General MedicineTier 1Approach to a presentation

Undifferentiated presentations - seizure

Red flags

Status epilepticus (>5 min continuous or recurrent without recovery) - emergency
First seizure in adulthood - always needs structural/metabolic workup
Fever + seizure + reduced consciousness beyond post-ictal - meningoencephalitis
Focal neurological deficit post-ictally beyond expected Todd's paresis duration
Seizure in pregnancy with hypertension/proteinuria - eclampsia
Head injury preceding the seizure

Structural

Stroke, tumour, traumatic brain injury, cortical malformation, mesial temporal sclerosis

Metabolic/toxic

Hypoglycaemia, hyponatraemia, hypocalcaemia, uraemia, hepatic encephalopathy
Alcohol/benzodiazepine withdrawal, drug toxicity (see pharm-tox seizures note), eclampsia

Infective

Primary epilepsy syndromes

Genetic generalised epilepsies (young onset), focal epilepsy from an identified or cryptogenic lesion

Mimics

Syncope with convulsive movements (brief, few jerks, rapid recovery), psychogenic non-epileptic seizures (PNES - longer duration, fluctuating course, closed eyes, pelvic thrusting), migraine with aura, TIA

Eyewitness account - onset (sudden vs aura), duration, movements (tonic-clonic vs focal), tongue biting (lateral), incontinence, post-ictal confusion/Todd's paresis
Provoking factors - sleep deprivation, alcohol, flashing lights, missed anticonvulsant doses
Prior seizures, epilepsy diagnosis, medication adherence
Cardiac history/family history of sudden death if syncope mimic considered

Post-ictal state (confusion, drowsiness) vs rapid recovery (favours syncope)
Tongue laceration (lateral - favours seizure), signs of incontinence
Full neurological exam for focal deficit (Todd's paresis resolves within 48h - persistent deficit needs imaging)
Cardiovascular exam if syncope mimic considered

Glucose, UEC, calcium, magnesium, LFT immediately
ECG (arrhythmia mimic, QT-prolonging drugs)
CT brain for first seizure/focal features/head injury; MRI for further characterisation
EEG - supports diagnosis and classification, not required acutely unless status epilepticus/non-convulsive status suspected
Anticonvulsant levels if known epileptic with breakthrough seizure

1. Acute seizure

Protect from injury, do not restrain rigidly or insert anything in the mouth
Benzodiazepine (IV lorazepam/diazepam, or buccal/intranasal midazolam if no IV access) if >5 minutes or recurrent
Second-line: IV phenytoin/valproate/levetiracetam if benzodiazepine-refractory; anaesthesia (propofol/thiopentone) for established status epilepticus

2. First unprovoked seizure

Investigate for a cause; anticonvulsant therapy usually deferred after a single unprovoked seizure with normal imaging/EEG, individualised by recurrence risk
Driving restrictions apply (jurisdiction-specific) - discuss immediately

3. Established epilepsy

Continue/optimise anticonvulsant, address adherence and provoking factors (sleep, alcohol)
Review medication levels/interactions if breakthrough seizure

4. Reversible causes

Correct hypoglycaemia, electrolyte disturbance; treat withdrawal (thiamine + benzodiazepine for alcohol); treat infection

Convulsive syncope (brief myoclonic jerks with a cardiac cause) is commonly mislabelled as epilepsy - rapid recovery and cardiac history are the clues
PNES and epileptic seizures can coexist in the same patient - don't assume all events are the same type
Driving and occupational implications are frequently forgotten in the acute setting but are a mandatory part of first-seizure management
Persistent focal deficit beyond 48h needs urgent imaging, not reassurance as "prolonged Todd's paresis"

"A collateral eyewitness account does more diagnostic work here than almost any test."
"First unprovoked seizure with clean imaging doesn't automatically mean starting an anticonvulsant, but it does mean a driving conversation today."

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