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Seizures and Epilepsy

Frequently Asked Questions

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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
    foward 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.
  • Please
    take a moment to evaluate this monograph.

    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.