Seizures and Epilepsy: Types, First Aid and Treatment

A seizure is a burst of abnormal, excessive, synchronised electrical activity in the brain. What it looks like depends entirely on which part of the brain is involved — it may be a convulsion, or a few seconds of staring, or a strange smell, or an arm jerking, or a feeling that something familiar is happening again.

Around one person in ten will have a seizure at some point in life. Far fewer have epilepsy, and the distinction between those two facts is where most of the confusion in this subject begins.

⚖️ A seizure is not epilepsy

This distinction determines everything that follows and it is frequently blurred.

A provoked seizure happens because of an identifiable acute cause. Remove the cause and the seizure does not recur, and this is not epilepsy. Common provocations include:

• Alcohol withdrawal in someone physically dependent, typically twenty-four to forty-eight hours after stopping
• Low blood sugar, particularly in people on insulin or sulfonylureas
• Low sodium, from various causes including some medications
• Drugs — cocaine, amphetamines, some antidepressants at high dose, tramadol, and withdrawal from benzodiazepines
• Acute head injury
• Infection of the brain or its coverings
• High fever in young children, which produces febrile convulsions
• Eclampsia in pregnancy
• Severe sleep deprivation, usually together with another factor

Epilepsy means a tendency to unprovoked seizures. It is diagnosed after two unprovoked seizures more than twenty-four hours apart, or after a single unprovoked seizure where investigations show a high likelihood of further ones — an abnormal EEG, a structural lesion on imaging, or a recognised epilepsy syndrome.

Someone who has one seizure during alcohol withdrawal does not have epilepsy and does not need lifelong medication. Someone who has one seizure with an abnormal scan and abnormal EEG may be diagnosed with epilepsy on that single event.

🧠 The types

Modern classification is based on where the seizure starts, and the older terms — grand mal, petit mal — have been replaced because they described appearance rather than mechanism.

Getting the type right is not academic. Some medications that work well for focal seizures make generalised epilepsies worse, which is covered below.

🤝 First aid

For a convulsive seizure:

Call an ambulance if: the seizure lasts more than five minutes; a second seizure follows without recovery in between; the person does not regain consciousness; they are injured; it happened in water; they have difficulty breathing afterwards; it is their first seizure; or they are pregnant or have diabetes.

Afterwards, expect confusion, drowsiness, headache and aching muscles for a period. Someone recovering from a seizure may be disoriented and occasionally agitated, and that is part of the recovery rather than aggression.

🔍 What else it might be

Misdiagnosis is common in both directions, and a substantial proportion of people treated for epilepsy turn out not to have it.

An eyewitness account is the single most valuable piece of information in diagnosing seizures — more than any test. A description of exactly what happened, in what order, and for how long, ideally from someone who saw it, changes the diagnosis more often than anything else. A phone video, where someone thinks to take one, is genuinely useful and should not feel intrusive.

🧪 Investigations, and their limits

EEG records electrical activity from the scalp. It supports the diagnosis and helps classify the type, and it is widely misunderstood in two directions.

A normal EEG does not exclude epilepsy — a routine recording lasts twenty minutes or so and captures only what happens in that window. Many people with definite epilepsy have normal routine recordings. Sleep-deprived and prolonged recordings improve the yield.

An abnormal EEG does not confirm epilepsy either. Minor abnormalities occur in people who will never have a seizure, and treating an EEG finding rather than a clinical picture is a recognised route to unnecessary lifelong medication.

MRI looks for a structural cause — scarring, malformation, a tumour, previous injury. It is standard in adults with new epilepsy and in focal seizures at any age.

Blood tests and an ECG exclude provoking causes and cardiac explanations. The ECG matters particularly, since a rhythm disorder mistaken for epilepsy is both treatable and dangerous if missed.

💊 Choosing a medication

Around two thirds of people become seizure-free on medication, most on the first or second drug tried. The choice depends on seizure type, age, sex, other conditions and other medications.

🔴 Valproate and pregnancy

This warrants its own section because it is the most consequential prescribing issue in epilepsy.

Sodium valproate is highly effective, particularly in generalised epilepsies. It also causes major congenital malformations in a substantial proportion of pregnancies where it is taken, and neurodevelopmental problems — reduced cognitive ability and higher rates of autism spectrum disorder — in a considerable share of children exposed in the womb.

Regulators in many countries have therefore restricted it: it must not be used in girls or women who could become pregnant unless there is no effective alternative and the conditions of a pregnancy prevention programme are met, including reliable contraception and documented annual review. In some jurisdictions restrictions now extend to men considering fathering a child.

What follows practically:

• Any woman or girl taking valproate should know exactly why, and should have had that conversation documented
• Never stop it abruptly on discovering a pregnancy — uncontrolled seizures carry their own serious risks to mother and baby. Seek urgent specialist advice instead
• Pregnancy should be planned in advance with the neurology team, ideally months ahead, since switching drugs takes time and is done before conception rather than after
• High-dose folic acid is recommended before conception and in early pregnancy for women with epilepsy

⚠️ The specific cautions for each drug

Lamotrigine and rash. A serious skin reaction including Stevens-Johnson syndrome can occur, and the risk relates directly to how fast the dose is increased. That is why the titration schedule is unusually slow and must be followed exactly. Any rash in the first weeks means stopping and being assessed the same day. Valproate roughly doubles lamotrigine levels, so a much lower lamotrigine dose is used when the two are combined — missing that is a recognised cause of serious rash.

Levetiracetam and behaviour. Irritability, aggression, anxiety and low mood are common enough to be the main reason it is stopped. They appear early, are reversible, and are worth warning family about in advance, since the person may not recognise the change in themselves.

Carbamazepine and phenytoin as enzyme inducers. Both accelerate the breakdown of many other drugs, most importantly hormonal contraception, which is covered below. Carbamazepine also carries a serious rash risk associated with a specific genetic variant, and testing is recommended before starting in people of some Asian ancestries.

Topiramate. Cognitive slowing and word-finding difficulty are common and dose-related, and it is not suitable in pregnancy.

All antiepileptic drugs. A small increase in suicidal thinking has been described across the class, and any new mood change or thoughts of self-harm should be reported rather than attributed to circumstance.

💊 Contraception and interactions

This runs in both directions and both directions cause problems.

Enzyme-inducing antiepileptics — carbamazepine, phenytoin, phenobarbital, topiramate at higher doses — reduce the effectiveness of the combined pill, the patch, the ring, the progestogen-only pill and the implant. The injection and the intrauterine devices are unaffected and are usually recommended instead.

Combined hormonal contraception reduces lamotrigine levels substantially, which can allow seizures during the weeks it is taken, and levels then rise during the pill-free interval. Anyone on lamotrigine starting or stopping the combined pill needs a dose review.

Levetiracetam, gabapentin and several other newer drugs do not have these interactions, which is one of their practical advantages.

🔑 Adherence and triggers

Missed doses are the leading cause of breakthrough seizures in people previously well controlled. Antiepileptic drugs work by maintaining a steady level, and a missed dose creates a trough during which the threshold falls.

What helps: a pill organiser, phone alarms, keeping a spare supply at work or in a bag, never running out, and generally sticking to the same manufacturer, since switching between brands of some antiepileptics can alter blood levels enough to matter.

Common triggers to identify and manage:

• Sleep deprivation — the most consistent trigger of all, and worth treating as a medical priority rather than a lifestyle preference
• Alcohol, particularly binge drinking and the withdrawal that follows
• Missed medication
• Illness and fever
• Stress
• Hormonal cycles in some women, with seizures clustering around menstruation
• Flashing lights, though photosensitivity affects only a minority
• Recreational drugs

A seizure diary recording date, time, type, duration and what preceded it is more useful than any account from memory and frequently reveals a pattern nobody had noticed.

🏠 Safety and daily life

Driving is regulated everywhere, generally requiring a defined seizure-free period before a licence is restored, and it must be reported to the licensing authority. Concealing it carries legal and insurance consequences as well as obvious risk.

Showers rather than baths is the standard advice, because drowning in a bath is a genuine and recurring cause of death in epilepsy. Swimming should be supervised by someone who knows what to do.

Cooking using the back rings, and a microwave where practical, reduces burn risk.

Heights, ladders and machinery need individual assessment based on how well controlled the seizures are.

Work — most jobs are entirely compatible with controlled epilepsy, and employers have legal obligations regarding reasonable adjustments in many countries.

🔄 When medication does not control it

Around a third of people continue to have seizures despite medication. Before accepting that, several things are checked, because much apparent resistance is not.

• Is the diagnosis correct — a substantial proportion of drug-resistant epilepsy turns out to be functional seizures or syncope
• Is the seizure type correctly classified, since the wrong drug class can worsen it
• Is the drug actually being taken, consistently
• Was the dose adequate before it was abandoned
• Are triggers being addressed, particularly sleep and alcohol

Where resistance is genuine, options include combining drugs with different mechanisms, epilepsy surgery where a single focus can be identified — which can be curative and is consistently referred later than it should be — vagus nerve stimulation, and the ketogenic diet, which has good evidence particularly in children.

Referral to a specialist epilepsy centre is appropriate once two appropriate drugs have failed, rather than after ten years of trying combinations.

🏁 Coming off treatment

After a sustained period free of seizures — commonly two years or more — withdrawing medication can be considered.

The decision weighs the epilepsy syndrome, the EEG, whether there is a structural cause, how long control took to achieve, and the consequences of a recurrence for that individual, particularly regarding driving and employment. Relapse rates are significant, and a proportion of people who relapse do not regain control as easily as before.

Where it is attempted, reduction is gradual over months and never abrupt, since sudden withdrawal can precipitate status epilepticus.

🚨 When to seek help

• A convulsion lasting more than five minutes, or repeated seizures without recovery — emergency
• A first seizure of any kind
• A change in seizure pattern, type or frequency
• Injury during a seizure, or a seizure in water
• Any rash in the first weeks of lamotrigine or carbamazepine — same day
• New mood change, aggression or thoughts of self-harm after starting or changing medication
• Pregnancy, or planning it — urgently, and before stopping anything
• Being prescribed a new medicine, since interactions are extensive

Antiepileptic medication is stocked in the anticonvulsants category, including Keppra (levetiracetam), which is broad spectrum with very few interactions, alongside Lamictal, Tegretol, Topamax, Dilantin and Neurontin. The choice depends on seizure type and must follow a neurological diagnosis, since the wrong class can worsen some epilepsies. No antiepileptic should ever be stopped abruptly.

❓ Frequently asked questions

📑 Sources and editorial

• ILAE operational classification of seizure types and definition of epilepsy
• NICE guideline on epilepsies in children, young people and adults
• Regulatory restrictions and pregnancy prevention requirements for valproate
• Evidence on lamotrigine titration rate and serious cutaneous reactions
• Literature on antiepileptic drug interactions with hormonal contraception
• Research on sudden unexpected death in epilepsy and modifiable risk factors
• Studies of misdiagnosis rates in epilepsy, including syncope and functional seizures
• FDA prescribing information for levetiracetam, lamotrigine, carbamazepine, phenytoin and topiramate
• Related products: anticonvulsants category
• RXshop Editorial Team — reviewed by James Carter, MD, Neurology