Seizures Seizures are symptoms of a brain problem.

They happen because of sudden, abnormal electrical activity in the brain. When people think of seizures, they often think of convulsions in which a person's body shakes rapidly and uncontrollably. Not all seizures cause convulsions. There are many types of seizures and some have mild symptoms. Seizures fall into two main groups. Focal seizures, also called partial seizures, happen in just one part of the brain. Generalized seizures are a result of abnormal activity on both sides of the brain. Most seizures last from 30 seconds to 2 minutes and do not cause lasting harm. However, it is a medical emergency if seizures last longer than 5 minutes or if a person has many seizures and does not wake up between them. Seizures can have many causes, including medicines, high fevers, head injuries and certain diseases. People who have recurring seizures due to a brain disorder have epilepsy. Epilepsy Epilepsy is a brain disorder that causes people to have recurring seizures. The seizures happen when clusters of nerve cells, or neurons, in the brain send out the wrong signals. People may have strange sensations and emotions or behave strangely. They may have violent muscle spasms or lose consciousness. Epilepsy has many possible causes, including illness, brain injury and abnormal brain development. In many cases, the cause is unknown. Doctors use brain scans and other tests to diagnose epilepsy. It is important to start treatment right away. There is no cure for epilepsy, but medicines can control seizures for most people. When medicines are not working well, surgery or implanted devices such as vagus nerve stimulators may help. Special diets can help some children with epilepsy. "Seizure" is a general term that refers to a sudden malfunction in the brain that causes someone to collapse, convulse, or have another temporary disturbance of normal brain function, often with a loss or change in consciousness. Seizure Basics Most seizures are caused by abnormal electrical discharges in the brain or by fainting (decrease in blood flow to the brain). Symptoms may vary depending on the part of the brain involved, but often include unusual sensations, uncontrollable muscle spasms, and loss of consciousness. Some seizures may be the result of another medical problem, such as low blood sugar, infection, a head injury, accidental poisoning, or drug overdose. They also can be due to a brain tumor or other health problem affecting the brain. And anything that results in a sudden lack of oxygen or a reduction in blood flow to the brain can cause a seizure. In some cases, a seizure's cause is never discovered. When seizures occur more than once or over and over, it may indicate the ongoing conditionepilepsy. Some kids under 5 years old have febrile seizures, which can occur when they develop a medium or high fever ² usually above 100.4° F (38° C). While terrifying to parents, these seizures are usually brief and rarely cause any life-threatening, serious, or long-term problems, unless the fever is associated with a serious infection, such as meningitis. In kids under 5 years old, breath-holding spells can cause seizures. These aren't the spells where kids hold their breath to get back at their parents. Instead, these occur in kids who have an exaggerated reflex so that when they're hurt or emotionally upset they stop taking in a breath (with or without crying hard first). They then turn blue or very pale, often pass out, and might have a full convulsion-like seizure in which the body is stiff and they're unconscious and not breathing. While scary to parents, these spells usually stop on their own and the kids almost never suffer any harm from them. Call your doctor if such a spell occurs. In older kids, about 10% or more have standard fainting spells (also called syncope), which is often associated with a brief seizure or seizure-like spell. A child may stiffen or even twitch or convulse a few times. Fortunately, this rarely indicates epilepsy. Most kids recover very quickly (seconds to minutes) and don't require specialized treatment. If Your Child Has a Seizure A child who is having a seizure should be placed on the ground or floor in a safe area, preferably on his or her right side. Remove any nearby objects. Loosen any clothing around the head or neck. Do not try to wedge the child's mouth open or place an object between the teeth, and do not attempt to restrain movements. Once the seizure seems to have ended, gently comfort and protect your child. It's best for kids to remain lying down until they have recovered fully and want to move around. Call 911 immediately if your child: y has difficulty breathing y turns bluish in color y has sustained a head injury y seems ill y has a known heart condition y has never had a seizure before y might have ingested any poisons, medications, etc. If your child has previously had seizures, call 911 if the seizure lasts more than 5 minutes or is for some reason very alarming to you and you're worried for your child's safety. If your child is breathing normally and the seizure lasts just a few minutes, you can wait until it lets up to call your doctor. Following the seizure, kids are often be tired, confused, or exhausted and may fall into a deep sleep (called the postictal period). You do not need to try to wake your child as long as he or she is breathing comfortably. Do not attempt to give food or drink until your child is awake and alert.

For a child who has febrile seizures, the doctor may suggest giving fever-reducing medicine (such as ibuprofen or acetaminophen), followed by a lukewarm sponge bath if medication doesn't bring the fever down. After a seizure ² particularly if it is a first or unexplained seizure ² call your doctor or emergency medical services for instructions. Your child will usually need to be evaluated by a doctor as soon as possible. Definition A seizure is the physical findings or changes in behavior that occur after an episode of abnormal electrical activity in the brain. See also: y Generalized tonic clonic seizure y Partial (focal) seizure y Petit mal (absence) seizure y Epilepsy y Fever (febrile) convulsions (seizures in children with high fever) Symptoms Simple partial seizures can be caused by congenital abnormalities(abnormalities present at birth), tumor growths, head trauma, stroke, andinfections in the brain or nearby structures. Generalized tonic-clonic seizures are associated with drug and alcohol abuse, and low levels of blood glucose (blood sugar) and sodium. Certain psychiatric medications, antihistamines, and even antibiotics can precipitate tonic-clonic seizures. Absence seizures are implicated with an abnormal imbalance of certain chemicals in the brain that modulate nerve cell activity (one of these neurotransmitters is called GABA, which functions as an inhibitor). Myoclonic seizures are commonly diagnosed in newborns and children. Symptoms for the different types of seizures are specific. Causes & Risk Factors A seizure may be related to a temporary condition, such as exposure to drugs, withdrawal from certain drugs, a high fever, or abnormal levels of sodium orglucose in the blood. If the repeated seizures do not happen again once the underlying problem is corrected, the person does not have epilepsy. In other cases, injury to the brain (for example, stroke or head injury) causes brain tissue to be abnormally excited. In some people, a problem that is passed down through families (inherited) affects nerve cells in the brain, which leads to seizures. In these cases, the seizures happen spontaneously, without an immediate cause, and repeat over time. This is epilepsy. Idiopathic seizures are chronic seizures that occur without an identifiable cause. They usually begin between ages 5 and 20, but can occur at any age. The person can have a family history of epilepsy or seizures. Other more common causes of seizures include: y Tumors (such as brain tumor) or other structural brain lesions (such as bleeding in the brain) y Traumatic brain injury, stroke, or a transient ischemic attack (TIA) y Stopping alcohol after drinking heavily on most days y Illnesses that cause the brain to deteriorate y Dementia such as Alzheimer's disease y Problems that are present from before birth (congenital brain defects) y Injuries to the brain that occur during labor or at the time of birth y Low blood sugar or sodium levels in the blood y Kidney or liver failure y Use of cocaine, amphetamines, or certain other recreational drugs y Stopping certain drugs, such as barbiturates and benzodiazepines, after taking them for a period of time y Infections (brain abscess, meningitis, encephalitis, neurosyphilis, or AIDS) y Phenylketonuria (PKU) can cause seizures in infants. Tests & Diagnostics Patients seeking help for seizures should first undergo an EEG that records brain-wave patterns emitted between nerve cells. Electrodes are placed on the head, sometimes for 24 hours, to monitor brain-wave activity and detect both normal and abnormal impulses. Imaging studies such as magnetic resonance imaging (MRI) and computed axial tomography (CT)²that take still "pictures"²are useful in detecting abnormalities in the temporal lobes (parts of the brain associated with hearing) or for helping diagnose tonic-clonic seizures. A complete blood count (CBC) can be helpful in determining whether a seizure is caused by a neurological infection, which is typically accompanied by high fever. If drugs or toxins in the blood are suspected to be the cause of the seizure(s), blood and urine screening tests for these compounds may be necessary. Antiseizure medication can be altered by many commonly used medications such as sulfa drugs, erythromycin, warfarin, and cimetidine. Pregnancy may also decrease serum concentration of antiseizure medications; therefore, frequent monitoring and dose adjustments are vital to maintain appropriate blood concentrations of the antiseizure medication²known as the therapeutic blood concentration. Diagnosis requires a detailed and accurate history, and a physical examination is important since this may help identify neurological or systemic causes. In cases in which a central nervous system (CNS) infection (i.e., meningitis or encephalitis) is suspected, a lumbar puncture (or spinal tap) can help detect an increase in immune cells (white blood cells) that develop to fight the specific infection. Treatments If someone who has never had a seizure before has one, call 911 or your local emergency number immediately. Persons with epilepsy should always wear a medical alert tag. Most seizures stop by themselves. However, a person having a generalized seizure may be injured; breathe food, fluid, or vomit into the lungs; or not get enough oxygen. During a generalized seizure, it is important to protect the person from injury. Turn the person on the side, so that any vomit leaves the body and does not enter the lungs. See: Seizure first aid

After a generalized seizure, most people go into a deep sleep. Do not prevent the person from sleeping. The person will probably be disoriented, or possibly agitated for awhile after awakening. EMERGENCY FIRST AID y Do not attempt to force a hard object (such as a spoon or a tongue depressor) between the teeth. You can cause more damage than you can prevent. y Do not try to hold the person down during the seizure. y Turn the person to the side if vomiting occurs. Keep the person on his or her side while sleeping after the seizure is over. y If the person having a seizure turns blue or stops breathing, try to position their head to prevent their tongue from blocking their airways. Breathing usually starts on its own once the seizure is over. y CPR or mouth-to-mouth breathing is rarely needed after seizures and cannot be performed during the seizure. If a person has repeated or prolonged seizures without regaining consciousness or returning to normal behavior, the body may develop a severe lack of oxygen. This an emergency situation. Seek immediate medical help. AFTER THE SEIZURE Treat any injuries from bumps or falls. Record details of the seizure to report to the person's primary health care provider. You should note the following details: y How long it lasted y What body parts were affected y Type of movements or other symptoms y Possible causes y How the person behaved after the seizure Complications About 30% of patients with severe seizures (starting in early childhood), continue to have attacks and usually never achieve a remission state. In the United States, the prevalence of treatment-resistant seizures is about one totwo per 1,000 persons. About 60±70% of persons achieve a five-year remission within 10 years of initial diagnosis. Approximately half of these patients become seizure-free. Usually the prognosis is better if seizures can be controlled by one medication, the frequency of seizures decreases, and there is a normal EEGand neurological examination prior to medication cessation. People affected by seizure have increased death rates compared with the general population. Patients who have seizures of unknown cause have an increased chance of dying due to accidents (primarily drowning). Other causes of seizure-associated death include abnormal heart rhythms, water in the lungs, or heart attack. Prevention Instructions for taking any prescribed medications should be strictly followed. Family members should observe and record any seizure information to make sure the person gets proper treatment. Good health habits may help to control seizures. Because sleep deprivation, stress, and a poor diet can contribute to increased seizures, good sleep habits, stress reduction, proper exercise, and sound nutrition may help. There is no specific way to prevent all seizures. Use helmets when appropriate to prevent head injury. This will lessen the likelihood of a brain injury and subsequent seizures. Avoid recreational drugs. People with epilepsy should take medication as directed and avoid excessive amounts of alcohol. People with uncontrolled seizures should not drive. Each state has a different law that determines which people with a history of seizures are allowed to drive. People with uncontrolled seizures also should avoid activities where loss of awareness would cause great danger, such as climbing to high places, biking, and swimming alone. Types of Seizures Seizures take many forms. Before your doctor can prescribe the right treatment, he or she must figure out which type (or types) you have. That's the purpose of all the tests discussed in the Diagnosis section²not just to tell whether you have epilepsy but also to tell what kind. There are so many kinds of seizures that neurologists who specialize in epilepsy are still updating their thinking about how to classify them. Usually, they classify seizures into two types, primary generalized seizures and partial seizures. The difference between these types is in how they begin: Primary generalized seizures Primary generalized seizures begin with a widespread electrical discharge that involves both sides of the brain at once. Hereditary factors are important in many of these seizures. Partial seizures Partial seizures begin with an electrical discharge in one limited area of the brain. Some are related to head injury, brain infection, stroke, or tumor, but in most cases the cause is unknown. One question that is used to further classify partial seizures is whether consciousness (the ability to respond and remember) is "impaired" or "preserved." The difference may seem obvious, but really there are many degrees of impairment or preservation of consciousness. Identifying certain seizure types and other characteristics of a person's epilepsy like the age at which it begins, for instance, allows doctors to classify some cases into epilepsy syndromes. This kind of classification helps us to know how long the epilepsy will last and the best way to treat it. Primary Generalized Seizures

y y y y y

Absence seizures Atypical absence seizures Myoclonic seizures Atonic seizures Tonic seizures

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Clonic seizures Tonic-clonic seizures

Partial Seizures

y y y

Simple partial seizures Complex partial seizures Secondarily generalized seizures Absence Seizures What are they like? Here's a typical story: Frank, a 7-year-old boy, often "blanks out" anywhere from a few seconds to 20 seconds at a time. During a seizure, Frank doesn't seem to hear his teacher call his name, he usually blinks repetitively, and his eyes may roll up a bit. During shorter seizures, he just stares. Then he continues on as if nothing happened. Some days Frank has more than 50 of these spells. How long do they last? Usually less than 10 seconds, but it can be as long as 20. They begin and end suddenly. Tell me more Absence seizures are brief episodes of staring. (Although the name looks like a regular English word, your neurologist may pronounce it ab-SAWNTZ.) Another name for them is petit mal (PET-ee mahl). During the seizure, awareness and responsiveness are impaired. People who have them usually don't realize when they've had one. There is no warning before a seizure, and the person is completely alert immediately afterward. Simple absence seizures are just stares. Many absence seizures are considered complex absence seizures, which means that they include a change in muscle activity. The most common movements are eye blinks. Other movements include slight tasting movements of the mouth, hand movements such as rubbing the fingers together, and contraction or relaxation of the muscles. Complex absence seizures are often more than 10 seconds long. Who gets them? Absence seizures usually begin between ages 4 and 14. The children who get them usually have normal development and intelligence. What's the outlook? In nearly 70% of cases, absence seizures stop by age 18. Children who develop absence seizures before age 9 are much more likely to outgrow them than children whose absence seizures start after age 10. Children with absence seizures do have higher rates of behavioral, educational, and social problems. What else could it be? Absence seizures can resemble some complex partial seizures or episodes of daydreaming: Questions to Ask How frequent are the episodes? Daydreaming Not frequent. Seizures Complex partial: Rarely more than several times per day or week. Absence: Could be many times per day. Any time, including during physical activity; often with hyperventilation (deep or rapid breathing.) Usually yes. Some complex partial seizures begin slowly with a warning. No. Complex partial: Up to several minutes Absence: Rarely more than 15-20 seconds Complex partial: Automatisms are common. Absence: Just stares. Complex partial: Confused. Absence: Alert.

In what situations do they occur?

Boring situation.

Do they begin abruptly?

No.

Can they be interrupted? How long do they last?

Yes. Until something interesting happens. Probably just stares.

Does the person do anything during the episode? What is the person like immediately after the episode?

Alert.

How is the diagnosis made? The EEG (electroencephalogram), which records brain waves, is helpful in diagnosing absence seizures. Having the child breathe very rapidly often will produce a seizure. Images of the brain such as CT and MRI scans are usually normal, so they are seldom needed if the EEG and other features are typical. Atypical Absence Seizures What are they like? Here's a typical story: "It's hard to tell when Kathy's having one of her "staring spells". During the spells she doesn't respond as quickly as at other times. But even when she's not having a seizure she often just stares and responds slowly." How long do they last? Usually 5 to 30 seconds (commonly more than 10), with a gradual beginning and ending.

y y y

Tell me more Atypical (a-TIP-i-kul) means unusual or not typical. The person will stare (as they would in any absence seizure) but often is somewhat responsive. Eye blinking or slight jerking movements of the lips may occur. This behavior can be hard to distinguish from the person's usual behavior, especially in those with cognitive impairment. Unlike other absence seizures, these seizures usually cannot be produced by rapid breathing. Who gets them? They generally begin before age 6. Most of the children affected have below-average intelligence and other types of seizures that are difficult to control. Many have Lennox-Gastaut syndrome. What's the outlook? Atypical absence seizures usually continue into adulthood. What else could it be? Sometimes ordinary behavior for these children will look like an atypical absence seizure. Daydreaming and inattentiveness can mimic these seizures. How is the diagnosis made? The diagnosis can be difficult if the behavior during seizures is similar to the child's usual behavior. The EEG (electroencephalogram), which records brain waves, will be used, but most children with these seizures have patterns on their EEG when they're not having a seizure that are similar to the seizure pattern. Myoclonic Seizures What are they like? Here's a typical story: "In the morning, I get these 'jumps.' My arms fly up for a second, and I often spill my coffee or drop what I'm holding. Now and then my mouth may shut for a split second. Sometimes I get a few jumps in a row. Once I've been up for a few hours, the jumps stop." How long do they last? They're very brief jerks. Usually they don't last more than a second or two. There can be just one, but sometimes many will occur within a short time. Tell me more Myoclonic (MY-o-KLON-ik) seizures are brief, shock-like jerks of a muscle or a group of muscles. "Myo" means muscle and "clonus" (KLOH-nus) means rapidly alternating contraction and relaxation²jerking or twitching²of a muscle. Even people without epilepsy can experience myoclonus in hiccups or in a sudden jerk that may wake you up as you're just falling asleep. These things are normal. In epilepsy, myoclonic seizures usually cause abnormal movements on both sides of the body at the same time. They occur in a variety of epilepsy syndromes that have different characteristics: Juvenile myoclonic epilepsy: The seizures usually involve the neck, shoulders, and upper arms. In many patients the seizures most often occur soon after waking up. They usually begin around puberty or sometimes in early adulthood in people with a normal range of intelligence. In most cases, these seizures can be well controlled with medication but it must be continued throughout life. Lennox-Gastaut syndrome: This is an uncommon syndrome that usually includes other types of seizures as well. It begins in early childhood. The myoclonic seizures usually involve the neck, shoulders, upper arms, and often the face. They may be quite strong and are difficult to control. Progressive myoclonic epilepsy: The rare syndromes in this category feature a combination of myoclonic seizures and tonic-clonic seizures. Treatment is usually not successful for very long, as the patient deteriorates over time. Who gets them? The epileptic syndromes that most commonly include myoclonic seizures usually begin in childhood, but the seizures can occur at any age. Other characteristics depend on the specific syndrome. What's the outlook? The outlook for patients with the various syndromes that include myoclonic seizures varies widely. See the specific syndromes for more information. What else could it be? As mentioned, some episodes of myoclonus are normal. Some myoclonic seizures occur in reflex epilepsies, triggered by flashing lights or other things in the environment. How is the diagnosis made? The seizures themselves are easy to identify. The syndromes usually can be diagnosed on the basis of the medical history and often EEG patterns. Atonic Seizures What are they like? Here's a typical story: "When Bob has a 'drop' seizure, he falls to the ground and often hits his head and bruises his body. Even if I'm right next to him and prepared, I may not catch him. Even with carpet in the bedroom and mats in the bathroom, he gets hurt." How long do they last? Less than 15 seconds. Tell me more Muscle "tone" is the muscle's normal tension. "Atonic" (a-TON-ik) means "without tone," so in an atonic seizure, muscles suddenly lose strength. The eyelids may droop, the head may nod, and the person may drop things and often falls to the ground. These seizures are also called "drop attacks" or "drop seizures." The person usually remains conscious. Another name for this type of seizure is "akinetic" (a-kin-ET-ik), which means "without movement." Who gets them? Atonic seizures often begin in childhood. What's the outlook? They often last into adulthood. Many people with atonic seizures are injured when they fall, so they may choose to use protection such as a helmet.

What else could it be? Patients who have seizures that cause them to fall when they're standing often have tonic seizures (involving sudden muscle contraction) rather than atonic seizures. How is the diagnosis made? Usually descriptions of the seizures by witnesses will suggest the diagnosis. Some EEG monitoring may be performed to confirm it. If the seizures persist, other tests may be used to make sure that changes in the heart rhythm or blood pressure are not causing the patient to fall down Tonic Seizures What are they like? Here's a typical story: "When Jeff has an episode, he just stiffens up. Both arms are raised over his head and his face has a grimace, as if someone is pulling on his cheeks. If he's standing, he may lose his balance and fall. These seizures don't knock him out like the tonic-clonic seizures, but if he has a few close together, he is often tired." How long do they last? Usually less than 20 seconds. Tell me more Muscle "tone" is the muscle's normal tension at rest. In a "tonic" seizure, the tone is greatly increased and the body, arms, or legs make sudden stiffening movements. Consciousness is usually preserved. Tonic seizures most often occur during sleep and usually involve all or most of the brain, affecting both sides of the body. If the person is standing when the seizure starts, he or she often will fall. Who gets them? They are particularly common in people who have the epilepsy syndrome called Lennox-Gastaut syndrome, but they can occur in anyone. What's the outlook? Tonic seizures in Lennox-Gastaut syndrome may become more difficult to control over time. Some patients do achieve a good outcome. What else could it be? Children with neurological impairments sometimes make movements that could be mistaken for tonic seizures. The EEG should be able to tell the difference. How is the diagnosis made? The EEG can clearly show these seizures if they occur during monitoring. Clonic Seizures What are they like? Clonic seizures consist of rhythmic jerking movements of the arms and legs, sometimes on both sides of the body. How long do they last? The length varies. Tell me more "Clonus" (KLOH-nus) means rapidly alternating contraction and relaxation of a muscle -- in other words, repeated jerking. The movements cannot be stopped by restraining or repositioning the arms or legs. Clonic (KLON-ik) seizures are rare, however. Much more common are tonic-clonic seizures, in which the jerking is preceded by stiffening (the "tonic" part). Sometimes tonic-clonic seizures start with jerking alone. These are called clonic-tonic-clonic seizures! Who gets them? Clonic seizures are not seen very often. They can occur at various ages, including in newborns. What's the outlook? Brief and infrequent clonic seizures in infants usually disappear on their own within a short time. Other types may need prolonged treatment. What else could it be? Occasionally "jitteriness" in a young infant can be mistaken for a clonic seizure, especially if it is severe (during crying, for instance). Changing the position of the baby's arms or legs should reduce or stop jitteriness. The jittery infant also will be more alert than an infant who is having a clonic seizure. Children with neurological impairments sometimes have repetitive movements that could be mistaken for clonic seizures. How is the diagnosis made? The doctor should recognize the appearance of a clonic seizure if he or she witnesses an episode. The EEG pattern will change during a seizure, so video-EEG is very useful. A factor distinguishing clonic from tonic-clonic seizures is that clonic seizures are not followed by a period of tiredness or confusion. Tonic-clonic seizures usually are. Tonic-clonic Seizures What are they like? Here's a typical story from a parent's view:"These seizures frighten me. They only last a minute or two but it seems like an eternity. I can often tell Heather's going to have one because she acts cranky and out of sorts. It begins with an unnatural shriek. Then she falls, and every muscle seems to be activated. Her teeth clench. She's pale, and later she turns slightly bluish. Shortly after she falls, her arms and upper body start to jerk, while her legs remain more or less stiff. This is the longest part of the seizure. Finally it stops and she falls into a deep sleep." How long do they last? Generally, 1 to 3 minutes. A tonic-clonic seizure that lasts longer than 5 minutes probably calls for medical help. A seizure that lasts more than 30 minutes, or three seizures without a normal period in between, indicates a dangerous condition called convulsive status epilepticus. This requires emergency treatment. Tell me more This type is what most people think of when they hear the word "seizure." An older term for them is "grand mal." As implied by the name, they combine the characteristics of tonic seizures and clonic seizures. The tonic phase comes first: All the muscles stiffen. Air being forced past the vocal cords causes a cry or groan. The person loses consciousness and falls to the floor. The tongue or cheek may be bitten, so bloody saliva may come from the mouth. The person may turn a bit blue in the face. After the tonic phase comes

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the clonic phase: The arms and usually the legs begin to jerk rapidly and rhythmically, bending and relaxing at the elbows, hips, and knees. After a few minutes, the jerking slows and stops. Bladder or bowel control sometimes is lost as the body relaxes. Consciousness returns slowly, and the person may be drowsy, confused, agitated, or depressed. Who gets them? They affect both children and adults. What's the outlook? For children who have had a single tonic-clonic seizure, the risk that they will have more seizures depends on many factors. Some children will outgrow their epilepsy. Often, tonic-clonic seizures can be controlled by seizure medicines. Many patients who are seizure-free for a year or two while taking seizure medicine will stay seizure-free if the medicine is gradually stopped. The risk that an individual will have more seizures depends on factors such as whether his or her EEG shows any epilepsy waves, or whether the doctor finds any abnormalities on a neurological exam. Among children with no epilepsy waves and a normal exam, about 70% of those who have had tonic-clonic seizures will stay seizure-free without medication. The comparable number is less than 30% for children with epilepsy waves and an abnormal exam. All these figures are more favorable than those for partial seizures. What else could it be? Some nonepileptic (psychogenic) seizures resemble tonic-clonic seizures. The surest way to tell the difference is with video-EEG monitoring. In some cases, the same person may have both tonic-clonic and nonepileptic seizures. People who faint sometimes develop tonic or clonic movements. These movements are rarely as intense or prolonged as a tonicclonic seizure. How is the diagnosis made? The typical appearance of a tonic-clonic seizure is usually easy to recognize. The doctor will want a detailed description of the seizures. An EEG and other tests may help to confirm the diagnosis or suggest a cause. Simple Partial Seizures What are they like? They are remarkably different from person to person, depending on the part of the brain where they begin. The one thing they all have in common is that the person remains alert and can remember what happens. Here are a couple of experiences: "I almost enjoy them. The feeling of déja vu, as if I've lived through this moment and I even know what's going to be said next. Everything seems brighter and more alive." "It is a pressure that starts in my stomach, then rises to my chest and throat. When it reaches my chest, I smell an unpleasant odor of something burnt. At the same time I feel anxious." Sometimes the seizure activity spreads to other parts of the brain, so another type of seizure follows the simple partial seizure. This can be a complex partial seizure or a secondarily generalized seizure. How long do they last? Only a short time, usually less than 2 minutes. Tell me more Doctors often divide simple partial seizures into categories depending on the type of symptoms the person experiences: Motor seizures: These cause a change in muscle activity. For example, a person may have abnormal movements such as jerking of a finger or stiffening of part of the body. These movements may spread, either staying on one side of the body (opposite the affected area of the brain) or extending to both sides. Other examples are weakness, which can even affect speech, and coordinated actions such as laughter or automatic hand movements. The person may or may not be aware of these movements. Sensory seizures: These cause changes in any one of the senses. People with sensory seizures may smell or taste things that aren't there; hear clicking, ringing, or a person's voice when there is no actual sound; or feel a sensation of "pins and needles" or numbness. Seizures may even be painful for some patients. They may feel as if they are floating or spinning in space. They may have visual hallucinations, seeing things that aren't there (a spot of light, a scene with people). They also may experience illusions²distortions of true sensations. For instance, they may believe that a parked car is moving farther away, or that a person's voice is muffled when it's actually clear. Autonomic seizures: These cause changes in the part of the nervous system that automatically controls bodily functions. These common seizures may include strange or unpleasant sensations in the stomach, chest, or head; changes in the heart rate or breathing; sweating; or goose bumps. Psychic seizures: >These seizures change how people think, feel, or experience things. They may have problems with memory, garbled speech, an inability to find the right word, or trouble understanding spoken or written language. They may suddenly feel emotions like fear, depression, or happiness with no outside reason. Some may feel as though they are outside their body or may have feelings of déja vu ("I've been through this before") or jamais vu ("This is new to me"² even though the setting is really familiar). Who gets them? Anybody can get them. They may be more likely in people who have had a head injury, brain infection, stroke, or brain tumor but most of the time the cause is unknown. What's the outlook? These seizures often can be controlled by seizure medicines. What else could it be? Medical disorders such as, stomach disorders or a pinched nerve can cause some similar symptoms. Hallucinations can accompany psychiatric illness or the use of certain drugs. And some symptoms (such as déja vu) are experienced by almost everyone at some time. Whether the symptoms represent simple partial seizures depends on how often they occur and whether they are associated with other episodic changes or other seizure types. How is the diagnosis made? A complete medical history and physical examination can help to rule out other possible causes of the symptoms and assess the likelihood of epilepsy.

Complex Partial Seizures What are they like? Here's a typical story: "Harold's spells begin with a warning; he says he's going to have a seizure and usually sits down. If I ask him how he feels, he just says 'I feel it.' Then he makes a funny face, a mixture of surprise and distress. During the seizure he may look at me when I call his name but he never answers. He just stares and makes odd mouth movements, as if he's tasting something. Sometimes he'll grab the arm of the chair and squeeze it. He may also pull at his shirt as though he's picking lint off of it. After a few minutes, when he's coming out of it, he asks a lot of questions. He never remembers his 'warning' or these questions. The seizures make him tired; if he has two in the same day, he often goes to sleep after the second one." And another story: "Susan's seizures usually occur while she's asleep. She makes a grunting sound, as if she's clearing her throat. Then she'll sit up in bed, open her eyes, and stare. She may clasp her hands together. If I ask her what she's doing, she doesn't answer. After a minute or so, she lies down and goes back to sleep." How long do they last? They usually last between 30 seconds and 2 minutes. Afterward, the person may be tired or confused for about 15 minutes and may not be fully normal for hours. Tell me more These seizures usually start in a small area of the temporal lobe or frontal lobe of the brain. They quickly involve other areas of the brain that affect alertness and awareness. So even though the person's eyes are open and they may make movements that seem to have a purpose, in reality "nobody's home." If the symptoms are subtle, other people may think the person is just daydreaming. Some people can have seizures of this kind without realizing that anything has happened. Because the seizure can wipe out memories of events just before or after it, however, memory lapses can be a problem. Some of these seizures (usually ones beginning in the temporal lobe) start with a simple partial seizure. Also called an aura, this warning seizure often includes an odd feeling in the stomach. Then the person loses awareness and stares blankly. Most people move their mouth, pick at the air or their clothing, or perform other purposeless actions. These movements are called "automatisms" (aw-TOM-ah-TIZ-ums). Less often, people may repeat words or phrases, laugh, scream, or cry. Some people do things during these seizures that can be dangerous or embarrassing, such as walking into traffic or taking their clothes off. These people need to take precautions in advance. Complex partial seizures starting in the frontal lobe tend to be shorter than the ones from the temporal lobe. The seizures that start in the frontal lobe are also more likely to include automatisms like bicycling movements of the legs or pelvic thrusting. Some complex partial seizures turn into secondarily generalized seizures. Who gets them? Anybody can get them. They may be more likely in people who have had a head injury, brain infection, stroke, or brain tumor but most of the time the cause is unknown. What's the outlook? As for many other kinds of seizures, the outlook depends on whether the cause is known. They may be outgrown or controlled with medication. If medication is not effective, some can be eliminated by epilepsy surgery. What else could it be? Complex partial seizures sometimes resemble daydreaming or absence seizures : Questions to Ask How frequent are the episodes? Daydreaming Not frequent. Seizures Complex partial: Rarely more than several times per day or week. Absence: Could be many times per day. Any time, including during physical activity. Usually yes. Some complex partial seizures begin slowly with a warning. No. Complex partial: Up to several minutes. Absence: Rarely more than 15-20 seconds. Complex partial: Automatisms are common. Absence: Just stares. Complex partial: Confused. Absence: Alert.

In what situations do they occur? Do they begin abruptly?

Boring situation. No.

Can they be interrupted? How long do they last?

Yes. Until something interesting happens. Probably just stares.

Does the person do anything during the episode? What is the person like immediately after the episode?

Alert.

How is the diagnosis made? Careful observation should make the diagnosis pretty certain in most cases. Secondarily Generalized Seizures What are they like? Seizures of this kind start as a partial seizure²that is, they start in one limited area of the brain. The forms they take vary as much as other partial seizures. But then (sometimes so quickly that the partial seizure is hardly noticed) the seizure spreads throughout the brain, becoming "generalized." Here's how a couple of people with epilepsy described their secondarily generalized seizures:

y y

The seizures start with a tingling in my right thumb. In seconds, my thumb starts jerking. Soon, my whole right hand is jerking. I have learned that by rubbing and scratching my forearm I can sometimes stop the seizure. Other times the jerking spreads up my arm. When it reaches my shoulder, I pass out and people tell me that my whole body starts to jerk. I see this colored ball on my right side. It seems to grow until it fills up my whole view. Everything becomes like a dream and I don't feel real. It is the strangest feeling. Sometimes the seizure stops then, and sometimes it goes all the way and I fall to the floor and have a grand mal [tonic-clonic seizure]. How long do they last? The generalized, convulsive phase of these seizures usually lasts no more than a few minutes, the same as primary generalized seizures. The preceding partial seizure is usually not very long. Sometimes this part is so brief that it is hard to detect. Tell me more These seizures are called "secondarily generalized" because they only become generalized (spread to both sides of the brain) after the initial or "primary" event, a partial seizure, has already begun. They happen when a burst of electrical activity in a limited area (the partial seizure) spreads throughout the brain. Sometimes the person does not recall the first part of the seizure. These seizures occur in more than 30% of people with partial epilepsy. Who gets them? They can affect people of all ages who have partial seizures. What's the outlook? Many seizures of this kind can be controlled with medication. If a person has tonic-clonic seizures that are not well controlled with medication, the doctor should investigate to see whether they might be secondarily generalized seizures that begin in a limited area of the brain. If they are, surgery could be an option. What else could it be? It may be difficult to distinguish these seizures from primary generalized tonic-clonic seizures, especially if they occur during sleep or are not witnessed by anyone else. Most convulsive seizures during sleep are secondarily generalized seizures that do begin as partial seizures. How is the diagnosis made? The EEG and MRI are often helpful in telling the difference between these seizures and primary generalized tonic-clonic seizures.