Focal seizures

Last reviewed: 23 Aug 2023
Last updated: 25 Apr 2023



History and exam

Key diagnostic factors

  • movement of one side of the body or one specific body part
  • premonitory sensation or experience (fear, epigastric sensation, déjà vu, jamais vu)
  • automatisms (picking at clothes, smacking of the lips)
  • temporary aphasia
  • staring and being unaware of surroundings
More key diagnostic factors

Other diagnostic factors

  • postictal focal neurological deficit (Todd paralysis, aphasia)
  • persistent focal neurological deficit
  • poor memory
  • stigmata of neurocutaneous syndromes
Other diagnostic factors

Risk factors

  • febrile seizure
  • traumatic brain injury
  • central nervous system (CNS) infection
  • stroke
  • brain tumor
  • intellectual disability and/or cerebral palsy
  • dementia
  • family history of seizures
  • intracranial vascular malformations
  • malformations of cortical development (MCDs)
  • male sex
More risk factors

Diagnostic investigations

1st investigations to order

  • blood glucose
  • CBC
  • electrolyte panel
  • toxicology screen
  • lumbar puncture and cerebrospinal fluid analysis
  • CT head
  • MRI brain
  • electroencephalogram (EEG)
More 1st investigations to order

Investigations to consider

  • video/electroencephalogram (EEG) long-term monitoring (LTM)
  • PET scan
  • single photon emission computed tomography (SPECT) scan
  • functional MRI scan
  • magnetoencephalography (MEG) scan
  • neuropsychological testing
  • Wada test
More investigations to consider

Emerging tests

  • 7T MRI scan

Treatment algorithm


acute repetitive seizures: in the community

acute repetitive seizures: in the hospital


adults <60 years old

adults ≥60 years old

women of childbearing potential

pregnant women




Ramses Ribot, MD

Assistant Professor of Clinical Neurology

Department of Neurology, Epilepsy Division

University of Miami, Miller School of Medicine




RR declares that he has no competing interests.

Andres M. Kanner, MD, FANA, FAES, FAAN

Professor of Clinical Neurology

Director, Comprehensive Epilepsy Center and Head, Section of Epilepsy

Department of Neurology

University of Miami, Miller School of Medicine




AMK has received honoraria from Eisai Laboratories for lectures given at international scientific meetings, and from the Epilepsy Foundation of America for being Co-Editor in Chief of AMK is an author of a number of references cited in this topic.


Dr Ramses Ribot and Dr Andres M. Kanner would like to gratefully acknowledge Dr Vikram R. Rao, Dr John D. Hixson, and Dr Jeffrey Cohen, previous contributors to this topic.


VRR served as a paid consultant for Neuropace, Inc., manufacturer of the Responsive Neurostimulation (RNS) System. JDH has received research funding and consultancy funds from UCB, Inc. JC declares that he has no competing interests.

Peer reviewers

Edward Bromfield, MD


Epilepsy Division

Brigham and Women's Hospital

Associate Professor of Neurology

Harvard Medical School




At the time of review, EB declared that between 2004 and 2009, he received speaking honoraria from UCB Pharma, Novartis, Abbott Laboratories, GlaxoSmithKline, and Pfizer. He received consulting fees from UCB Pharma, Genzyme, and Spherics, and research funding from UCB Pharma. Unfortunately, we have since been made aware that EB is deceased.

Angus A. Wilfong, MD

Associate Professor

Pediatrics and Neurology

Baylor College of Medicine

Medical Director

Comprehensive Epilepsy Program

Texas Children's Hospital




AAW declares that he has no competing interests.

Cigdem I. Akman, MD

Assistant Professor

Division of Pediatric Neurology

Columbia University College of Physicians and Surgeons

New York



Not disclosed.

Pasquale Striano, MD, PhD

Consultant Neurologist

Muscular and Neurodegenerative Diseases Unit

"G Gaslini" Institute


Epilepsy Centre

Federico II University




PS declares that he has no competing interests.

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