Types of Seizures - Epilepsy Management & Treatment. Texas Foundation

Epilepsy Seizures – Seizure Management

3 Major Groups of Seizures

There are now 3 major groups of seizures:

  1. Generalized onset seizures: These seizures affect both sides of the brain or groups of cells on both sides of the brain at the same time. This term was used before and still includes seizures types like tonic-clonic, absence, or atonic to name a few.
  2. Focal onset seizures: The term focal is used instead of partial to be more accurate when talking about where seizures begin. Focal seizures can start in one area or group of cells in one side of the brain.
    1. Focal Onset Aware Seizures: When a person is awake and aware during a seizure, it’s called a focal aware seizure. This used to be called a simple partial seizure.
    2. Focal Onset Impaired Awareness: When a person is confused or their awareness is affected in some way during a focal seizure, it’s called a focal impaired awareness seizure. This used to be called a complex partial seizure.
  3. Unknown onset seizures: When the beginning of a seizure is not known, it’s now called an unknown onset seizure. A seizure could also be called an unknown onset if it’s not witnessed or seen by anyone, for example when seizures happen at night or in a person who lives alone.
    1. As more information is learned, an unknown onset seizure may later be diagnosed as a focal or generalized seizure.

Symptoms During a Seizure

For Generalized Onset Seizures

  • Motor symptoms may include sustained rhythmical jerking movements (clonic), muscles becoming weak or limp (atonic), muscles becoming tense or rigid (tonic), brief muscle twitching (myoclonus), or epileptic spasms (body flexes and extends repeatedly).
  • Non-motor symptoms are usually called absence seizures. These can be typical or atypical absence seizures (staring spells). Absence seizures can also have brief twitches (myoclonus) that can affect a specific part of the body or just the eyelids.

For Focal Onset Seizures

  • Motor symptoms may also include jerking (clonic), muscles becoming limp or weak (atonic), tense or rigid muscles (tonic), brief muscle twitching (myoclonus), or epileptic spasms. There may also be automatisms or repeated automatic movements, like clapping or rubbing of hands, lip smacking or chewing, or running.
  • Non-motor symptoms: Examples of symptoms that don’t affect movement could be changes in sensation, emotions, thinking or cognition, autonomic functions (such as gastrointestinal sensations, waves of heat or cold, goosebumps, heart racing, etc.), or lack of movement (called behavior arrest).

For unknown onset seizures:

  • Motor seizures are described as either tonic-clonic or epileptic spasms.
  • Non-motor seizures usually include a behavior arrest. This means that movement stops – the person may just stare and not make any other movements.

More Types of Seizures

Absence Seizures

Epilepsy Does Not Define MeAn absence seizure causes a short period of “blanking out” or staring into space. Like other kinds of seizures, they are caused by brief abnormal electrical activity in a person’s brain.

  • An absence seizure is a generalized onset seizure, which means it begins in both sides of the brain at the same time.
  • An older term is petit mal seizures.
  • Absence seizures usually affect only a person’s awareness of what is going on at that time, with immediate recovery.
  • There are two types of absence seizures that may look a bit different. Both types of seizures are short, and people often don’t notice them at first. They may come and go so quickly that no one notices anything wrong. Or observers may mistake the symptoms for simple daydreaming or not paying attention.
    • Typical Absence Seizures
      • These seizures are the most common.
      • The person suddenly stops all activity. It may look like he or she is staring off into space or just has a blank look.
      • The eyes may turn upwards and eyelids flutter.
      • The seizures usually last less than 10 seconds.
    • Atypical Absence Seizures
      • These absence seizures are called atypical because they may be longer, have a slower onset and offset, and involve different symptoms.
      • The seizure still starts with staring into space, usually with a blank look.
      • There is usually a change in muscle tone and movement. You may see
        • Blinking over and over that may look like fluttering of the eyelids
        • Smacking the lips or chewing movements
        • Rubbing fingers together or making other hand motions
      • An atypical absence seizure lasts longer, up to 20 seconds or more.
    • Absence seizures are most common in children from age 4 to 14. However, older teens and adults may also have absence seizures.

Atonic Seizures

Muscle “tone” is the muscle’s normal tension. “Atonic” (a-TON-ik) means “without tone.” So in an atonic seizure, muscles suddenly become limp.

  • Part of all of the body may become limp. The eyelids may droop, the head may nod or drop forward, and the person may drop things.
  • If standing, the person often falls to the ground.
  • These seizures typically last less than 15 seconds.
  • People may get injured when they fall. Head protection, such as a helmet or other protective gear, may be needed.
  • These seizures are also called “drop attacks” or “drop seizures.”
  • People can have just one atonic seizure or several in a row. When an atonic seizure happens, try your best to make sure the person is in a safe place to prevent injuries and falls.
  • In some types of epilepsy (like Lennox-Gastaut or Dravet syndrome), seizures can happen in clusters with two or more at one time or in one day. If a person is at risk for seizure clusters, they should talk to their doctor or nurse about ways to treat clusters.

In an atonic seizure, the person’s body will suddenly become limp.

  • If sitting, their head or upper body may slump over.
  • If standing, the person many fall limply to the ground. Since the muscles are weak or limp, the person falls like a rag doll.
  • When a person’s muscles are stiff or rigid, they will fall like a tree trunk. These are usually called tonic seizures.

When the seizure starts in one area of the brain:

  • Atonic seizures can start in one part of the brain with a loss of tone in one part of the body.
  • This is called a focal motor atonic seizure.

When the seizure starts on both sides of the brain:

  • Usually, atonic seizures affect both sides of the brain.
  • These are called generalized onset atonic seizures.
  • These seizures would begin with a sudden drop or loss of tone affecting the head, trunk, or whole body.
  • Usually a person having a generalized atonic seizure is not fully aware during the event.

Atypical Absence Seizures

These seizures are a type of absence seizure that is atypical (a-TIP-i-kul). This means it’s different, unusual, or not typical compared to typical absence seizures, which were previously called petit mal seizures. They are a type of generalized onset seizure, which means they start in both sides of the brain.

  • The person will stare (just like in absence seizure) but they may be able to respond a bit.
  • Eye blinking, chewing movements, lip smacking, or slight jerking movements of the lips may occur.
  • There may be rubbing of the fingers or hands or other small hand movements.
  • Symptoms of absence seizures can be difficult to pick up in a person with other cognitive or behavioral problems. It may be hard to tell what is due to a seizure or from other behaviors.
  • These seizures may begin and end gradually. This is different from the sudden start and stop of a typical absence seizure.
  • Falling during the seizure is also more common than it is during typical absence seizures.
  • Atypical absence seizures usually last 5 to 30 seconds, most often more than 10 seconds.
  • These seizures generally begin before age 6. Most of the children with this type of seizure have cognitive and developmental problems. They may also have other types of seizures that are hard to control. Many have Lennox-Gastaut syndrome.

When people have atypical absence seizures, you may notice

  • The person is not fully aware of what is going on around them. For example, they will not notice if someone is talking to them.
  • If they are talking to someone, they may stop talking in the middle of the sentence.
  • Atypical absence seizures most often affect school age children. A teacher may want to talk to the parent, because the child is having problems at school.
  • Atypical absence seizures usually continue into adulthood.

When a single atypical absence seizure ends, the person usually is awake and continues doing whatever they were doing before the seizure.

  • No first aid is needed during a single seizure.
  • Sometimes a person may have more than one atypical absence at a time or have groups of seizures. When this happens, the person may be confused or tired afterwards.
  • Stay with the person after the seizures until they are back to their usual self and safe to be alone.
  • If a different type of generalized seizure (like an atonic or tonic-clonic seizure) happens after the atypical absence, follow first aid steps for these seizures.

People who have atypical absence seizures may have just one seizure or they can have several in a row. The seizures could also be spaced out throughout the day.

Clonic Seizures

Epilepsy Does Not Define Me“Clonus” (KLOH-nus) means fast stiffening and relaxaing of a muscle that happens repeatedly. In other words, it is repeated jerking. The movements cannot be stopped by restraining or repositioning the arms or legs.

Clonic (KLON-ik) seizures are rare and most commonly occur in babies. Most often, clonic movements are seen as part of a tonic-clonic seizure.

  • Jerking movements alone, as with a clonic seizure, may last a few seconds to a minute.
  • Jerking or clonic movements that follow stiffening of muscles, as in a tonic-clonic seizure, can last seconds to 1-2 minutes.
  • A clonic seizure may sometimes be hard to distinguish from a myoclonic seizure. The jerking is more regular and sustained during a clonic seizure.
  • Clonic seizures can affect people of all ages, including newborns.
  • In infants, the clonic seizures are very brief and don’t happen very often. They may also go away on their own in a short period of time.
  • Clonic seizures that don’t go away on their own will need long term treatment.
  • Clonic seizures can affect people of all ages, including newborns.
  • In infants, the clonic seizures are very brief and don’t happen very often. They may also go away on their own in a short period of time.
  • Clonic seizures that don’t go away on their own will need long term treatment.

When it starts in one area of the brain:

  • Clonic seizures can start in the motor area on one side of the brain. These are called focal clonic seizures.
  • The jerking movements would affect just one side or part of the body or face.

When it starts on both sides of the brain:

  • Clonic seizures can also affect both sides of the brain at once. These would be called generalized clonic seizures.
  • The jerking movements would affect both sides of the body or the whole body at once.

Febrile Seizures

Children aged 3 months to 5 or 6 years may have tonic-clonic seizures when they have a high fever. These are called febrile seizures (pronounced FEB-rile) and occur in 2% to 5% of all children. There is a slight tendency for them to run in families. If a child’s parents, brothers or sisters, or other close relatives have had febrile seizures, the child is a bit more likely to have them.

Sometimes the seizure comes “out of the blue.” A fever may begin silently in a previously healthy child and a seizure can be the first sign that alerts the family that the child is ill.

  • Febrile seizures cannot be prevented by giving the child lukewarm baths, applying cool cloths to the child’s head or body, or using fever-reducing medications such as acetaminophen (Tylenol) or ibuprofen (Advil, Motrin). Doing these things may make a feverish child feel better, but they do not prevent febrile seizures.
  • During a seizure, place the child on his or her side on a protected surface and observe carefully. Keep track of the time, and if the seizure lasts longer than 5 minutes, call 911 or take the child to an emergency facility if you can do so safely.
  • Most children who have febrile seizures do not require daily treatment with seizure medicines. Some children who have repeated episodes of multiple febrile seizures are treated with phenobarbital, Depakote (valproate), or another seizure medicine, which reduces the risk of having more seizures.
  • Children who have had unusually long febrile seizures and children who live in a remote area with poor access to medical care also may be considered for treatment.
  • Rarely some children with prolonged febrile seizures or frequent episodes of febrile seizures are treated prophylactically with phenobarbital.
  • Other medications can be given at the time of a febrile seizure.
  • Diastat (diazepam) gel or liquid diazepam can be given by rectum.
  • Clonazepam (Klonopin) wafers can be placed on the tongue or a tablet form of diazepam or lorazepam can be crushed and put between the cheek and the gum.
  • Giving the child diazepam (Valium) when illness or fever begins can reduce the risk of recurring febrile seizures. To prevent one febrile seizure in this way, however, 14 other children who were never destined to have another febrile seizure will also be treated! Thirty percent of children treated with Valium have troublesome side effects such as sleepiness, irritability, and poor coordination that may last for several days.

Among children who have their first febrile seizure before their first birthday, half will have at least one more. Among children who are older than 1 year when the first seizure occurs, about 1 in 4 will have more.

The long-term outlook is excellent, however. The vast majority of children with febrile seizures do not have seizures without fever after age 5.

Risk factors for later epilepsy include:

  • Abnormal development before the febrile seizure.
  • Complex febrile seizures: These are defined as seizures that last longer than 15 minutes, more than one seizure in 24 hours, or seizures in which only one side of the body is affected.
  • Seizures without fever in a parent or a brother or sister.

If the child has none of these risk factors, the chances of later epilepsy are just about the same as for any other child.

Children with one of these risk factors have a 2.5% (1 in 40) chance of later epilepsy.

Those with two or three risk factors have a risk of later epilepsy that ranges from 5% (1 in 20) to over 10%.

In rare cases, febrile seizures that last more than 30 minutes may cause scar tissue in the temporal lobe of the brain. In some of these patients, chronic epilepsy develops, which often can be effectively treated.

If you have concerns about your child’s febrile seizures, consider consulting an epilepsy specialist.

Focal Aware Seizures

Epilepsy Does Not Define MeA focal onset seizure begins in one side of the brain. They were previously called partial seizures. Focal onset seizures are the most common type of seizure experienced by people with epilepsy. For short, the term focal seizure can be used.

When the seizure begins in one side of the brain and the person has no loss of awareness of their surroundings during it, it is called a focal onset aware seizure. This type of seizure was previously called a simple partial seizure.

Anybody can get them. They may be more likely in people who have had a head injury, brain infection, stroke, or brain tumor. Yet many times the cause is unknown.

When people have focal aware seizures, they are fully awake, alert, and able to recall events during the seizure. Some are “frozen” during the seizure, so they may or may not be able to respond to others during the seizures. Overall, these seizures are brief, usually lasting less than 2 minutes.

Focal Onset Impaired Awareness Seizures (Complex Partial Seizures)

A focal onset seizure begins in one side of the brain. We used to call these partial seizures. Focal onset seizures are the most common type of seizures in adults with epilepsy.

When the seizure begins in one side of the brain and the person has a change in their level of awareness during some or all of it, it is called a focal onset impaired awareness seizure. The word “onset” is optional.

  • This type of seizure was previously called a complex partial seizure.
  • Some people may also call them temporal lobe seizures if they start in the temporal lobes of the brain. An even older term is “psychomotor seizure.”
  • These seizures usually start in one area or group of brain cells, most often in the temporal lobe or frontal lobe of the brain. They can also start in other areas too.
  • The seizures starting in the frontal lobe tend to be shorter than the ones from the temporal lobe.
  • Focal seizures can include involuntary movements called automatisms (aw-TOM-ah-TIZ-ums) like rubbing of the hands, lip-smacking, chewing movements. When they involve the frontal lobes, you may see bicycling movements of the legs or pelvic thrusting or other complex movements.
  • Some focal onset impaired awareness seizures (usually ones beginning in the temporal lobe) start with a focal aware seizure (previously call simple partial seizure), which is commonly called an aura.
    • In this case, the focal aware seizure quickly involves other areas of the brain that affect alertness and awareness.
    • The person loses awareness and stares blankly. So even though their eyes are open and they may make movements that seem to have a purpose, in reality “nobody’s home.”
    • If the symptoms are subtle, other people may think the person is just daydreaming.
    • Awareness may be only partially impaired, rather than absent. Any decrease in awareness of the self or environment at any time during a seizure makes it a focal impaired awareness seizure.
    • A person’s ability to respond may be impaired. Some seizures make the person unable to move yet still aware of what is happening around them.
    • Impairment of awareness is similar to the concept of impairment of consciousness.
  • Some focal impaired awareness (complex partial) seizures can spread to both sides of the brain. Previously called secondarily generalized seizures, the new name for this is focal to bilateral tonic-clonic seizures.
    • They usually last between 30 seconds and 3 minutes.
    • Afterward, the person may be tired or confused for about 15 minutes and may not be return to normal function for hours.

Some people can have seizures of this kind without realizing anything has happened.

The seizure can wipe out memories of events just before or after it.

Most people move their mouth, pick at the air or their clothing, or perform other involuntary purposeless actions (automatisms). Occassionally, people just freeze up, which is called a focal impaired awareness behavior arrest seizure.

Less often, people may repeat words or phrases, laugh, scream, or cry.

Some people do things during these seizures that can be dangerous or embarrassing, such as walking into traffic or taking their clothes off. These people need to plan ahead and take safety precautions.

Focal to Bilateral Tonic-Clonic Seizures (Secondarily Generalized Seizures)

These seizures are called focal to bilateral tonic-clonic, because they start in a limited area on one side of the brain and spread to involve both sides. This is different from a generalized onset tonic-clonic seizure, which starts on both sides of the brain.

Focal onset seizures have an abnormal region of brain leading to the electrical storm of a seizure. The place and cause of focal onset may not be detectable by testing. Generalized onset seizures are believed to result from neurochemical and genetic abnormalities widespread throughout brain, and no focal injured brain region is involved.

  • Bilateral tonic-clonic seizures happen in more than 3 out of 10 people with focal epilepsy.
  • Sometimes the person does not recall the beginning of the seizure or the seizure spreads quickly so the first part is hard to see. This part usually lasts seconds to less than a minute.
  • The bilateral tonic-clonic part of these seizures usually lasts less than 2 or 3 minutes.

They can happen in people of any age who have focal onset seizures.

  • These seizures may look dramatic. They start suddenly and the movements can be strong or forceful.
  • The seizure may begin with an aura or focal onset aware seizure (previously called simple partial seizure). For example, the seizure may start with a smell, feeling of nausea, or change in sensation or movement. The eyes or head may turn forcefully to one side. The person is fully aware of what’s happening at this point.
  • This seizure type can also begin with a focal onset impaired awareness seizure (previously called complex partial seizure). The person may be confused or not aware of what happens during the seizure.
  • The bilateral tonic-clonic part usually begins with stiffening of the muscles (called the tonic phase).
    • Air being forced past the vocal cords causes a cry or groan. The sound probably does not reflect pain or distress, because the person is not aware at this point.
    • The person loses consciousness and falls to the floor.
    • The tongue or cheek may be bitten, so bloody saliva may come from the mouth.
    • Breathing can be temporarily impaired, and the person may look blue in the face.
  • Jerking movements happen next (called the clonic phase).
    • The arms, legs, and face begin to jerk quickly and repeatedly; bending and relaxing at the elbows, hips, and knees can be seen.
    • After a few minutes, the jerking slows and stops.
  • A person may lose control of their bladder or bowel as the body relaxes.
  • Consciousness returns slowly. The person may be drowsy, confused, agitated, or depressed after the seizure, for hours or sometimes for days.
  • The active part of the seizure generally lasts 1 to 3 minutes. It can take much longer (minutes to hours) for some people to fully recover after it.
  • A tonic-clonic seizure that lasts longer than 5 minutes is a medical emergency.
  • It may be hard to tell if a tonic-clonic seizure starts as focal or generalized onset, especially if they occur during sleep or are not seen by anyone else. Then they are called unknown onset tonic-clonic seizures.
  • Most tonic-clonic seizures during sleep begin in one area and have a focal onset.

Gelastic and Dacrystic Seizures

Epilepsy Does Not Define MeGelastic and dacrystic seizures are focal (or partial) seizures that start in an area at the base of the brain called the hypothalamus.

  • Gelastic seizures is the term used to describe focal or partial seizures with bouts of uncontrolled laughing or giggling. They are often called laughing seizures. The person may look like they are smiling or smirking.
  • Dacrystic seizures are focal or partial seizures when a person makes a crying sound. They may also look like they are grimacing.
  • The emotions (laughing or crying) are often forced and the person can’t stop them from happening.
  • Most people don’t feel happy or a sense of well-being during a gelastic seizure. The opposite may happen – they may feel scared or a loss of control. Some people may feel anxious that they will laugh at a socially inappropriate time.
  • Usually a person is aware of what’s going on around them during these seizures.

These focal or partial seizures come from the area of the brain called the hypothalamus. This is found at the base of the brain.

  • The gelastic or dacrystic seizures are usually seen in people with a lesion or area on the hypothalamus called a hamartoma. The term hypothalamic harmatoma or HH is used to describe this.
  • This lesion or spot congenital (meaning it’s been present since birth) is not a type of cancer.
  • Seizures associated with HH usually start as focal seizures. Other seizure types may be seen as the person gets older.
  • Gelastic and dacrystic seizures may spread to affect both sides of the brain, resulting in absence, atonic, tonic (also called drop attacks), and tonic-clonic seizures.

Gelastic and dacrystic seizures may not be recognized as seizures for years because of the way they look. People don’t expect that someone may laugh or cry during a seizure. Often the seizures go unrecognized until some other seizure type appears.

  • These seizures begin in infancy in 1 out of 3 children. The average age when gelastic seizures start is around 10 months.
  • Gelastic seizures often happen as a child is falling asleep, but they can occur at any time.
  • Infants and children will be awakened from sleep by a gelastic seizure, then settle down and go right back to sleep.

Gelastic seizures are often short, lasting 10 to 20 seconds or less. They may look different with each child, yet there are some common features, such as:

  • They often start with an aura. The person may look startled or even have a look of panic or fear.
  • There can also be an unpleasant feeling in the stomach (like butterflies), a tickling in the chest or headache. Automatic behaviors, such as lip smacking or swallowing may be seen.
  • The person may stare. Their eyes may seem vacant, dilate, and move up and to one side.
  • There often is a slight smile that seems a bit forced and laughter or grunting that seems unusual or not appropriate at that time. In infants, there may be grunting and unusual squirming as well.
  • Some children look for comfort from a parent or favorite toy for no apparent reason. Others may run to a place where they feel safe.
  • Parents report that their child’s gelastic seizures appear triggered by loud noises or fearful responses to sudden actions.
  • These seizures can occur many times a day. In some cases, as many as 100 a day have been seen. 

Myoclonic Seizures

Myoclonic (MY-o-KLON-ik) seizures are brief, shock-like jerks of a muscle or a group of muscles. “Myo” means muscle and “clonus” (KLOH-nus) means rapidly alternating contraction and relaxation—jerking or twitching—of a muscle. Usually they don’t last more than a second or two. There can be just one, but sometimes many will occur within a short time.

Even people without epilepsy can experience myoclonus in hiccups or in a sudden jerk that may wake you up as you’re just falling asleep. These things are normal.

In epilepsy, myoclonic seizures usually cause abnormal movements on both sides of the body at the same time. They occur in a variety of epilepsy syndromes that have different characteristics:

  • Juvenile myoclonic epilepsy: The seizures usually involve the neck, shoulders, and upper arms. In many patients the seizures most often occur soon after waking up. They usually begin around puberty or sometimes in early adulthood in people with a normal range of intelligence. In most cases, these seizures can be well controlled with medication but it must be continued throughout life.
  • Lennox-Gastaut syndrome: This is an uncommon syndrome that usually includes other types of seizures as well. It begins in early childhood. The myoclonic seizures usually involve the neck, shoulders, upper arms, and often the face. They may be quite strong and are difficult to control.
  • Progressive myoclonic epilepsy: The rare syndromes in this category feature a combination of myoclonic seizures and tonic-clonic seizures. Treatment is usually not successful for very long, as the patient deteriorates over time.

The epileptic syndromes that most commonly include myoclonic seizures usually begin in childhood, but the seizures can occur at any age. Other characteristics depend on the specific syndrome.

Nonepileptic Seizures or Events

Epilepsy Does Not Define MeEvents that look like seizures but are not due to epilepsy are called “nonepileptic seizures.” Some people prefer to use the term “events” rather than seizures. You will see the terms used interchangeably here.

A common type is described as psychogenic (si-ko-JEN-ik), which means beginning in the mind. Psychogenic seizures or events are caused by subconscious thoughts, emotions, or “stress,” not abnormal electrical activity in the brain. Doctors consider most of them psychological in nature, but not purposely produced. Usually the person is not aware that the spells are not “epileptic.” The term “pseudoseizures” has also been used in the past to refer to these events, but we prefer to avoid this term as it is not accurate and has a negative meaning.

It’s important to know that some seizures that are not epilepsy could be caused by other physical problems. These are nonepilepsy seizures too, but not caused by a psychological condition. Further testing is needed to find the exact cause so they can be treated properly.

Psychogenic nonepileptic events are common. About 20% of the people referred to comprehensive epilepsy centers for video EEG (electroencephalogram) monitoring are found to have nonepileptic seizures. About 1 in 6 of these people also has epileptic seizures or has had them in the past.

Psychogenic nonepileptic events have been more widely recognized during the past several decades. They are most often seen in adolescents and young adults, but they also can occur in children and the elderly. They are 3 times more common in females.

The events most often look like focal impaired awareness (complex partial) or tonic-clonic (grand mal) seizures. Family members report episodes in which the person stiffens and jerks. Doctors rarely witness the actual event, so they are drawn toward the diagnosis of epilepsy. Often years can be spent trying to treat the spells as epileptic seizures without success.

Refractory Seizures

Seizures sometimes are not controlled with seizure medications. A number of different terms may be used to describe these including: “uncontrolled,” “intractable,” “refractory,” or “drug resistant.” How often does this happen?

  • Studies suggest that epilepsy fails to come quickly under control with medicines in about one-third of cases, but the true frequency depends upon the definition of uncontrolled.
  • Most epilepsy specialists agree that refractory epilepsy is epilepsy for which seizures are frequent and severe enough, or the required therapy for them troublesome enough, to seriously interfere with quality of life.
  • However, in more recent years, the epilepsy community has recognized the need to continue striving for ‘no seizures’ and the best control possible.
  • The International League Against Epilepsy (ILAE) has proposed the following definition of drug resistant epilepsy and suggests that this term be used instead of the term ‘refractory epilepsy’.
  • Drug resistant epilepsy occurs when a person has failed to become (and stay) seizure free with adequate trials of two seizure medications (called AEDs).
  • These seizure medications must have been chosen appropriately for the person’s seizure type, tolerated by the person, and tried alone or together with other seizure medications.

Seizures can be uncontrolled for four broad reasons.

  • The diagnosis is wrong.
  • The treatment is wrong.
  • Despite the best treatment, triggers or lifestyle factors may affect seizure control.

Properly diagnosed seizures do not respond to the best medical treatment.

Not all uncontrolled seizures are considered refractory or drug resistant. For example:

  • If the diagnosis is corrected and seizures can be brought under control with a different treatment, then they would not be considered refractory.
  • If triggers of lifestyle factors could be avoided or modified preventing breakthrough seizures, then medication therapy may work better. A person in this situation would not be considered drug resistant, but different drug trials may be considered and non-drug treatments may be considered to help control seizures.

Tonic Seizures

Muscle “tone” is the muscle’s normal tension at rest. In a tonic seizure, the tone is greatly increased: the body, arms, or legs become suddenly stiff or tense.

  • A person may be aware or have only a small change in awareness during a tonic seizure.
  • They usually happen during sleep and usually involve all or most of the brain, affecting both sides of the body.
  • They are short, usually less than 20 seconds.
  • A person may fall if standing when a tonic seizure starts.

When it starts in one area of the brain:

  • Stiffening of a part of the body may begin in one area and stay local. These are called focal tonic seizures.

When it starts on both sides of the brain:

  • The whole body or both sides of the body may become stiff or tense from the beginning. These are called generalized tonic seizures.
  • Tonic seizures can happen in anyone.
  • They are more common in people who have Lennox-Gastaut syndrome or other syndromes with mixed seizure types.
  • Stiffening or other movements can be seen in other neurological problems, especially in children.
  • A written description or video of what happens during the seizure is very important. For example, tonic seizures start suddenly with forceful movements. Events that start more slowly may be due to another condition.
  • When a tonic seizure ends, the person may or may not be sleepy or confused.
  • Typically, no first aid is needed unless a person is not fully aware during or after the seizure.
  • Preventing injury is a key part of first aid for tonic seizures. Some people may need to wear protective equipment like a helmet to prevent head injuries from falls.

Tonic-Clonic Seizures

This type of seizure (also called a convulsion) is what most people think of when they hear the word “seizure.” An older term for this type of seizure is “grand mal.” As implied by the name, they combine the characteristics of tonic and clonic seizures. Tonic means stiffening, and clonic means rhythmical jerking.

  • The tonic phase comes first.
    • All the muscles stiffen.
    • Air being forced past the vocal cords causes a cry or groan.
    • The person loses consciousness and falls to the floor.
    • A person may bite their tongue or inside of their cheek. If this happens, saliva may look a bit bloody.
  • After the tonic phase comes the clonic phase.
    • The arms and usually the legs begin to jerk rapidly and rhythmically, bending and relaxing at the elbows, hips, and knees.
    • After a few minutes, the jerking slows and stops.
  • The person’s face may look dusky or a bit blue if they are having trouble breathing or the seizure lasts too long.
  • The person may lose control of their bladder or bowel as the body relaxes.
  • Consciousness, or a person’s awareness, returns slowly.
  • These seizures generally last 1 to 3 minutes. Afterwards, the person may be sleepy, confused, irritable, or depressed.
  • A tonic-clonic seizure that lasts longer than 5 minutes needs immediate medical help. Call 911 for emergency help.
  • A seizure that lasts more than 10 minutes, or three seizures in a row without the person coming to between them, is a dangerous condition. This is called status epilepticus; emergency treatment in a hospital is needed.