Seizures are a common clinical presentation—but behind each episode lies a nuanced web of causes, classifications, and considerations. Effective care begins with pattern recognition, cause exploration, and clinical prioritisation.
This guide walks through how clinicians approach seizure care—from the first event to long-term planning—by connecting symptoms to anatomy, treatment, and safety.
🔍 Step 1: Was it a seizure?
Before jumping to medication, pause and ask:
Did the patient really have a seizure—or something that looked like one?
Seizures can be confused with:
- Fainting (syncope)
- Panic attacks
- Hypoglycaemia
- Movement disorders
- Non-epileptic events (often psychogenic)
Key clinical features to explore:
- Were there rhythmic movements or convulsions?
- Did they lose consciousness?
- Was there confusion or sleepiness after?
- Did anyone witness unusual behaviour before the event—like déjà vu, fear, or strange smells?
These features help us decide if this was a seizure, and if so, what type.
🧠 Step 2: What kind of seizure was it?
Seizures are caused by abnormal electrical activity in the brain. Symptoms often reflect the area affected:
Brain Region | What You Might Notice |
|---|---|
Temporal lobe | Strange smells, déjà vu, abdominal rising, automatisms |
Frontal lobe | Sudden movements, speech arrest, complex motor activity |
Occipital lobe | Visual hallucinations like flashing lights |
Parietal lobe | Numbness, tingling, or spatial confusion |
By matching symptoms to brain regions, we start localising the origin of the seizure—a key skill in neurology.
📋Step 3: What do you do during the event?
In the moment, pharmacology isn’t the priority. Safety is.
In real life, seizure management often starts with a bystander—not a doctor. Knowing what to do is vital.
Tonic-clonic seizure first aid:
- ✅ Gently guide to the ground
- ✅Keep the person safe—move nearby objects
- ✅ Turn them on their side after jerking stops
- ✅ Stay calm and stay with them
- ✅ Observe duration and features
- ✅ Time the seizure—this matters diagnostically!
- ❌ Don’t restrain them or put anything in their mouth
🚨 Call an ambulance if:
- The seizure lasts longer than 5 minutes
- Another seizure starts before they recover
- They’re injured or in water
- They don’t wake up afterward
- They're pregnant or medically unwell
🧠 Clinical reasoning tip: The priority isn’t “treating the seizure”—it’s ruling out potentially reversible or dangerous causes. Starting anti-seizure medication without identifying the true trigger could mask red flags
🧠 Step 4: How do you investigate it afterwards?
When someone has a seizure for the first time, doctors don’t always rush to prescribe medication. Instead, they explore why the seizure happened.
What do we check?
- EEG: Detects abnormal electrical patterns
- Blood tests: Look for low sodium, glucose issues, infection
- Brain imaging: MRI or CT to detect tumours, bleeds, or scars
- Lumbar puncture: If infection (e.g., meningitis) is suspected
A single seizure might be caused by something temporary - a fever, missed medication, or head trauma. In these cases, we treat the underlying issue instead of starting long-term medication.
🙌 Step 5: When and why to start medication? (and which ones?)
Not everyone with one seizure needs lifelong treatment. Doctors weigh the risks carefully.
Medication is usually considered if:
- The person has had two or more seizures
- Tests suggest a high risk of recurrence (e.g. abnormal EEG suggesting an ongoing predisposition to seizures)
- There's a known brain condition
- The person prefers to reduce future risk- especially with driving or pregnancy concerns
The choice depends on seizure type, side effects, and the person’s lifestyle. For example, sodium valproate can affect pregnancy and isn’t ideal for young women planning a family.
💊 Why Do Different Seizure Types Need Different Drugs?
Seizure types aren’t just labels - they reflect where and how abnormal electrical activity starts and spreads in the brain. And that anatomical and electrophysiological origin determines which medications will actually help (or potentially worsen ) the condition.
🌐 Carbamazepine for Focal Seizures
Focal seizures begin in a specific part of the brain, often with symptoms linked to that region - like sensory changes, automatisms, or localised motor movements.
Carbamazepine works by blocking voltage-gated sodium channels in neurons. These channels are essential for initiating and propagating action potentials.
👉 So why does this help in focal seizures?
- In focal epilepsy, there's often a hyperactive group of neurons firing excessively, creating a localized electrical storm. By blocking sodium channels, carbamazepine reduces excitability of these neurons, making it harder for the abnormal signals to spread.
- Because it targets this focal activity, it's very effective - but it can worsen generalised seizure types by interfering with normal spread across broader circuits.
🧠 Clinical relevance: Choosing carbamazepine for a generalised seizure could actually increase risk—so classification before treatment is key
🌐 Sodium Valproate for Generalised Seizures
Generalised seizures involve both hemispheres of the brain from the outset. These might be tonic-clonic, absence, or myoclonic seizures - more diffuse and symmetric in presentation.
Sodium valproate acts mainly by enhancing GABAergic inhibition, which calms neuronal networks. It also modulates T-type calcium channels involved in thalamocortical rhythms - especially relevant in absence seizures.
👉 Why does this help?
- Generalised seizures are often due to network-wide instability—not a single focus. GABA is the brain’s primary inhibitory neurotransmitter, so boosting its effects dampens excessive synchronization across brain regions.
- It’s a broad-spectrum agent that tackles different seizure types by stabilising the entire neural network.
⚠️ Caution: While effective, sodium valproate is teratogenic and not ideal for women considering pregnancy - so treatment must also consider reproductive health.
🌐 Levetiracetam as a Flexible Option
Levetiracetam has a less direct mechanism—it binds to synaptic vesicle protein SV2A, influencing how neurotransmitters are released into synapses.
👉 Why is this useful?
- This mechanism doesn’t rely on specific ion channels, making it less likely to interfere with normal function in different seizure types.
- It can help both focal and generalised seizures, especially when other meds cause side effects or aren’t tolerated.
🧠 Clinical logic: It’s often chosen when patients have mixed seizure types, are sensitive to other drugs, or need a safer side-effect profile. Its low interaction potential makes it particularly valuable in complex cases.
The type of seizure reflects where the brain is malfunctioning, and the medication choice reflects how we can restore balance—whether by quieting overactive neurons (carbamazepine), calming widespread networks (valproate), or modulating neurotransmitter release more subtly (levetiracetam).
🗂️ Step 6: How do you support ongoing care?
Seizure care doesn’t end after the seizure stops. Doctors check in over time and ask:
- Are the seizures under control?
- Are medications causing problems (e.g. tiredness, mood changes)?
- Is the person taking their meds regularly?
- Are there concerns about driving, contraception, or work?
Long-term management includes psychological support, lifestyle changes, and monitoring for new symptoms. Seizures affect people’s lives—not just their neurons
⚠️ Red flags for neurologist referral:
- Diagnostic uncertainty
- Poor seizure control despite adherence
- Cognitive decline or new focal deficits
- Women considering pregnancy
🧩 Step 7: How Do We Prevent Seizures Without Medication?
Seizure care isn’t just about stopping what’s happening—it’s about preventing what could happen next. While pharmacological treatments often play a key role, many people can reduce seizure frequency through non-medication strategies that target the brain’s environment and thresholds for excitability.
Let’s explore the why and how behind these approaches.
🛏️ 1. Sleep Hygiene
Sleep deprivation increases cortical excitability, especially in the frontal lobes. That means the brain becomes more susceptible to abnormal discharges. Consistent sleep routines help stabilise electrical activity and reduce seizure risk.
Tips for patients: Regular bedtimes, limiting screens before sleep, and creating restful spaces.
🧘 2. Stress Management
Stress isn’t just psychological—it has physiological ripple effects. It elevates cortisol and adrenaline, which can increase neural firing rates and reduce inhibitory control in the brain.
Interventions that help:
- Mindfulness and meditation to recalibrate attention
- Cognitive Behavioural Therapy (CBT) to reframe stress responses
- Exercise as a mood and neurochemical regulator
⚡ 3. Trigger Avoidance
Some seizures have identifiable triggers. These don’t cause epilepsy, but they lower the threshold enough to provoke an event in a vulnerable brain.
Common triggers include:
- Strobe lights or visual stimuli (especially in photosensitive epilepsy)
- Missed meals → hypoglycaemia
- Alcohol or dehydration
🥑 4. Dietary Therapies
The ketogenic diet alters brain metabolism by shifting energy use from glucose to ketone bodies, which seem to suppress hyperexcitable neurons.
Why it works:
- Ketones may enhance GABAergic inhibition
- Glucose restriction may reduce neuronal firing
Accessible alternatives: - Modified Atkins Diet
- Low Glycaemic Index therapy
Note: These are complex and not DIY—a specialist-led approach is essential.
🔌 5. Neurostimulation Devices
For patients with drug-resistant epilepsy, devices can help modulate brain activity.
- Vagus Nerve Stimulators (VNS): Send gentle pulses to calm the brain via parasympathetic pathways
- Responsive Neurostimulators (RNS): Monitor electrical activity and respond to early spikes
🧠 6. Behavioural and Psychological Support
CBT, counselling, and even biofeedback can play a role, particularly when stress or emotional regulation is a known trigger.
- Biofeedback helps patients recognise and control physiological cues like muscle tension or heart rate.
- CBT reduces anxiety—a known seizure amplifier
🌍 7. Whole-Person and Community Care
Prevention can be deeply personal. Social connectedness, emotional support, and stigma reduction all matter.
Group programs that focus on patient empowerment, routine building, and coping strategies have shown promise in reducing seizure burden—especially in rural and underserved populations.
🩺 Part 1: What Happened?
Sam had just finished a sprint across the field when he suddenly dropped to the ground. Bystanders report:
- Whole-body shaking lasting ~90 seconds
- No response during the event
- Frothing at the mouth
- Urinary incontinence
- Confusion for ~20 minutes afterward
🧠 Part 2: First Aid & Immediate Concerns
- A coach with first aid training ensured Sam was safely on his side.
- No tongue injury, no cyanosis.
- Nearest hospital is 45 minutes away.
- Paramedics were called; Sam stabilised with airway support and monitoring.
Discussion prompt:
What red flags suggest this was a generalised tonic-clonic seizure?
What would you do if you were the first responder?
🕵️♀️ Part 3: Differential Diagnosis
- Epileptic seizure vs heat-related collapse vs cardiac syncope vs arrhythmia
- Past similar episode 6 months ago—family dismissed it as dehydration
- No known epilepsy diagnosis, but dad recalls “blank staring spells” when younger
Neuro clue: Could this be evolving juvenile myoclonic epilepsy? Or an atypical presentation?
🧪 Part 4: Investigations
- Rural ED does bloods → glucose normal, mild dehydration
- ECG normal
- MRI/CT head not available locally → arranged through regional network for next day
- EEG ordered for follow-up but has a 3-week wait
Context matters: What barriers exist in rural settings to timely workup?
💊 Part 5: Treatment Planning
- The local GP initiates seizure safety counselling: driving restrictions, swimming precautions, school support
- Sam and his family are hesitant about starting medication without a diagnosis
- The GP consults with a neurologist via telehealth—the plan is to await EEG before initiating therapy unless further events occur
Pharmacological angle: Would you empirically start treatment? When is it appropriate?
🧩 Part 6: Prevention and Holistic Care
- The follow-up consult focuses on triggers—sleep deprivation, heat exposure, and overexertion
- School counsellor is engaged for psychoeducational support
- Family referred to an online rural epilepsy support network
Non-pharmacological strategies introduced:
- Consistent sleep, hydration, pacing of physical activity
- Stress management at school
💡 Key Clinical Reasoning Tips
- ⚠️ Not all seizures are epilepsy—identify the cause first
- 🧩 Don’t just treat seizures—identify their origin: cortical, metabolic, structural?
- 📍 Symptoms can hint at brain location—use neuroanatomy to guide you
- 🛟 Seizure first aid is an essential skill for all future healthcare workers
- 🎯 Medication isn’t always the answer—treat underlying causes and weigh risks
- 🧠 Classify before prescribing: focal vs generalised, provoked vs unprovoked
- 🚗 Long-term thinking matters—driving, pregnancy, stigma, and work all play a role
- 🧭 Think beyond the brain—consider systemic ripple effects and the person’s broader context
Seizures don’t happen in isolation—they’re signals, not just symptoms. Explore the body’s metabolic equilibrium, psychosocial stressors, medication interactions, and access to care. Seizure management isn’t just about stopping the next episode—it’s about supporting the person, building knowledge, and thinking critically. As a future doctor, your diagnostic reasoning matters just as much as your prescription pad. What you notice, what you ask, and what you consider all shape the care experience.
Sometimes the best interventions aren’t prescriptions—they’re perspective shifts.
- 📝 All posts on the nervous system →
- 📝 Structure and function of the CNS →
- 📝 Pathophysiology of seizures →
- 📝 Understanding seizure classification →
- 📝 Localisation of seizures →
- 📝 Neurotransmitters 101 →
- 📝 Consciousness and how we can lose it →
- 📝 Clinical cases in seizure localisation →
- 📝Principles of seizure management →
- 📝Neurotransmitters on drugs! →
- 📝A beginner's guide to EEG →
- 📝A beginner's guide to neuroimaging →
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