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of everyone affected by epilepsy

Section 2: General management

2.1 Diagnosis1

Relevant Tools:A.1, A.14

A diagnosis of epilepsy can have important physical,  psychosocial and economic implications for the patient, so it is important that the diagnosis is correct.2 Misdiagnosis rates in the UK are between 20-31%.3,4 Therefore the diagnosis of epilepsy should be made by a neurologist or epilepsy specialist.2,1

The role of your practice in the care of patients with suspected epilepsy is vital

Primary care should make prompt referrals in suspected cases of epilepsy, and services should be provided in acute hospitals to enable patients with probable recent-onset seizures to be seen within two weeks of onset.1,2

There is no single test that can diagnose epilepsy. The most important information used in deciding if a person has epilepsy is the description of what they have experienced along with an eyewitness account of the event.

The role of primary care can be key at this stage, as the GP is often the first to suspect epilepsy.

You should attempt to:

  • obtain a first-hand witness account of the seizure5
  • record the diagnostic features5
  • provide basic first aid and safety advice, including not to drive, pending specialist assessment5
  • encourage the use of a mobile phone or other technology to video record any further suspected seizures as an aid to diagnosis by the specialist.

Information lost at this stage can profoundly affect the subsequent clinical course.5 This section of the website contains a guide to the questions that can help you effectively refer these patients to a specialist (see A.1).

Formal diagnosis is carried out by a neurologist or other epilepsy specialist because there are many different seizure types and epilepsy syndromes, and classification of these is complex.

You should provide information on the following; some of which is available from the Epilepsy Action website www.epilepsy.org.uk

  • driving
  • risks (including first aid)
  • what to do if a second seizure occurs
  • how to access the voluntary sector
  • the importance of keeping a diary of seizures6 and what happened around them.

An understanding of the classification of basic seizure types is useful in primary care. Table 3 outlines how the most common seizure types manifest themselves. Since seizure classification changes from time to time, is it important that healthcare professionals keep up to date on seizure classifications.

Table 3: Seizure types
Seizure typeDescription
Generalised seizures
Tonic-clonic seizures
  • Loss of consciousness
  • May pass urine or bite the side of the tongue or mouth
  • May need to sleep or have severe headaches
  • Tonic phase: the muscles contract, the body stiffens.
  • This is followed by the clonic phase
  • Clonic phase: uncontrollable jerking of the body
  • The patient may let out a cry as air is forced out of the lungs and the lips may go blue due to lack of oxygen
  • When the patient comes round they cannot remember anything
  • They will need time to recover – from minutes to hours in some cases
Absence seizures
  • This is a momentary lapse in awareness
  • More common in children and teenagers
  • The patient may stop what they are doing, stare, blink or look vague for a few seconds before carrying on with what they were doing
  • It can go unnoticed and onlookers may think that the patient is just daydreaming
Atonic seizures (drop attacks)
  • Loss of muscle tone, spontaneous falls
Myoclonic seizures
  • Brief, forceful jerks affecting arms, legs, and sometimes the whole body
Focal seizures
 
  • The patient may remain alert or may not be aware of what is happening
  • Symptoms are varied and may include one or more of the following: twitching, numbness, sweating, dizziness, nausea, disturbances to hearing, vision, smell or taste, strong sense of deja vu
  • The patient may display involuntary movements, including: plucking at clothes, smacking lips, swallowing repeatedly or wandering around
  • These seizures can often progress to other types of seizure

Note: focal seizures vary widely and may include other symptoms not included in the examples above

More information for patients is available at epilepsy.org.uk

Non-epileptic attack disorder (NEAD)

Non-epileptic seizures are different from epileptic seizures because they are not caused by disrupted electrical activity in the brain. These seizures are psychological and are caused by the impact of thoughts and feelings on the way the brain works. People can have NEAD and epilepsy seizures.

About 20% of people who are referred to a specialist for 'difficult to control' epilepsy have NEAD. Treatment should be tailored to the individual to address the underlying psychological causes. AEDs have no effect on NEAD.

References

1 Scottish Intercollegiate Guidelines Network (SIGN), 2003. Diagnosis and management of epilepsy in adults. A national clinical guideline. Edinburgh: SIGN.

2 National Institute for Health and Clinical Excellence (NICE), 2012. The epilepsies: The diagnosis and management of the epilepsies in adults and children in primary and secondary care. [CG137]. London: NICE.

3 Sander JW, 2004.The use of anti-epileptic drugs – Principles and practice. Epilepsia. 45(6): 28-34.

4 Joint Epilepsy Council, 2005. Epilepsy prevalence, incidence and other statistics. [online] (Accessed 12/04/2012)

5 Epilepsy Action, 2005. Role of Primary Care in Epilepsy Management 2. Leeds: Epilepsy Action.

6 Epilepsy Action, 2011. Downloadable Seizure Diary. [online] Leeds: Epilepsy Action. (Accessed 12/02/2012).

7 Epilepsy Action. 2011. First aid for seizures. [online] (Accessed 14/01/2012).

8 Epilepsy Action, 2011. Generalised seizures. (Accessed 14/01.2012).

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