First-time seizure

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Seizure Types

Classification is based on the international classification from 1981[1]; More recent terms suggested by the ILAE (International League Against Epilepsy) task Force.[2]

Focal seizures

(Older term: partial seizures)

  • Without impairment in consciousness– (AKA Simple partial seizures)
    • With motor signs (ex. facial twiching or rhythmic ipsilateral extremity movements)
    • With sensory symptoms (ex. tingling or pereiving a certain smell)
    • With autonomic symptoms or signs (ex. tachycardia or diaphoresis)
    • With psychic symptoms (including aura, ex. sense of déjà-vu)
  • With impairment in consciousness - (AKA Complex Partial Seizures--Older terms: temporal lobe or psychomotor seizures)
    • Simple partial onset, followed by impairment of consciousness
    • With impairment of consciousness at onset
  • Focal seizures evolving to secondarily generalized seizures
    • Simple partial seizures evolving to generalized seizures
    • Complex partial seizures evolving to generalized seizures
    • Simple partial seizures evolving to complex partial seizures evolving to generalized seizures

Generalized seizures

  • Absence seizures (Older term: petit mal; brief dissociative states without postural changes)
    • Typical absence seizures
    • Atypical absence seizures
  • Myoclonic seizure (violent muscle contractions)
  • Clonic seizures (rhythmic jerking)
  • Tonic seizures (stiffening)
  • Tonic–clonic seizures (Older term: grand mal)
  • Atonic seizures (loss of muscle tone)


  • Sudden Unexpected Death in Epilepsy
  • Generalized tonic-clonic seizure is the major risk factor for SUDEP, and seizure freedom is strongly associated with decreased risk
    • Annual incidence of SUDEP in children is 1 in 4500
    • Incidence in adults is 1 in 1000

Clinical Features

  • Abrupt onset, may be unprovoked
  • Brief duration (typically <2min)
  • AMS
  • Jerking of limbs
  • Postictal drowsiness/confusion
  • Todd paralysis
  • Lateral tongue biting - 100% specificity

Differential Diagnosis

Causes of first-time seizure




  • Glucose
  • CBC
  • Chemistry
  • Pregnancy test
  • Utox
  • Head CT
  • LP (if SAH or meningitis/encephalitis is suspected)

Indications for Head CT due to Seizure[4]

  • If patient has returned to a normal baseline:
    1. When feasible, perform a neuroimaging of the brain in the ED on patients with a first-time seizure
    2. Deferred outpatient neuroimaging may be used when reliable follow-up is available



Several states have mandatory DMV reporting requirements

  • No anticonvulsant treatment necessary if patient hasCite error: Closing </ref> missing for <ref> tag:
    • Normal neuro exam
    • No acute or chronic medical comorbidities
    • Normal diagnostic testing (including normal imaging)
    • Normal mental status
  • Treatment generally indicated if seizure due to an identifiable neurologic condition


  • Discharge (no need to start antiepileptic[5]) with neuro follow up
  • Risk for recurrent seizure is greatest within the first 2 years after a first seizure (21%-45%)

See Also

External Links


  1. Proposal for revised clinical and electroencephalographic classification of epileptic seizures. From the Commission on Classification and Terminology of the International League Against Epilepsy. Epilepsia 1981; 22:489.
  2. Epilepsia 2015; 56:1515-1523.
  3. Harden C et al. American Academy of Neurology and the American Epilepsy Society. Practice guideline summary: Sudden unexpected death in epilepsy incidence rates and risk factors. Neurology April 25, 2017 vol. 88 no. 17 1674-1680.
  4. ACEP Clinical policy: Critical issues in the evaluation and management of adult patients presenting to the emergency department with seizures. Ann Emerg Med 2004; 43:605-625
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