Seizure Types and Classification There are many different seizure types and groups. Seizure classification is a way of naming the different types of epileptic seizures and putting them into groups.
Recognising Seizure Stages There can be up to four stages of a seizure and each stage is different, occurs at different times and the common symptoms experienced are different.
Photosensitive Epilepsy In some people, seizures can be triggered by flashing or flickering lights, or by certain geometric shapes or patterns.
Febrile SeizuresA febrile seizure is a seizure or convulsion caused by a sudden increase in a child’s body temperature and often the seizure can be the first sign of a fever.
Seizure Emergencies There are a small group of people with epilepsy who have severe or even life-threatening seizures. Here we cover some seizure emergency situations.
Epilepsy Syndromes Epilepsy syndromes are specific groups of epilepsy conditions characterized by distinct patterns of seizures, symptoms, and electroencephalogram (EEG) findings, often associated with particular age groups and causes.
The Human Brain
The brain is made up of millions of nerve cells called neurons. These cells generate electrical impulses and messages to produce thoughts, feelings, sensations, movement and control body functions.
Regions of the brain
The brain is divided into two halves, left and right, called hemispheres. The right hemisphere controls the left side of the body and left hemisphere controls the right.
Each hemisphere has four lobes – frontal, parietal, temporal and occipital.
Cerebrum
This is the largest part of the brain and includes both hemispheres, and all the lobes. It is the centre of intellect, memory, language and consciousness, receiving and interpreting sensory information and controlling movement.
Frontal Lobes
Are our behavioural and emotional control centre. They are also involved in voluntary movement, planning, initiation, problem solving, memory, language, judgement, impulse control, and social and sexual behaviour.
Parietal Lobes
Are involved with touch, temperature and pain perception (sensation), awareness of the body and where it is in space.
Temporal Lobes
Play a large role in understanding language, speech, learning, memory, personality and behaviour.
Occipital Lobes
Are primarily responsible for vision
Cerebellum
The cerebellum is responsible for co-ordination, and maintaining of posture, muscle tone, and balance.
Brainstem
Controls basic body functions such as breathing, swallowing, heart rate, blood pressure, consciousness, and whether you are awake or sleepy.
If you want to know more about the brain and its functions, go to:
Epilepsy is a disorder of the brain, and seizures are caused by a temporary disruption of the electrical activity in the brain.
Epilepsy is diagnosed when someone has a tendency to have recurrent seizures.
Approximately 3% to 3.5% of Australians will be diagnosed with epilepsy at some point in their lives and over 250,000 Australians currently live with epilepsy.
Epilepsy can start at any age although it is more likely to be diagnosed in childhood or senior years.
There are many different types of epilepsies and people’s experiences differ greatly. Some types of epilepsy are age-limited and the person eventually stops having seizures. For others, epilepsy is a life-long condition.
Approximately two thirds of people with epilepsy become seizure free with medication.
What causes epilepsy?
So, you’ve been diagnosed with epilepsy, and you don’t know why you’ve got it. Why do you, or why does your loved one have seizures?
There are many possible causes of epilepsy. but there are also situations where it is just not clear.
In about half of people diagnosed, they will never know the cause of their epilepsy.
Firstly, anyone can develop epilepsy. It does not discriminate and is seen in all ages and cultures.
Anything that causes damage to brain tissue, can cause seizures. Even if this is just a tiny area of the brain, it can affect how the brain cells send and receive messages and may lead to seizures and epilepsy.
Some known causes
People can have epilepsy from birth, inherit it or develop it from injury, disease, or infection. Some events that can cause epilepsy include:
Head injury or brain trauma
Stroke or brain haemorrhage
Lack of oxygen to the brain for instance during birth trauma, heart attack or drug overdose
Brain infections
Brain tumours
In other circumstances, epilepsy may be caused by:
Brain abnormalities present at birth
Genetic factors
Conditions that affect the brain such as Alzheimer’s Disease
Alcohol or drug abuse
Sometimes there may be more than one cause of the epilepsy. Many times, there is no known cause
The cause may influence treatment
If you do learn why you have developed epilepsy, sometimes knowing the cause may help you understand it a bit better and give you some idea about the type of seizures you may have. It can also influence the type of medication or treatment best suited, the chances of seizures responding to treatment, and the possible course of your epilepsy.
Seizures
A seizure happens when the usual electrical impulses in the brain are disrupted, causing them to rapidly fire all at once. Depending on where the seizure happens in the brain, this can cause changes in:
sensation and feeling
awareness and consciousness
emotions and behaviour
movement
Seizures vary. Some are severe and some very subtle. Some are very brief and some last up to two or three minutes. Most seizures are generally over in less than two minutes.
Under certain circumstances, anyone can have a seizure and not all seizures are diagnosed as epilepsy.
Seizure Triggers
Sometimes you may become aware that specific events or circumstances can set off or “trigger” your seizures. These are usually called seizuretriggers.
Triggers for seizures are not the same as the cause for your epilepsy. Some seizure triggers are listed below, where as causes of epilepsy include things such as structural damage to the brain from events like a stroke or head injury, genetics, brain infections or tumours. A lot of the time, a cause of epilepsy cannot be determined.
Triggers differ from person to person. Identifying your seizure triggers can help you to reduce or even avoid seizures.
Some reported seizuretriggers include:
Missed medication
Lack of sleep
Physical fatigue and exhaustion
Stress, excitement, emotional upset
Menstruation/hormonal changes
Illness or fever
Poor diet or low blood sugar
Flickering lights or geometric patterns
Other medications
Alcohol use
Illicit drugs
What are your seizuretriggers?
If you’re not sure the best way to find out is to keep a diary of not only your seizures, but the circumstances around your seizures. Note things like if you were unwell, feeling stressed, drinking alcohol, had just woken up, not slept well, or having your period.
any special circumstances surrounding it (eg sickness, menstruation, drinking alcohol, late night, forgotten medication),
if you were awake or asleep,
what you were doing and how you felt before the seizure.
If you notice a circumstance is happening consistently before seizures, it may be a seizure trigger for you.
You may notice that your seizures have a pattern or predominantly occur at similar times of the day
Take note of what happens around the times of your seizures, and not just when you have a seizure.
Once you have an idea what your seizure triggers might be, then you can work on reducing your exposure to these triggers, or managing them, for instance, managing stress.
What seizures look like
FOCAL ONSET SEIZURES
Focal seizures are classified depending on whether the persons awareness is changed and if there is any movement. Some focal seizures are very subtle and easy to miss.
Focal aware seizures – The person is awake and aware of what is happening
If a seizure does not impair consciousness and the person has full awareness of what is going on around them during the seizure it is called a focal aware seizure.
People often call these seizures their “aura” but they are actually a seizure – which may or may not lead on to a more significant seizure. For instance, the seizure may spread to become a focal impaired awareness seizure or progress into a bilateral tonic clonic seizure.
Examples of focal aware seizures include:
Focal motor seizures – movements, such as jerking, posturing or stiffening of arm/s or leg/s, twitching of face
Focal sensory seizures –sensations, such as numbness, tingling or burning feeling in a part of the body
Focal autonomic seizures – involuntary body changes, such as blushing, looking pale or grey, increased heart rate, butterflies in the stomach, nausea, and perspiring
Focal cognitive seizures – difficulties with speech or thinking, or features such as déjà vu, hallucinations (visual, smell, taste or hearing), illusions or perceptual distortions
Focal emotional seizures – feeling emotions such as joy, sadness, anxiety, fear or panic.
Focal seizures – impaired awareness
Some focal seizures cause a change in awareness, consciousness, and behaviour. These are called focal impaired awarenessseizures.
These focal seizures vary greatly from person to person, depending on where they start and spread within the brain. They are frequently not recognised as seizures by onlookers. Many of these seizures show features such as:
A vacant stare, loss of expression or a vague, confused appearance
Altered or impaired consciousness or awareness and the person may or may not respond
If they do respond, it is usually inappropriate to the situation
Sometimes people have unusual and repetitive behaviour such as chewing, fidgeting, walking around, mumbling or vocalising
The seizure can range from 30 seconds to 3 minutes
After the seizure, the person is often confused for a short time, and may not remember anything that happened before or during the event.
Tiredness is common after the seizure.
Both focal aware and focal impaired awareness seizures can simply be called focal seizures.
GENERALISED ONSET SEIZURES
Tonic clonic seizures
This is the most recognised seizure type.
A tonic clonic seizure is a seizure that has a tonic (muscle stiffening) followed by clonic (muscle jerking) phase. Tonic clonic seizures can be frightening to witness. There are slight variations, but a typical tonic clonic seizure will look like:
A sudden loss of consciousness, sometimes with vocalisation or calling out
The eyes, head and body may turn in one direction
The body becomes stiff (tonic), followed by jerking of the muscles (clonic)
If standing, the person will fall
Breathing may be shallow or briefly stopped which may cause the lips and face to look greyish/blue
The person will not respond when spoken to
Excess saliva may come of the person’s mouth, and there may also be blood if they have bitten their tongue or the inside of their cheek
There may be loss of bladder or bowel control so the person may wet or soil themselves
The seizure usually lasts less than 2 minutes
Immediately after the seizure breathing can be quite laboured and sound like heaving snoring (usually less than a minute)
After the seizure there is usually a period of confusion, headache, soreness and the person usually needs to sleep it off.
Myoclonicseizures
A myoclonic seizure is a seizure where a single brief muscle jerk or series of single jerks happen. A person having a myoclonic seizure typically has a sudden jerk of the arms and upper body, which can vary in severity, but can cause them to spill or drop what they are holding, or fall off a chair. If severe enough, a myoclonic seizure can also cause a fall.
The seizures are often mistaken for clumsiness before diagnosis.
Note: Even people without epilepsy can experience sudden jerks upon falling asleep, but these are normal and not seizures.
Tonic seizures
A tonic seizure involves increased muscle tone (stiffening) of the body usually very brief, lasting a few seconds. If the person is standing they will suddenly fall stiffly to the ground. This is often termed a “drop attack”.
Tonic seizures often occur during sleep and in clusters of varying intensity of stiffening. The person is unaware during these events. At the beginning of tonic seizures with more intense stiffening, people may make an exhalation or loud sigh sound. With more severe and prolonged tonic seizures the person may look like they have a tremor or shaking.
Tonic seizures often occur in people with intellectual disability or more complex epilepsies.
Atonic seizures
An atonic seizure is a type of seizure that involves the sudden loss of muscle tone. If standing, this can cause a “drop attack” where the person suddenly slumps to the ground. If sitting, a simple head nod (as if the person is trying to fight off sleep) may be seen. These seizures are very brief, less than 2 seconds and may involve the head, body or limbs.
Atonic seizures often occur in people with intellectual disability or more complex epilepsies.
Absence seizures
The most common absence seizure is the typical absence seizure. There are other less common types of absence seizures that are briefly discussed here.
A typical absence seizure starts and ends abruptly, is very brief with no awareness during the seizure. Absence seizures usually begin in childhood (but can occur in adolescents and adults) and are easily missed, or misinterpreted as daydreaming or inattentiveness.
Typically, they will look like:
the seizure starts suddenly with the person stopping their activity
you will see staring, loss of facial expression and unresponsiveness
sometimes eye blinking or upward eye movements are seen
the seizure can last from two to 20 seconds and ends abruptly
the person usually recovers immediately and resumes their previous activity, with no memory of what happened during the seizure
These seizures can happen numerous times a day causing learning to be disrupted. They generally respond well to medication.
The below group are less common absence seizure types:
*Atypical absence seizures
The seizure does not start and end as suddenly as a typical absence, it can be more gradual. They are often seen with other features such as loss of muscle tone of the head, trunk or limbs (often seen as a gradual slump) and subtle jerking. The loss of awareness may be minor with the person continuing an activity, but more slowly or with mistakes.
These seizures often occur in people with intellectual disability and complex epilepsies.
*Myoclonic absence
Rhythmic myoclonic jerks of the shoulders and arms and lifting of the arms during the seizure can be seen. The myoclonic jerks are usually seen in both arms, but may be one-sided or not symmetrical. Puckering (jerking) of the lips, twitching of the corners of the mouth, or jaw jerking can also be seen. Sometimes rhythmic jerks of the head and legs may occur. Seizures last 10-60 seconds and typically occur daily. The level of awareness varies from complete loss of awareness to retained awareness.
*Absence with eyelid myoclonia
These are absence seizures accompanied by brief, often rhythmic, fast myoclonic jerks of the eyelids at the same time with an upward movement of the eyeballs and of the head. This can look like fluttering of the eyelids and simultaneous rolling back of the eyes. These seizures are typically very brief and occur many times a day. Mostly awareness is retained.
UNKNOWN ONSET SEIZURES
There are seizures that cannot be clearly diagnosed as focal or generalised, and may even be considered both. The “Unknown Onset” classification is used when a seizure is unable to be classified due to either:
not enough information or
an unusual nature of the seizure, or
the inability to classify the seizure as either focal or generalised onset.
Unknown onset seizures are not truly separate types of seizures, but temporary labels for seizure types for which the onset is unknown. As more information becomes available over time or through further testing, the seizure type may be changed to a generalised or focal onset seizure.
For instance a person reports having a tonic clonic seizure, but the start of the seizure was not seen. Therefore it is uncertain if it was a focal or generalised onset.
Epileptic spasms are classified in unknown onset
Epileptic spasms (which include infantile spasms) are seen in infants and appear like:
A sudden bending or lunging forward (flexion) of the upper body followed by stiffening
Often the arms are flung out as the knees are pulled up and the body bends forward
Less often, the head can be thrown back (extension) as the body and legs stiffen in a straight-out position
Movements can be more subtle and limited to grimacing or head nodding
These spasms are longer than a myoclonic jerk, but shorter than a tonic seizure.
Each seizure lasts only a second or two but they usually occur in clusters, several in a row.
What is a syndrome?
There are many different types of epilepsy classifications. Many people are now given a specific diagnosis or name for their epilepsy, rather than just told that ‘you have epilepsy’. Some types of epilepsy are further classified as syndromes and are defined based on a unique combination of symptoms.
An epilepsy syndrome is a type of epilepsy that depends upon:
family history
what age the seizures start
seizure type(s)
cause, and other linked diseases/conditions
how the syndrome progresses over time
presence or absence of brain abnormalities
EEG findings
brain scan findings (such as CT, MRI, PET)
seizures response to medication.
A diagnosis of a particular epilepsy syndrome is useful in deciding the possible treatment options, what course the condition may take, and the possible genetic risk of passing it on to offspring.
Seizure classification is a way of naming the many different types of epileptic seizures and putting them into groups.
In 2017, the International League Against Epilepsy revised its classification of seizures to make diagnosing and classifying seizures more accurate and simpler. Some of the words you may have heard to describe seizures, such as ‘tonic-clonic’ are still used while others, such as ‘partial’ and ‘grand mal’ are no longer used.
Doctors look at the following three things when classifying a seizure:
Where in the brain the seizure starts (e.g. the onset)
If the person is aware or not during the seizure
Whether the seizure involves movement.
Most people will only have one or two seizure types. Sometimes a person with more complex or severe epilepsy may experience a number of different seizure types.
Focal onset (formerly known as partial seizures) means the seizure starts in just one small region of the brain. It may spread to other areas of the brain.
These seizures can often be subtle or unusual and may go unnoticed or be mistaken for anything from being intoxicated to daydreaming. About 60% of people with epilepsy have focal onset seizures – which are also simply known as focal seizures.
Focal onset seizures can be further divided into two groups relating to a person’s awareness during a seizure:
Focal aware: the person is fully aware of what’s happening around them but may not be able to talk or respond (formerly known as simple partial seizures). They are usually brief, and are often called a warning or ‘aura’ (that a more significant seizure may develop) but are actually part of the seizure.
Focal impaired awareness: awareness is affected (formerly known as a complex partial seizure) and the person may appear confused, vague or disorientated.
A focal seizure may progress to a bilateral tonic-clonic seizure meaning that it starts in one area of the brain and then spreads to both sides causing muscle stiffening and jerking.
Generalised onset means the seizure affects both hemispheres (sides) of the brain from the onset. Because of this, a person may lose consciousness at the start of the seizure. Generalised onset seizures almost always affect awareness in some way, so the terms ‘aware’ or ‘impaired awareness’ aren’t used. However, they can be classified further by movement:
Generalised motor seizure: may involve stiffening (tonic) and jerking (clonic), known as tonic-clonic (previously known as grand mal) or other movements
Generalised non-motor seizure: These seizures involve brief changes in awareness, staring, and some may have automatic or repeated movements like lip-smacking.
Types of Generalised Onset Seizures
There are many types of seizures in this classification. They include:
Absence – a sudden lapse in awareness and responsiveness that look like brief staring spells or daydreaming
Tonic-Clonic – the body stiffens (the tonic phase) and then the limbs begin to jerk rhythmically (the clonic phase)
Myoclonic – sudden single jerks of a muscle or a group of muscles that may last no more than a second or two
Tonic – Can occur when a person is asleep or awake and involves a brief stiffening of the body, arms or legs. The person will suddenly fall if standing or sitting.
Atonic – brief seizures that cause a sudden loss muscle tone and the person often falls to the ground or will have a sudden head nod if sitting.
Clonic – although uncommon they cause jerking in various parts of the body
Unknown onset means the seizure cannot be diagnosed as either focal or generalised onset. Sometimes this classification is temporary and as more information becomes available over time or through further testing, the type of seizure may be changed to a generalised or focal onset seizure.
Rarely, doctors might be sure that someone has had an epileptic seizure, but can’t decide what type of seizure it is. This could be because they don’t have enough information about the seizure, or the symptoms of the seizure are unusual.
Most people will only have one or two seizure type(s), which may vary in severity. A person with severe or complex epilepsy or significant damage to the brain may experience a number of different seizure types.
Many people think seizures are all pretty much the same. In fact, there are many different types of seizures and even some seizure types, although they have the same name – such as focal seizures – can vary enormously.
A seizure is a temporary disruption of the electrical activity in the brain and can present in many ways including changes to sensation, awareness, behaviour, or movement. Some seizures are very brief and others can last longer. Not all seizures involve jerking or convulsions and not all seizures are diagnosed as epilepsy.
To better understand what is happening in the brain when a seizure occurs, it is helpful to understand the stages of a seizure. There can be up to four stages of a seizure and each stage is different, occurs at different times and the symptoms experienced are different.
It is important to note that not everyone will have all four stages of a seizure.
The four stages of a seizure are:
Prodrome (before seizure)
The Aura (early seizure)
Ictal (seizure)
Postictal (after seizure)
Before the seizure: the prodrome
The prodromal stage is usually a feeling or sensation that can happen several hours or even days before the seizure. Some people report symptoms consistently happening hours ahead of a seizure, while others may not be fully aware of this happening, but people close to them may have pick up on subtle changes.
The most common symptoms of a prodrome include confusion, anxiety, irritability, headache, tremor, and anger or other mood disturbances.
A prodrome is different from aura. It is not considered part of the actual seizure.
For those who experience it, once recognised, a prodrome may serve as a warning sign of an impending seizure.
During the seizure: early ictal and ictal stage
Ictal means a seizure. The ictal stage includes the time between the beginning (aura, if present) and the end of the seizure.
The aura (early ictal stage)
Some people with epilepsy experience what they call an “aura” which has traditionally been thought of as a warning a seizure is about to happen. The aura is actually the beginning or onset of a seizure.1
Auras are common, but not everyone with epilepsy has one. An aura typically happens a few seconds before main symptoms of a seizure or, it can happen in isolation. At this stage, the person has awareness of what is happening and can describe the symptoms.
The symptoms of the aura depend on where the seizure is starting in the brain, so they can vary greatly. Symptoms may include feelings of fear, déjà vu, sensations in the stomach such as nausea, heartburn or butterflies, dreamlike or outer body experiences, unusual smells or tastes, and hallucinations. The aura is usually remembered (but not always), and person can recall the happenings during this stage well enough.
Another term for aura is a focal aware seizure.
The seizure activity that causes an aura may stay confined to one small area of the brain and remain as an aura (focal aware seizure) in isolation.
The aura may progress to other areas of the brain and cause the person’s awareness to become impaired, which is then called a focal impaired awareness seizure.
The aura can also spread widely to both hemispheres of the brain, which will then become a convulsive (tonic clonic) seizure which is termed a focal to bilateral tonic clonic seizure when it spreads in this manner.
The seizure (ictal stage)
This is the stage of the seizure that most people are familiar with and would identify as a seizure. This stage is where you can usually clearly see signs such as changes in behaviour, consciousness or movement.
Seizures present in many different ways for each person with epilepsy. A person may experience very few, or many noticeable symptoms. Some of these can include:
Change in consciousness, confusion, vagueness
Unresponsiveness or inappropriate responses
Unable to move or speak
Stiffening and/or jerking of the limbs
Eye or head jerking movements
Chewing or lip-smacking
Speaking gibberish or vocalising
Fidgeting
Wandering
Drooling
Loss of bladder and/or bowel control
Pale or flushed skin
Dilated pupils
Sweating
Increased heart rate
After the seizure (post-ictal stage)
The time after a seizure is called the post-ictal period. With some seizures, people have an immediate recovery, such as absence seizures, while others may take the person several minutes to return to baseline. For more severe seizures such as tonic clonic seizures, some people can feel dreadful for hours, even days afterward.
The length of the post-ictal stage depends on the seizure type, severity, and region of the brain affected.
Many people need a rest or sleep after a seizure, even if it appears mild. Typical symptoms that happen after a seizure include:
Headache or migraine
Confusion, memory loss
Difficulty with speech or finding names or words
Body soreness
Tiredness, drowsiness, lethargy
Nausea
Feeling sad
Symptoms difficult to describe
So much surrounding a seizure can be difficult to articulate, especially when the person has memory loss for all or part of the seizure. For instance, unusual feelings or sensations, déjà vu, an aura that is like an outer body feeling, hallucinations or strange smells or tastes.
Not everyone has four stages with their seizures. Some will have less, depending on their seizure type. Still, one of the most disabling aspects of epilepsy is that seizures are usually unpredictable. If someone with epilepsy can have more awareness of their seizure stages, especially the prodrome, then they may be able to recognise symptoms much earlier and have more of a forewarning and be able to take themselves to a safe place or alert a loved one before a seizure happens.
In some people, seizures can be triggered by flashing or flickering lights, or by certain geometric shapes or patterns. This is called photosensitive epilepsy. Some people with epilepsy only have photosensitive seizures, whilst others may have other seizure types as well as photosensitive seizures.
This is a type of reflex epilepsy is seen in up to 5% of people with epilepsy, and because the seizures are usually triggered by some sort of visual stimulation, they can be reduced with simple avoidance strategies. Medication is usually used to help gain seizure control.
Although prognosis is generally very good, photosensitive seizures may persist.
How do I know if I have photosensitive epilepsy?
It is important to have a clear diagnosis, and keep good records or a seizure diary to help differentiate the seizures and their triggers. Photosensitive epilepsy can be diagnosed by having a routine EEG with strobe (flickering) light or pattern stimulation. A routine EEG should include this.
Today’s lifestyle can involve spending many hours using (visual) technology. While a seizure may occur in these conditions, it may also be a spontaneous or chance event – so don’t conclude your seizures are photosensitive seizures just because you had one or two when using technology.
How is it treated?
In most cases the photosensitive seizures can be well controlled by antiseizure medication and avoiding known triggers.
What are the triggers?
Our modern environment is a rich source of potentially seizure-triggering visual stimuli. Typical sources can include:
strobe lighting
television, electronic or video games, or the images on the screen
shimmering sunlight reflected off snow or water, or sunlight filtering through trees whilst in a moving vehicle
venetian blinds
striped walls or clothing
Less common stimuli are:
moving escalators
rotating helicopter blades
faulty fluorescent lights
welding lights
mobile phone flashes
New potentially provocative sources turn up now and then unexpectedly.
What are other factors involved?
Whether or not a photosensitive seizure happens is also influenced by:
whether the eyes are open, closed or closing at the time of the stimulation
the speed or flicker of the flashing (light)
the contrast and brightness of the stimuli – in general, with brighter stimuli and strong contrasts in colour, the more likelihood of inducing seizures
how long the stimulation goes for – a seizure is more likely to occur with longer exposure
the colour of the flicker (if any) – red flicker is more provocative and colour oscillating from red to blue
how large and close the screen is – the larger and closer someone is, the more “field of view” it takes up and is more likely to trigger a seizure
Managing photosensitive epilepsy
Types of stimuli that may trigger a seizure
Almost all people with photosensitive epilepsy are sensitive to flickering lights. Many natural light sources can provoke epileptic seizures as well. With the increasing use of technology, there is more exposure to provoking factors (e.g. screen time, visual images and strobe lights) than ever before. Avoiding sources of triggers is the best advice.
The following precautions only apply to those people who are diagnosed with photosensitive epilepsy.
Television: There are many different types of screen technology, and modern television screens are much less likely to trigger seizures. An older cathode ray tube (CRT) TV created its picture with flicker and although not recommended, if you get very close to the screen you can see the flicker.
Liquid crystal display (LCD) and plasma screen televisions do not use the scanning lines and therefore are less likely to trigger seizures than the older CRT televisions. Plasma screens tend to be brighter and have higher contrast than LCD televisions; this increased contrast may increase the risk of seizure activation.
For people with photosensitive epilepsy, the current advice is to opt for an LCD TV over a plasma TV.
It is important to keep a good distance from any screen because seizures may be provoked by images on the screen such as, flashing sequences or rapid changes from light to dark or to contrasting colours, such as from red to blue, rather than from the screen itself. So, the further away you sit from the screen, the less likely a seizure will occur.
It has not been proven that 3D movies are any more likely to trigger a seizure than 2D movies if someone has photosensitive epilepsy.
Tips:
Sit at least 2.5 metres from a television screen in a well-lit room
Sit at an angle rather than directly in front of the screen
Don’t watch the screen in the dark
Use a remote control or cover one eye to lessen the effect if you have to change channels manually
Do not watch the screen when fast forwarding, rewinding or adjusting the vertical hold
In the cinema, try to sit well back from the screen and near a light source, such as in an aisle seat where there is a guiding light
Look away from any content that makes you feel uncomfortable
A smaller screen set at low brightness and contrast is preferable.
In daily life, other factors such as sleep deprivation and drug or alcohol use may also play a role in provoking photosensitive seizures.
Video games: Apart from the screen display, the content and images of video-games are play a role in photosensitive seizures. Other factors that may play a role, particularly if the game is being played for a long time, include emotional excitement or tension, fatigue, eyestrain and difficulties sleeping, which can contribute to seizures.
Also, people tend to sit closer to a video game screen than when watching a TV program.
Tips:
Sit as far away from the screen as possible
Play the game in a well-lit room and reduce the brightness of the display
Avoid continuous exposure to the same pattern and don’t play when overtired
Check games for epilepsy or seizure warnings
If you do find that a game(s) makes you feel like you are going to have a seizure, then it is best to stop playing and keep exposure to the game in short bursts (have a break every 10-15 minutes) or avoid that particular game altogether.
It is good to take regular breaks from any electronic games and refresh.
Computer monitors: It is uncommon for a computer screen to trigger a seizure. Only in exceptional cases would it be necessary to restrict computer work. If you are sensitive to screen flicker on older monitors, a screen filter may help. You could always try an anti-glare filter to reduce screen glare. High quality monitors, liquid crystal or LCD screens with a flicker (refresh) rate of at least 60Hz may not pose a problem. Once again, it is more likely to be the images on the screen that may cause a seizure.
It is uncommon for seizures to be triggered by hand-held screens.
3D movies: There is much hype and concern about the effect of 3D movies being a seizure trigger, but this is not the case. In people with photosensitive epilepsy, the risks of a seizure being triggered by 3D movies is no greater than conventional 2D programs. For people with non-photosensitive epilepsy the risk of 3D movies triggering a seizure is negligible.
Lights: The frequency of a flashing or flickering light most likely to trigger seizures will vary from person to person. Generally it is between 8-30 flashes per second, but this can vary. Many people seem to be sensitive around 15-20 flashes per second. Again, it is also dependent on the brightness and intensity of the light, and how long the person is exposed to it.
Ordinary lighting in a room is preferable to fluorescent, but faulty fluorescent lights are rarely the trigger of a seizure
Fans: Ceiling fans in a lit room can create a flicker effect. A pedestal fan is best if you feel the ceiling fan may trigger a seizure.
Geometric patterns: Some people are sensitive to geometric patterns which have strong contrasts of light and dark such as stripes or checks. Some of these patterns can create an optical illusion. Some buildings and public places may have large areas like this, such as carpet. The average person will just feel some visual distortion, but if you feel strange in this environment, it is important to leave or at least cover one eye.
These patterns may also be on a television or computer screen, or something in the natural environment, such as sunlight through trees, or through Venetian blinds. Such contrasting patterns are more likely to be a trigger if they are moving, changing direction or flashing, rather than if they are still.
Camera flashes: These rarely trigger seizures unless fired in rapid succession.
Red flickering light and strobe/disco lights: These can trigger seizures, particularly if the room is darkened and there are other triggers such as stress, excitement, tiredness, sleep deprivation and alcohol. For those who are photosensitive, the risk will greatly depend on the speed of the flashing light.
Tip:
It is sensible to avoid strobe lighting like those at nightclub’s and music festivals if you have photosensitive epilepsy, but this is a common social activity for young people, so it may be a hard one to resist. Some people these events even if they are photosensitive, and find they can tolerate it. Responsible clubs and DJs may display warnings if these lights are used and retail employers may turn off flashing lights in their store if requested.
Sunlight: This can trigger seizures in a number of ways such as: the shimmering of light off water or through leaves of trees, and light flickering through posts or railings when moving quickly, such as travelling past in a vehicle. Some people may even be affected by looking outside through a screen door.
Tips:
Cover one eye with the hand to lessen the effect of the flicker as binocular (looking through both eyes) vision is needed to trigger a seizure.
Polaroid sunglasses or Zeiss Clarlet F133 Z1 Blue lenses may also help reduce the risk.
Management
Knowing what sources may trigger your photosensitive seizures, and reducing your exposure to them plays a significant role in reducing or stopping this type of seizure. Many people still need medication, but try to:
Tips:
Avoid events with strobe lighting if you can
Avoid video games with high contrast flashing and have frequent breaks if playing video games
Cover or patch one eye if you cannot avoid certain sources of stimulus (eg travelling in a vehicle when sunlight is flickering through the trees)
Wear glasses that reduce the amount of light as much as possible, such as polarised sunglasses
Blue lenses, (type Zeiss Clarlet F133 Z1), have proven effective for some people
Use smaller TVs and computer screens. Ask about specific computer screens when purchasing a computer
Reduce the contrast of TV and computer screens
Use a remote control
Keep a good distance to any screen (ideally at least three times its width)
When using any screen, keep the room well lit.
These are general suggestions, and depending on your sensitivity, not all approaches may be necessary or effective.
Some antiseizure medications can contribute to sleeping difficulties or daytime drowsiness
Sleep apnoea is about twice as common in people with poorly controlled epilepsy than in the general population
People with epilepsy and a sleep disorder have a poorer quality of life compared to those with no sleep disorder.
Treatment of the sleep disorder improves seizure control and quality of life
Lastly, sleep disorders can exacerbate seizures and epilepsy can exacerbate certain sleep disorders
Why do so many seizures happen during sleep?
Seizures during sleep can occur with any type of epilepsy. Some people have seizures occurring only during sleep whilst others have both daytime and night-time seizures. People who have only night-time seizures in their sleep are defined as having nocturnal epilepsy.
The International League Against Epilepsy (ILAE) defines nocturnal seizures as ‘seizures occurring exclusively or predominantly (more than 90%) from sleep.’
It is estimated around 12 percent of people with epilepsy have nocturnal seizures.
Why do nocturnal seizures occur?
Epileptic seizures are often strongly influenced by the sleep-wake cycle.
In wakefulness, our brain waves remain fairly constant, but when we go off to sleep, we have a change of state – from awake to asleep. Plus, during sleep, there are many changes of state, which are called sleep stages. It is thought that a change of state has an effect on the brains ‘epileptic activity’ in people with epilepsy. Some seizures occur predominantly at a certain stages of sleep.
It’s believed that nocturnal seizures are triggered by changes in the electrical activity in your brain when moving between the different stages of sleep, and between sleep and awakening stage. We go to bed and shift from
wakefulness to drowsiness to
light sleep to deep sleep to
Rapid Eye Movement (REM) sleep
and this whole cycle occurs 3-4 times per night.
There are dramatic changes on EEG during these sleep stage changes.
Stages of Sleep
Sleep is divided into 5 stages: Non-REM Stages 1, 2, 3, and 4 and REM sleep.
Seizures don’t seem to happen during REM sleep, but may occur at any other time during the sleep cycle, often in light sleep – that is, stages 1 and 2 of sleep. Nocturnal seizures can also occur when waking or stirring during the night.
This generally means there are more common times at which nocturnal seizures happen:
Within the first or second hour after going off to sleep (early nocturnal seizures)
One to two hours before the usual time of wakening (early morning seizures)
Within the first hour or so after awakening (early morning seizures).
Seizures that occur during sleep may also happen during a daytime nap – they are not limited to night time.
Table 1 Stages of Sleep
Stage 1 – Sleep Onset Non-REM sleep
Stage 2 Non-REM sleep
Stage 3 Non-REM sleep
Stage 4 Non-REM sleep
Stage 5 REM sleep
Drowsiness/ very light sleep, easily awoken
Light sleep
Deep sleep starts
Deep sleep
“Active” sleep. When you dream
This is when you start falling asleep, and is usually brief.
Your brain activity heart rate and breathing start to slow down. You begin to reach a state of total relaxation in preparation for the deeper sleep to come.
This is also known as slow wave sleep. Your brain waves further slow but there may still be short bursts of faster of brain activity.
If you were to be suddenly awoken during this stage, you would be groggy and confused, and find it difficult to focus at first.
This is where you experience your deepest sleep of the night. Your brain is mostly slow wave activity, and it’s difficult to wake someone up when they are in this stage.
Your blood flow, breathing, and brain activity increases, but your muscles go into a paralysis-like state. The brain activity is similar to when you are awake.
Diagnosing nocturnal seizures
It can be difficult to diagnose nocturnal seizures because they happen during sleep, and the person may not be aware of them happening. Also, nocturnal seizures, particularly focal seizures, can be confused with some sleep disorders.
As with most other forms of epilepsy, a good history of the seizures, or even better, an eyewitness account is very important for diagnosis. The doctor may also suggest a video sleep EEG, often done during the day after being sleep deprived.
If left undiagnosed, the person may suffer from a lot of daytime sleepiness and have undetected seizures, putting them at risk.
This can impact concentration, attention and learning as well as behaviour and emotions resulting in reduced quality of life.
Are there specific types of epilepsy where people have nocturnal seizures?
Nocturnal seizures can happen to anyone with epilepsy, but they are often associated with certain types of epilepsy, including:
Nocturnal seizures can be any type of seizures. Sometimes they may be too subtle to detect.
Can they change to daytime seizures?
If a person has seizures only during sleep for several years, the chances of the seizures happening during wakefulness is small. However this does not mean daytime seizures won’t occur. For example, in situations of extreme stress, sleep deprivation or illness, medication changes or withdrawal, the risk of a seizure is increased, day or night. Daytime seizures may also occur if someone with nocturnal epilepsy decides to take a nap, or even becomes excessively drowsy during the day.
With good seizure and lifestyle management however, the risks of a daytime seizure can be greatly reduced.
How are they managed?
It is important to aim for the best seizure control possible because nocturnal seizures can disrupt sleep, sometimes quite a lot. This can then become a cycle of sleep deprivation, which is a known trigger for seizures, and consequently more seizures
Treatment of nocturnal seizures is generally the same as daytime seizures, although sometimes the specialist may recommend a higher evening dose of antiseizure medication
Medical management of seizures is based on the type of seizures rather than when they occur
Driving
When seizures occur only during sleep they are not considered a hazard to driving. In people who have never had a seizure while awake but who have an established pattern of seizures exclusively during sleep, the risk of subsequent seizures while awake is sufficiently low to allow private driving (not commercial), despite continuing seizures while asleep.
In people with an established pattern of sleep-only seizures but a history of previous seizures while awake, the risk of further seizures while awake is higher. Therefore, a longer period of sleep-only seizures is required before driving by this group than in those who have never had a seizure while awake. This applies only to private vehicle drivers.
Sudden Unexpected Death in Epilepsy (SUDEP) is when a person with epilepsy dies suddenly and prematurely and no reason for death is found.
SUDEP deaths are often unwitnessed with many of the deaths occurring overnight during sleep. There may be obvious signs a seizure has happened, though this isn’t always the case.
Although the risk of SUDEP is very low, the risk increases for people with tonic-clonic seizures, especially if they happen at night or when asleep. Click here to take action against this risk
Some tips for getting a good night’s sleep include:
Keep the same bedtime and rising times as much as possible
Work with your internal body clock, so don’t ignore tiredness, go to bed when your body tells you so
Make sure your bedroom is a restful and calm place to be. Keep it dark at night and open the blinds when you wake up
Shift work is not ideal as it affects sleep times and quality of sleep
Don’t use screens – smart phones or tablets – for at least an hour before bedtime
Some people who have difficulties sleeping, or have interrupted sleep, use sedatives which may ultimately aggravate the problem. Try to improve your sleep regime with more natural techniques
Try not to resort to large amounts of coffee or other forms of stimulants to overcome tiredness. Avoid any caffeinated products or stimulating substances after lunch as this can also affect sleep quality and affect seizures for some people
Regular exercise can improve a restful sleep. Don’t exercise within four hours of bedtime though
Keep evening activities calm or use relaxation techniques to establish a more efficient sleep pattern. If there are things you are worried about, try not to think about them just before bedtime
A regular routine is vital with some people
If you have tried and failed to improve your sleep, there are many sleep specialists that can help.
Safety
For a person with nocturnal seizures, it is suggested:
Choose a low bed, avoid sleeping on a top bunk
Keep furniture away from the bedside to prevent injury during a fall
Consider using a safety mats on the floor next to the bed if the person tends to fall out of bed during seizures. Such mats are similar to those used in gyms
Wall mounted lamps pose less safety risks than ordinary table lamps or study lamps, which can be easily knocked over
Smoking in bed is unwise for anyone and particularly so for a person with nocturnal seizures
There are a number of devices for night-time seizure monitoring available for use in the home. They are designed to recognise that a seizure has occurred or that breathing has been disrupted, triggering an alarm so that help can be provided. An alarm or device cannot guarantee the safety of a person experiencing nocturnal seizures, however, some families have found monitors to be a useful part of a risk reduction plan and provide peace of mind
Some people advocate for the use of special anti-suffocation pillows to allow better airflow around the face. Whilst they are quite porous and allow airflow, the use of these pillows does not guarantee to prevent death from suffocation. The use of a special pillow is a personal choice
If there is someone available to help you if you have a seizure, check they know how to put you into the recovery position (onto your side) and what to do in case of emergency. See our First Aid page for advice
Finally, people who experience seizures exclusively during sleep may be allowed to drive.
For more information go to:
Sleep and epilepsy – Neurologist Dr Dan McLaughlin speaks about epilepsy and sleep
A febrile seizure is a seizure or convulsion caused by a sudden increase in a child’s body temperature and often the seizure can be the first sign of a fever. These can occur because the developing brain of a toddler or child is more sensitive to fever than an adult brain.
There appears to be a tendency for these seizures to run in families.
Febrile seizures are relatively common and typically happen between the ages of six months and six years. Between 2-4% of children have one or more febrile seizures by the age of five years. Approximately two thirds of these children will only have the one seizure, while others will have a seizure with following fevers.
It is generally not possible to prevent a febrile seizure from occurring.
Symptoms of febrile seizures
Febrile seizures can upsetting to witness, but they are generally not harmful to your child. Symptoms of typically include:
the body may become stiff and/or have jerking movements
the child will not respond (loss of consciousness)
the eyes may roll back
breathing is affected and shallow
the child may be red or very pale/bluish in the face
deep sleep is likely to happen for an hour or so afterwards.
Most febrile seizures are over in less than 2 minutes. Febrile seizures almost always stop by themselves.
To manage a febrile seizure is the same approach as any convulsive seizure.
Stay with the child
Time the seizure and watch them closely so you can describe it to the doctor later
Keep them safe: protect them from injury especially the head
Roll them onto their side after the seizure stops,
or immediately if there’s food, fluid, or vomit is in the mouth
Observe and monitor their breathing
DO NOT
Put anything in their mouth
Restrain them or hold them down
Treating the child’s fever with paracetamol or ibuprofen will not prevent a febrile seizure from happening.
Managing a fever
A fever is usually a sign your child is fighting an infection. If the fever is making your child miserable, you can help them to feel more comfortable by:
Making sure they are drinking enough to avoid becoming dehydrated
Dress them in light clothing or use light bedding. Don’t do cool baths or sponging (this can make them more uncomfortable and shiver, which may further increase the fever)
You can give paracetamol or ibuprofen if the fever is making your child hot and uncomfortable. Check the medicine packaging for the recommended dose and frequency
Check here for further information about when to seek medical help for a fever.
Calling an ambulance (000)
Most people will call an ambulance for their child’s first seizure, and it is important that you get your child seen by a doctor after a febrile seizure has occurred, especially if your child is very sick.
We also recommend calling an ambulance if:
You are in any doubt
An injury has occurred
The child has breathing difficulties after the seizure stops
There is food, fluid or vomit in mouth (they may have inhaled it)
The seizure happens in water
Another seizure quickly follows
The seizure lasts longer than 5 mins
The child does not wake up when the seizure stops
Outlook
In most cases, you can look after your child at home after a doctor has seen them for a febrile seizure. You may also find that your child may be sore, tired and grumpy for a day or two afterwards. Occasionally, children who have had a long febrile seizure need to be monitored in hospital for a while.
For most children the risk of developing epilepsy is no different from that of the general population and their development is not affected.
A very small proportion of febrile seizures are more complicated – that is, if the seizure last longer than 15 minutes, multiple seizures happen in a short space of time, or if the seizures have focal features. In this group the risk of developing epilepsy is slightly higher, but still low.
Watch Dr Kate Riney discuss Febrile Seizures
Epilepsy Syndromes
An epilepsy syndrome is diagnosed when the type of epilepsy has features such as specific seizure types, neurological features and characteristic EEG waveforms.
Epilepsy syndromes usually have age-dependent presentations and the person may have other medical or physical conditions.
When someone is diagnosed with an epilepsy syndrome, this influences the treatment choices and also carries with it more knowledge about outcomes and prognosis.
Some epilepsy syndromes are self-limited, meaning the seizures stop by a certain age, and others are associated with ongoing epilepsy.
There are over 30 epilepsy syndromes. These include:
Lennox-Gastaut Syndrome (LGS) is a severe form of childhood-onset epilepsy characterised by multiple seizure types. Nearly all people with LGS have some degree of intellectual disability, usually moderate to severe.
The cause of LGS is unknown in 1 out of 4 children. LGS is not something that anyone is born with, it develops over time and can evolve from other types of epilepsy such as infantile spasms, West Syndrome and tuberous sclerosis. It can also be caused by brain injury, infections, brain abnormalities, metabolic disorders, or genetic mutations.
Seizures
People with LGS experience different seizure types, and often have:
tonic (muscle stiffening) seizures, also known as “drop attacks”,
atonic (loss of muscle tone) seizures, also known as “drop attack”,
tonic clonic seizures,
atypical absence seizures,
myoclonic seizures (sudden brief muscle jerks),
focal seizures are sometimes seen.
Diagnosis
LGS may develop in children without a history of epilepsy but can also evolve from another type of epilepsy. The diagnosis may not always be obvious, and it may take several years to diagnose LGS in some circumstances.
Diagnosis is based on features which include:
multiple seizure types, which are resistant to medical treatment.
characteristic waveforms seen on EEG, which include slow spike-and-wave discharges and generalised paroxysmal fast activity (GPFA)
presence of intellectual disability. People with LGS have varying degrees of intellectual disability and behavioral issues. Intellectual disability can range from mild to severe, and often worsens over time.
Management
LGS is notoriously difficult to treat and is drug resistant.
Seizures often do not respond well to medication, and multiple anti-seizure medication are usually taken. Other treatment options may include dietary therapies, vagus nerve stimulation (VNS), or even surgery in some cases to control the drop attacks.
Prognosis
LGS is a lifelong form of epilepsy. Outcomes can vary greatly depending on the person, seizures and underlying cause. Whilst medical or surgical therapies may help, they do not completely stop the seizures. This means there is an increased risk of seizure-related injuries, particularly head and facial injuries due to drop attacks, and an increased risk of early death known as Sudden Unexpected Death in Epilepsy (SUDEP).
LGS has a significant impact on quality of life of the person and caregivers due to frequent seizures, injuries, hospitalisations, cognitive impairment, behaviours and the challenges of drug-resistant epilepsy.
Infantile epileptic spasms syndrome is a rare seizure disorder, previously referred to as West Syndrome. This syndrome mainly affects those in their first year of life, typically between 4-8 months of age but the onset and diagnosis can be outside these parameters.
Seizures
The spasms (seizures) typically happen during wakefulness and look like a sudden bending forward of the body with stiffening of the arms and legs. These are brief – and over in seconds. Some infants arch their backs as they extend their arms and legs. The spasms tend to cluster when the infant wakes up, and they can have a few, to up to hundreds of seizures per day.
There are many different causes of infantile spasms, which can happen before or after birth.
Diagnosis
Infants with this type of epilepsy will present with:
Seizures known as infantile or epileptic spasms
Developmental delays and cognitive problems or regression
A specific brain wave pattern on EEG called hypsarrhythmia
Early diagnosis is important for infantile epileptic spasms because early treatment affects prognosis and outcomes.
Management
Treatment is firstly commenced with specific medications known to act upon these seizures. These medications can be very effective but also have significant adverse side effects, which your doctor will discuss.
When these medical treatments do not improve the epileptic spasms, doctors may consider trying the ketogenic diet as well.
If there are brain lesions causing the spasms, the seizures may decrease if the lesions are removed by surgery.
It is very important for treatment to start as soon as possible. If spasms (and hypsarrhythmia) continue, they can have negative effects on the developing brain.
Prognosis
The outlook varies, and mostly depends on what is causing the epileptic spasms.
Many infants have neurological impairment before spasms begin and will have intellectual disabilities later in life.
Infantile spasms usually stop by age 4 or 5 but many children will develop other types of seizures or syndromes, like Lennox-Gastaut syndrome, which may not respond well to medication.
Outcomes may be better if:
Treatment is started quickly after the epileptic spasms start
There is normal development before the spasms started
Temporal lobe epilepsy (TLE) is a type of focal epilepsy where the seizures originate in the temporal lobe of the brain. Approximately 60 percent of all forms of epilepsy are focal in origin, with the majority originating in the temporal lobe.
The seizures are called focal seizures, or focal onset seizures. Sometimes focal seizures can evolve into a convulsive (tonic clonic) seizure which is then termed focal to bilateral seizure.
The temporal lobes sit at each side of the head, behind the ears. They are most commonly associated with memory function and also processing language, sound, emotions and visual recognition.
Damage to the temporal lobes can cause problems such as:
Difficulty in understanding spoken words
Difficulty learning and retaining new information
Memory difficulties
Disturbance with selective attention to what we see and hear (focus)
Persistent talking
Difficulty in recognising faces
Increased or decreased interest in sexual behaviour
Emotional disturbance
Seizure types
While TLE seizures primarily have focal seizures. These can vary greatly between individuals. They are broken down into two groups:
when awareness is retained – focal aware seizure, and
when awareness is impaired – focal impaired awareness seizure.
Note: Any focal seizure can spread to both hemispheres of the brain and become a tonic clonic seizure. This is called a focal to bilateral tonic-clonic seizure.
Symptoms of temporal lobe seizures can include the following:
Focal aware seizures: often referred to as “auras,” where the person is conscious (aware) and will know that something is happening and will remember the seizure afterwards. Sometimes they may not be able to move or communicate during the seizure, but they are aware of what is happening.
Symptoms can include:
Focal sensory seizure– numbness, tingling or burning sensation in a region of the body, unusual smell or taste, dizziness, feeling hot or cold
Focal motor seizure – jerking of a limb, twitching of the face, weakness or paralysis of a muscle group
Focal emotional seizure – changes in mood or emotion such as fear, panic, laughing, crying
Focal cognitive seizure – unable to speak, speech difficulty, déjà vu, visual hallucinations, hearing sounds
Focal behaviour arrest seizure – the person will just “freeze” and appear unable to move or talk
Remember, the person knows these seizures are happening and may not even consider them as a seizure, but merely as a warning of an impending seizure. What causes these symptoms though is seizure activity in a small region of the brain. Approximately 70% of focal aware seizures progress into a focal impaired awareness seizure.
Focal impaired awareness seizures: this is when there is a loss of awareness for some or all of the seizure. The person’s awareness is diminished, and they may be confused, may or may not be able to hear you, and not fully understand what you say or be able to respond appropriately. Often, they lose memory for some or all the seizure.
Symptoms vary but can include;
blank staring, disorientation or confusion, not responding appropriately, chewing or lip smacking, picking at clothes, fumbling, repetitive movements, unusual vocalisation or unable to speak, becoming unaware of surroundings, and wandering.
Sometimes these seizures are very subtle and not recognised as a seizure by onlookers, and other times they are mistaken for intoxication or psychiatric illness. This seizure type may be preceded by a focal aware seizure.
Both these seizure types can progress into a focal to bilateral tonic clonic seizure if they seizure activity spreads to both hemispheres of the brain.
Management
Medication: Many people with TLE gain seizure control with anti-seizure medication, but about 1 in 3 may not respond well to medication and continue to have seizures.
Poorly controlled seizures can significantly affect quality of life. People commonly report problems with memory, moods – primarily anxiety and depression, social isolation and difficulties getting or maintaining work.
People with TLE who have a poor response to antiseizure medication and should be considered for surgical assessment if this is the case. Surgery to remove the area causing the seizures is a possible option for many people with TLE.
If you’ve tried many medications, yet continue to have seizures, talk to your doctor or about other treatment options available that may help you. You may need a referral to a comprehensive epilepsy centre to investigate further options.
Surgery: If seizures fail to respond to medication, then epilepsy surgery may be an option.
Early surgical assessment and intervention has a good success rate and also benefits through improvements in quality of life. Epilepsy surgery is only suitable for a small number of people with drug resistant epilepsy, but fortunately TLE is one type of epilepsy that is often successfully treated with surgery.
Depending on the individual circumstances, up to 7 out of 10 people can be seizure-free after epilepsy surgery.
Listen here to neurosurgeon Dr Erica Jacobsen answer questions about epilepsy surgery.
Neuromodulation: For people where epilepsy surgery is not possible, other options such as neuromodulation – vagus nerve stimulation (VNS), deep brain stimulation (DBS) – is available for consideration. This can lead to fewer and shorter seizures, and better recovery after seizures.
This is a syndrome seen in childhood and is characterised by frequent absence seizures between the ages of 2 to 13 years (usually 4-10 years).
Seizures
Typically, an absence seizure will look like:
the person suddenly stops what they are doing
they will stare vacantly, with loss of facial expression and unresponsiveness
sometimes eye blinking, upward eye movements, or small movements of the hands are seen
the seizure can last from 3 to 20 seconds and start and end abruptly
straight after the seizure the person is wide awake, resumes their previous activity, usually unaware the seizure has happened or no memory of what happened during the seizure
Absence seizures are generalised onset seizures, which means the seizure affects both hemispheres (sides) of the brain from the onset. Because of this, a person loses awareness at the start of the seizure.
The seizures usually begin in childhood and are easily missed or mistaken as daydreaming, inattentiveness or “not listening”. They are very brief but occur multiple times a day. Childhood absence epilepsy is more common in girls.
Diagnosis
Childhood absence epilepsy is generally easy to diagnose with a routine EEG. Typical absence seizures can be easily provoked with hyperventilation (fast deep breaths) and show a specific waveform on EEG, confirming diagnosis.
Management
Absence seizures generally respond well to medication. Because these seizures can happen many times a day, causing brief loss of awareness for that time, it can impact learning or daily activities. Problems with attention may continue despite controlling the seizures.
Prognosis
Childhood development is typically normal, and many children outgrow absence seizures in their teenage years. In these cases, antiseizure medications can usually be weaned. However, some children may develop other seizure types or generalised epilepsy syndromes.
This syndrome is seen in adolescents or adults where absence seizures are seen, usually less than daily, much less frequently than childhood absence seizures. In about 80% of people with juvenile absence epilepsy, generalised tonic clonic seizures also occur, typically within 30 minutes of waking.
Seizures
An absence seizure will look like:
the person suddenly stops what they are doing
they will stare vacantly, with loss of facial expression and unresponsiveness
sometimes eye blinking, upward eye movements, or small movements of the hands are seen
the seizures are very brief and start and end abruptly
loss of awareness may vary. It can be complete loss of awareness, or the person may have some awareness and respond to commands, but have difficulty doing complex tasks
recovery is quick and the person usually can resume activity after the seizure
absence status epilepticus can occur
A tonic clonic seizure will look like:
a sudden loss of consciousness, sometimes with vocalisation or crying out
the eyes, head and body may turn in one direction
the body becomes stiff (tonic), followed by jerking of the muscles (clonic)
if standing, the muscle stiffening will cause the person to fall
breathing is compromised during the seizure which may cause the lips and face to look greyish/blue
the person will not respond when spoken to
excess saliva may come of the person’s mouth, and there may also be blood if they have bitten their tongue or the inside of their cheek
there may be loss of bladder control or less commonly bowel control
immediately after the seizure breathing can be quite laboured and sound like heaving snoring
after the seizure there is usually a period of confusion, headache, soreness and sleepiness.
Diagnosis
Juvenile absence epilepsy is generally easy to diagnose with a routine EEG. Typical absence seizures can be easily provoked with hyperventilation (fast deep breaths) and show a specific waveform on EEG, confirming diagnosis.
EEG abnormalities can be enhanced by sleep deprivation.
There may be a family history of epilepsy, but this is not always the case.
Attention deficit hyperactivity disorder and learning difficulties may also occur.
Management
Juvenile absence epilepsy usually responds to medication in most people, but treatment is life-long. Not everyone will gain full seizure control.
It is important to avoid seizure triggers such as sleep deprivation and alcohol consumption, as this syndrome is sensitive to these provoking factors. Hyperventilation may also precipitate absence seizures.
Prognosis
Most people respond well to medication with good seizure control, but often life-long anti-seizure medications are needed. If the medication is stopped, the seizures will recur.
Approximately 1 in 5 people with juvenile absence epilepsy will progress into juvenile myoclonic epilepsy.
Problems with attention and learning difficulties may continue despite good seizure control.
This is a common syndrome and accounts for approximately 10 percent of all epilepsies and is typically diagnosed in youth (10-24 years). Myoclonic seizures are seen, with or without generalised tonic clonic seizures in an otherwise normal individual. The EEG must show specific waveforms for diagnosis of this syndrome. A large number of people with juvenile myoclonic epilepsy have photosensitivity (seizures triggered by flashing lights)
Seizures in this group are sensitive to triggers such as sleep deprivation, stress and alcohol.
Seizures
A myoclonic seizure will look like:
Sudden single jerks, predominantly of the arms but can involve legs or the body.
Jerks can vary in severity but can be severe enough to cause the person to drop things. Similar to a jerk you have when going off to sleep.
The jerks typically happen within 1 to 2 hours of waking up whether it be after a full nights sleep or a daytime nap. There may be a single jerk or a cluster of jerks.
Sometimes these jerks make the person look clumsy or prone to dropping things.
Myoclonic seizures (jerks) are often triggered by lack of sleep and flashing lights.
A tonic clonic seizure will look like:
a sudden loss of consciousness, sometimes with vocalisation or crying out
the eyes, head and body may turn in one direction
the body becomes stiff (tonic), followed by jerking of the muscles (clonic)
if standing, the muscle stiffening will cause the person to fall
breathing is compromised during the seizure which may cause the lips and face to look greyish/blue
the person will not respond when spoken to
excess saliva may come of the person’s mouth, and there may also be blood if they have bitten their tongue or the inside of their cheek
there may be loss of bladder control or less commonly bowel control
immediately after the seizure breathing can be quite laboured and sound like heaving snoring
after the seizure there is usually a period of confusion, headache, soreness and sleepiness.
Diagnosis
People with juvenile myoclonic epilepsy often don’t present to the doctor until their first tonic-clonic seizure. Diagnosis is based on a good description of the events (jerks upon awakening) and an EEG which includes standard provoking features such as hyperventilation and photic stimulation (strobe light). A sleep and/or sleep deprived EEG may be needed.
There may be a family history of epilepsy, but this is not always the case.
Management
There are specific antiseizure medications that are chosen to treat juvenile myoclonic epilepsy, as some antiseizure medications can worsen the seizures. Juvenile myoclonic epilepsy usually responds to well medication, but treatment is life-long.
It is important to avoid seizure triggers such as sleep deprivation and alcohol consumption, and manage stress, as this syndrome is sensitive to these provoking factors and they increase the risk of seizures.
Prognosis
Most people with juvenile myoclonic epilepsy gain full seizure control with medication. Stopping medication could cause a relapse of seizures, even if seizures have been controlled for many years. Myoclonic seizures may disappear or diminish in severity with age.
Maintaining lifestyle (stress, sleep and alcohol) is important for good seizure control with this syndrome.
People with juvenile myoclonic epilepsy usually have normal development and cognition.
Self-limited epilepsy with centrotemporal spikes (previously called benign childhood epilepsy with centrotemporal spikes or rolandic epilepsy) is a self-limited* epilepsy syndrome that begins in an otherwise normal child in their early school years.
*Self-limited meaning that the epilepsy is age-related and seizures stop by a certain age.
The EEG shows a normal background with characteristic epileptiform abnormalities which are typically activated with drowsiness and sleep. Seizures stop by adolescence.
Seizures
Seizures can occur when the child is awake or asleep, but predominantly during sleep.
They generally happen within an hour after the child goes to sleep or 1-2 hours before they wake up. They may also be seen during daytime naps.
The child remains fully aware during the seizure which will show signs of:
facial twitching,
numbness or tingling of one side of the face or tongue
difficulty or inability to speak
drooling
These seizures are usually brief, 2-3 minutes in most cases, and most children have them infrequently.
Seizures may progress into a tonic-clonic seizure. A tonic clonic seizure will look like:
a sudden loss of consciousness, sometimes with vocalisation or crying out
the eyes, head and body may turn in one direction
the body becomes stiff (tonic), followed by jerking of the muscles (clonic)
if standing, the muscle stiffening will cause the person to fall
breathing is compromised during the seizure which may cause the lips and face to look greyish/blue
the person will not respond when spoken to
excess saliva may come of the person’s mouth, and there may also be blood if they have bitten their tongue or the inside of their cheek
there may be loss of bladder control or less commonly bowel control
immediately after the seizure breathing can be quite laboured and sound like heaving snoring
after the seizure there is usually a period of confusion, headache, soreness and sleepiness.
Diagnosis
Children with this epilepsy syndrome have very characteristic seizures. Diagnosis is generally based on a good description of the seizures and an EEG which should show a normal background, but with typical epileptiform waveforms associated with this syndrome. A sleep and/or sleep deprived EEG may be done.
Management
Most children with SeLECTS have infrequent seizures so are not usually prescribed anti-seizure medication. However, medication may be prescribed if a child is having daytime or frequent seizures, and possibly if there are many epileptic waveforms on EEG and learning, cognition and language problems are present.
Prognosis
Seizures occur for approximately 2 to 4 years and spontaneously resolve by the age of 15 to 16 years (in more than 95% of children) but can occasionally occur up to 18 years of age. The majority of children have less than 10 seizures.
Seizures usually respond well if medication is prescribed.
During the course of the active epilepsy, symptoms such as learning difficulties, impaired memory, language and behavioural problems may develop or worsen. These deficits often improve with age.
SeLECTS may potentially be an early presentation of other epileptic syndromes.
Dravet syndrome is a rare and complex epilepsy syndrome with frequent and difficult to treat seizures. Dravet syndrome typically starts in the first year of life in a normal developing child and symptoms range from mild to severe. Multiple seizure types are seen.
Epilepsy is just one part of Dravet syndrome and there are other associated conditions seen. These include cognitive and developmental delays, behavioral challenges, mobility issues, speech impairment, and difficulties with sleep.
Seizures
First seizures usually occur around 5 to 8 months of age and as the child develops, they may experience various seizure types, including focal (usually one-sided jerking) or generalised tonic-clonic seizures (convulsive). Seizures can be prolonged and occur with or without a fever. Other seizure types including myoclonic and atypical absence seizures appear between the age of 1 and 4 years.
The syndrome and seizure types can evolve through different stages to adulthood.
Unfortunately, seizures are usually resistant to treatment, and from the second year of life children start to lag in development behind their peers.
Diagnosis
Early diagnosis is important to guide appropriate treatment choice, and other supports can be initiated.
The clinical diagnosis is supported by the presence of abnormalities in the sodium channel gene SCN1A (found in over 80% of cases). Genetic testing is needed to confirm this. There may be a family history of febrile seizures or other types of epilepsy.
Recognising and understanding the diagnosis, treatment options, and other possible conditions associated with this syndrome is crucial for improving outcomes and fostering hope for the future.
Management
Currently there is no cure for Dravet syndrome, but several treatment options can help manage symptoms and improve quality of life. Many families report progress and improved quality of life through diligent management and supportive networks.
Medication: Dravet syndrome is initially treated with an appropriate antiseizure medication. There are recognised medications that are more effective for this syndrome, and some which should be avoided. Some new antiseizure medications such as stiripentol and fenfluramine are showing promising results. Seizures can also be responsive to cannabidiol, and there is an approved cannabidiol treatment in Australia for Dravet syndrome. Rescue medication is usually prescribed to be given outside the hospital setting for rapid treatment of prolonged seizures.
Dietary therapy: The classic ketogenic diet is also a consideration if the seizures are not well controlled after trialling medications and has shown significant effectiveness in some people.
Surgical options: These are limited; however, vagus nerve stimulation therapy has shown to be effective in decreasing the frequency and severity seizures.
Seizure management is focussed on improving seizure control, keeping medication side effects to a minimum, avoiding seizure triggers, maximising quality of life and reducing seizure-related risks. Support groups and online communities can be a valuable resource and support.
Other challenges and therapies:Children with Dravet syndrome often face additional challenges and managing these comorbidities is critical for holistic care. Many children will engage in various therapies—such as speech, occupational, and physical therapy—to help improve communication, motor skills, and overall functioning.
Prognosis
Dravet syndrome is a lifelong condition, and seizures are often difficult to control. Epileptic seizures in adults may be less frequent and severe than those experienced in childhood and the occurrence of prolonged seizures decreases with age. Because of the seizures and other associated issues, very few will live independently as adults.
Unfortunately, people with Dravet syndrome have an increased risk of death due to SUDEP (Sudden Unexpected Death in Epilepsy), prolonged seizures, and seizure-related accidents.
Despite the challenges associated with Dravet Syndrome, there is a lot of ongoing research, and new treatments are showing promising results and paving the way for better outcomes. With appropriate treatment and care, many children with Dravet Syndrome can lead fulfilling and meaningful lives.
Seizure Emergencies
What are seizure emergencies?
Most seizures last less than two minutes and stop on their own. Although many people with epilepsy have good seizure control, one in three people with epilepsy do not, and they continue to have seizures. Some people only have occasional seizures, but others may have frequent seizures.
There are a small group of people with epilepsy who have severe or even life-threatening seizures. These seizures are considered an emergency because they can be longer than usual (prolonged seizures) or happen in short succession one after the other (cluster seizures) with little or no recovery in-between. Both of these situations can lead to a medical state called status epilepticus.
All these situations are considered seizure emergencies and can lead to brain injury or even death if not treated quickly.
What is status epilepticus?
Status epilepticus (SE) is a prolonged or continuous seizure lasting longer than 5 minutes or seizure clusters (seizures occurring repeatedly) without full recovery in-between.
Although any seizure type, convulsive or non-convulsive, can become status epilepticus, the convulsive (tonic-clonic) seizures are the most serious form and pose a greater risk of complications.
Whatever the seizure type, SE is regarded as a medical emergency and can be life threatening or have long term consequences if it is not treated quickly. Studies show that it is unlikely that a prolonged or cluster seizures will stop after 5-10 minutes (without giving medication) and the best outcome is when an emergency seizure medication can be given as soon as possible.
The sooner medication is given, the more likely the seizures are to stop and the better the outcome is for the person. This is why some people have medication prescribed to be given by caregivers, outside the hospital setting, before an ambulance arrives.
Causes of Status Epilepticus [i]
SE can happen in people with and without epilepsy. Sometimes it is the first seizure the person has ever had, sometimes it is caused by a medical condition, or it may happen in someone with epilepsy or an epilepsy syndrome. Up to 5% of adults and 10-25% of children with epilepsy will have one episode of SE.
The main causes of SE are having epilepsy, febrile seizures, and stroke but there are many other causes, which include: [ii]
Brain injury
Low levels of anti-seizure medication or withdrawal or changes in anti-seizure medications
SE can happen with any seizure type, so it can be convulsive or non-convulsive. Symptoms will depend on the type of seizure and can range from appearing vague and confused (non-convulsive) to more serious muscle jerking (convulsive) and loss of consciousness.
Short term effects can cause bodily changes which worsen the longer the seizures continue. These include increased blood pressure and heart rate, irregular heartbeats, and changes in blood sugar levels.
The long-term effects of SE depend on the cause and how long the seizures continue. Seizures lasting longer than 60 minutes and are convulsive are linked with poorer outcomes. Some long-term effects of SE can include:
Memory and learning difficulties
Permanent damage to the brain
Continuing seizures
Medications for seizures outside the hospital setting
Emergency seizure medications are prescribed for people who have had, or likely to have episodes of SE or prolonged or cluster seizures. These medications can be given in the community setting in an easy to administer route and work quickly with the intention to stop a seizure early to prevent complications before it progresses to SE.[iii]
Outside the hospital setting, the medication is given either by drops or spray in the nose (intranasal), or in-between the teeth and cheek (buccal). When given this way, it is absorbed into the bloodstream through the mucous membranes. Because of the ease of administration, they can be given by family or caregivers in the community.
These medications are usually benzodiazepines – a group of medications known as sedatives which have a calming effect on the brain. They are administered in a way that:
is easy to do outside the hospital setting
is easily absorbed through the mucous membranes
works quickly
is very effective
The aim of these medications for seizures, is to:
stop prolonged or cluster seizures
prevent SE
protect the brain by shortening the seizure time
protect quality of life by preventing potential damage to the brain
reduce disruption to daily life and long stints in hospital.
In many situations, early treatment outside the hospital setting can stop the seizures and prevent the progression into SE and the need for lengthy hospitalisation. [iv]
The longer a seizure lasts, the harder it can be to stop. Since most seizure emergencies occur in the community, effective pre-hospital treatment relies on the use of fast absorbing and easy to administer drugs. Growing evidence supports the use of non-intravenous benzodiazepines in the out-of-the-hospital environment.
Emergency seizure medications are usually very effective, but if they don’t work and seizures continue or complications occur, then emergency medical treatment will be needed at hospital.
Having a plan for seizures and emergencies
There is often the need to have a more formalised plan in place if a seizure occurs outside the home environment such as at school or in the workplace. These are often referred to as seizure management plans (SMP).
A seizure management plan (SMP) is a document that provides essential information to anyone who may be able to assist someone having a seizure – whether that be family, friends, carers, teachers, colleagues or other involved professionals. It helps caregivers in all settings with quick access information about how to manage seizures and seizure emergencies, treatments, seizure first aid and safety specific to the person with epilepsy that they care for. This can help to lessen the impact of seizures on the person’s daily life and the risk of injury.
A seizure management plan is to ensure the right people know what to do when a seizure happens. They give everyone a clear direction and peace of mind.
When someone is likely to have prolonged or cluster seizures, they will also have an emergency medication order and plan to accompany the seizure management plan. Your treating specialist will write up the emergency medication order, but if you need either of these documents – seizure management plan or an emergency medication plan – we can assist with this and offer the necessary training to caregivers or staff.
If you want to learn more about seizure management planning, seizures, seizure emergencies or the administration of emergency medication for epilepsy, go to:
[i] Trinka, E., Cock, H., Hesdorffer, D., Rossetti, A.O., Scheffer, I.E., Shinnar, S., Shorvon, S. and Lowenstein, D.H. (2015), A definition and classification of status epilepticus – Report of the ILAE Task Force on Classification of Status Epilepticus. Epilepsia, 56: 1515-1523. https://doi.org/10.1111/epi.13121
[ii] Sánchez, S., & Rincon, F. (2016). Status Epilepticus: Epidemiology and Public Health Needs. Journal of clinical medicine, 5(8), 71. https://doi.org/10.3390/jcm5080071
[iii] Fedak Romanowski, Erin M. et al.(2020) Seizure Rescue Medications for Out-Of-Hospital Use in Children
The Journal of Pediatrics, Volume 229, 19 – 25, Oct 2020 https://doi.org/10.1016/j.jpeds.2020.10.041
[iv] Arzimanoglou, A., Lagae, L., Cross, J.H. et al. (2014) The administration of rescue medication to children with prolonged acute convulsive seizures in a non-hospital setting: an exploratory survey of healthcare professionals’ perspectives. European Journal of Pediatrics 173, 773–779 (2014). https://doi.org/10.1007/s00431-013-2255-5
Shah, A., and Kelso, A. (2015) Treating status epilepticus in the community. Prescribing in practice. 5 September, pg 21-24. https://wchh.onlinelibrary.wiley.com/doi/pdf/10.1002/psb.1380 Accessed June 2021
Many people think seizures are all pretty much the same. In fact, there are many different types of seizures and even some seizure types, although they have the same name – such as focal seizures – can vary enormously.
What are seizure emergencies?
