especially after the convulsion ends. There is still a need to
      move the person into the recovery position, the difference being that
      someone has to continuously hold the head in such a way as to keep the spine
      straight. This can pose a bit of difficulty for one attendant if the person
      who had the seizure is having difficulty breathing. This situation calls for
      a "jaw thrust", with the caveat that the neck should not be
      extended.

    • Seizures which are prolonged or
      which occur one after another… are a special circumstance in that they may
      hurt the brain. Emergency medical attention should be sought immediately.

    What observations
    about a seizure (or what I think was a seizure) might be important to my
    physician?

    The observations of a witness are
    generally key to diagnosing the various forms of seizure and in distinguishing
    seizures from episodes that can be confused with them (such as faints, various
    forms of tremor, and a host of unusual causes of episodic behavioral phenomena).
    While patients can often provide key information (or all the information
    necessary when there is no interruption of consciousness), a witness/observer is
    the only one who can provide the information which leads to an accurate
    diagnosis. Specific observations have particular relevance depending upon the
    whether this is a person’s first seizure, a recurrent seizure or an episode
    differing from past seizures.

    In general, it might be good to write
    down your observations soon after the episode while memory is fresh, using the
    following as a guide. [Some questions would best be directed to the person who
    had the episode, others to a witness].

    First Seizure

    • What was the person doing
      immediately before the episode?

    • Has there been any traumatic loss
      of consciousness in the recent (or remote) past? [Be able to provide
      details]. Has there been any recent illness (fever, "flu")?

    • Did the person seem to have a
      feeling that something was about to happen before the episode? Was it even
      more specific than a ‘feeling’?

    • As the seizure began, what did you
      see first? Was there any color change in skin, lips or nail-beds? Were there
      movements of eyes to one side? If so, which side? Did one side of the face
      twitch before the other? Did one limb start jerking before another? [In
      general, if any movements or postures were seen more on one side than
      another, it can be helpful to know which side did what.]

    • In non-convulsive episodes, a
      description of exactly what the person did/said during and shortly after the
      episode would be helpful. Note the duration of the spell; between onset and
      resolution of any confusional period which follows.

    • Was there passage of urine? of
      stool? Any vomiting?

    • Was there any bleeding in the
      mouth?

    • How long did the jerking part of
      the episode last?

    • After the episode, what did the
      person do?

    Recurrent Seizure

    • Did this seizure look the same as
      prior ones?

    • Was it longer or shorter than
      average?

    • Have there been any recent
      medication changes or missed doses of medication?

    • Has there been any recent change
      in sleep habit (eg.- up all night preceding the day of the seizure)?

    • How much (if any) recent alcohol,
      caffeine, marijuana, or cocaine has been used? When was it last used in
      relation to the time the episode/seizure happened?

    • Are there any new medications
      (prescription or non-prescription) being taken? Any herbal remedies?

    • Have there been any unusually
      stressful events in life recently?

    • Has there been any major change in
      weight since the last seizure? [Occasionally, a significant weight change
      may be associated with a change in blood anticonvulsant level in an
      individual who had long shown a stable blood level].

    Recurrent Seizure,
    but Different from Previous Seizures

    In addition to answers to questions,
    from the above section ("Recurrent Seizure") please consider the
    following:

    • Exactly how was the episode
      different from previous ones? Was there a different ‘warning’ or
      "aura"? Did the spell involve a different part or side of the
      body? Did it start differently?

    • Has there been any recent illness,
      new symptom of a possible illness? Any recent injury – especially blow to
      the head?

    "Should an extra
    dose of anticonvulsant be given as soon as possible after a seizure?"

    In someone who is taking
    anticonvulsant/anti-epileptic medication, a "breakthrough" seizure may
    be a sign of a blood anticonvulsant level which has fallen too low. But
    occasionally (uncommonly) a seizure can be a manifestation of toxicity from too
    much anticonvulsant in the system. Thus, unless there have been prior directions
    from a physician covering this contingency, or it is known that a scheduled dose
    of medication was missed, it is probably most wise to seek direction from your
    physician/neurologist before giving any extra medication.

    "I haven’t
    had a seizure in years but I still take medication to prevent seizures. Am I
    supposed to take this for the rest of my life?"

    It is easier for a physician to
    provide well-grounded advice regarding starting an anticonvulsant when a seizure
    disorder has developed or when a person is at unusually high risk for having
    seizures. Providing advice regarding when to discontinue medication in the
    absence of seizures is much more difficult. There needs to be a reasoned
    weighing of ongoing risk of seizure recurrence against factors such as
    medication side-effect(s), cost of medications, potential drug interactions,
    willingness to defer driving during and for a while after the withdrawal of
    anticonvulsant. These are matters best discussed with your
    physician/neurologist.

    "Is there
    anything other than medication that can be done to help prevent seizures?"

    Seizure activity can be evoked from
    any brain given the right combination of circumstances. The concept of a
    "seizure threshold" is based upon the fact that with enough
    physiological or pharmacologic ‘stress’, seizures can happen in any mammal
    (including humans). Individuals differ in what constitutes "enough" of
    a stress. Some of the factors which influence seizure threshold include genetics
    (family history), brain trauma (especially "open" or penetrating
    wounds to brain), a number of medications and drugs (including things not often
    thought of as "drugs"), body temperature, sleep deprivation and a host
    of metabolic variables (for example: blood sugar, blood oxygen level, blood
    minerals, hormones).

    There are a number of
    frequently-overlooked habits which can have a bearing upon seizure risk.

    • Caffeine (found in coffee, tea,
      over-the-counter ‘stay-awake’ pills and many carbonated beverages) lowers
      seizure threshold. This doesn’t mean that all persons with or at risk for
      seizures should abstain completely from anything with caffeine in it. It
      just means that moderation is probably wise here, especially if prevention
      of recurrent seizure is proving difficult.

    • Alcohol makes it easier to have a
      seizure. It does so both as its level rises in the blood stream and as it
      later falls. It also tends to interact with just about every drug used to
      treat or prevent epilepsy. Because of its complex effects upon metabolism,
      body water and mineral balance, sugar metabolism and even sleep, alcohol use
      should probably be avoided in anyone who has had or is at special risk of
      seizure.

    • Sleep-deprivation (as in changing
      from day-shift to night-shift work, or staying up all night to work on a
      term paper, etc.) probably does much to lower seizure threshold.

    • Combinations of the above are,
      more likely than not, additive in there effects.

    "What are some
    good sources of additional information regarding seizures and epilepsy?"

  • Your friendly neighborhood
    physician/neurologist.

  • The Epilepsy Foundation of America
    (Telephone: 1-800-332-1000) – a trove of educational resources, including
    bibliographic lists, videotapes, brochures and pamphlets.

  • Engel, J. Seizures and Epilepsy.
    Philadelphia: FA Davis, 1989.

  • Menkes, JH and Sankar, R:
    Paroxysmal Disorders. In Textbook of Child Neurology, 5th edition.
    Baltimore: Williams and Wilkins, 1995.

  • For lengthier or more reflective
    comments, feel free to write me at:

    Northeast Rehabilitation Hospital
    70 Butler Street
    Salem, NH 03079

    Acknowledgments:
    Thanks to Carl Billian, MD, Greg Lipshutz,
    MD and J. Prochilo for their critical reviews of this work and to N. Druke for
    kindly helping with illustrations.

    Copyright © James Whitlock, MD