Seizures in children may occur as a standalone event or may recur (epilepsy).
Etiology can be structural, genetic, infectious, metabolic, immune, or unknown.
An attempt should be made to identify the type(s) of epilepsy and the epilepsy syndrome by recognizing a pattern of seizure types, clinical features, and electroencephalogram characteristics.
Detailed history is of paramount importance in the diagnosis, as key diagnostic factors lie in the history as opposed to ancillary investigations.
Main treatment options will depend on the epilepsy syndrome and include anticonvulsant medication, a ketogenic diet, vagus nerve stimulation, and surgery, as well as consideration of lifestyle factors.
Generalized seizures are understood to originate at some point within the brain and rapidly engage bilaterally distributed networks. This can include both cortical and subcortical structures and may not necessarily involve the entire cortex. The 2017 International League Against Epilepsy classification presents three levels to help guide the clinician: 1) diagnosis of the seizure type; 2) diagnosis of the epilepsy type (focal epilepsy, generalized epilepsy, combined focal and generalized epilepsy, and an unknown group); 3) these two levels help determine the epilepsy syndrome, which is often an electroclinical syndromic diagnosis. Etiology is taken into account along each step.
Seizures may occur as a standalone event or they may recur, in which case the term "epilepsy" is used. This topic addresses generalized epilepsies. Previous terminology of "secondarily generalized" seizure (i.e., a focal-onset seizure that spread to involve the rest of the body) has now changed to "focal to bilateral tonic-clonic seizure." It is also recognized that if the onset of a seizure is unwitnessed or cannot be described, this would be an "unknown onset tonic-clonic seizure."
Febrile seizures are dealt with in a separate BMJ Best Practice topic. This topic does not include seizures in neonates.
History and exam
Key diagnostic factors
- tonic-clonic seizures
- staring spells or inattention
- brief, arrhythmic muscular jerking movements
- eyes rolling back in head
- unexplained falls
Other diagnostic factors
- tongue biting
- postictal phenomena
- seizure precipitated by fatigue or lack of sleep
- seizure precipitated by light or noise
- intercurrent illness
- developmental delay
- neurocutaneous stigmata
- genetic predisposition or family history
- perinatal asphyxia
- metabolic/neurodegenerative disorders
- head trauma
- structural abnormalities of the central nervous system
- autistic spectrum disorder
- central nervous system (CNS) infection
- neurocutaneous syndromes
- history of febrile seizures
1st investigations to order
- electroencephalogram (EEG)
- blood glucose level
- basic metabolic panel
Investigations to consider
- MRI brain
- CT brain
generalized onset seizure in progress
epilepsy syndromes in children <1 year of age (excluding neonates)
epilepsy syndromes in early childhood
epilepsy syndromes in middle childhood
epilepsy syndromes in late childhood or adolescence
unidentified epilepsy syndrome
- Nonepileptic seizures or "dissociative seizures"
- Breath-holding spells (prolonged cyanotic expiratory apnea)
- Long QT syndrome
- Epilepsies in children, young people and adults
- Antiseizure medication withdrawal in seizure-free patients: practice advisory update summary
Epilepsy: what is it?
Febrile seizuresMore Patient leaflets
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