Introduction

Epilepsy is a diagnosis that evokes fear and stigma, as evidenced by the commonly used phrase, ‘I wouldn’t do it in a fit!’. The definition of epilepsy is a tendency to recurrence of seizures, which is as broad a definition as are the variety of seizures.

Extrapolating from this, epilepsy is not a satisfactory diagnosis. It represents a symptom of another underlying diagnosis that has provoked the seizures. This has translated into an internationally accepted classification of seizures (see Fig 7.1),¹ which offers the road map to provide treatment options.

There is also an internationally accepted classification of the epilepsies² (note the plural) provided to allow the clinician to acknowledge that one type of epilepsy may incorporate numerous seizure types (see Box 7.1).

The classification of the epilepsies also permits prediction of prognosis, thereby making both classifications part and parcel of a better understanding of the condition. An easier way to describe this is that the description of seizures offers phenomenology of the event, and description of the epilepsies provides a syndromal approach. As these classifications should mirror current knowledge, the leaders in the field are constantly trying to improve their content and suggesting enhanced pedagogy.³

It can be seen that the study and management of epilepsy is a vibrant and complex endeavour. It encompasses many other illnesses that can themselves provoke seizures, fits, turns or any other such term that may be in vogue. The aim of this chapter is not to turn the family physician into an ‘epileptologist’ but rather to offer epilepsy’s ‘travel guide’ to better understanding and an appreciation of the pitfalls.

Diagnosis of Epilepsy

The diagnosis of epilepsy rests completely on a convincing history. If the patient satisfies the above definition, then the diagnosis is confirmed even in the absence of any positive tests. The tests provide an adjunct to clinical skill rather than a substitute.

A comprehensive history is the principal tool of all neurology. The patient often is unable to report exactly what happened during the seizure due to loss of consciousness, but the doctor should not capitulate at this point. The patient should be able to describe what they were doing just before the seizure and any preliminary symptoms, such as the perception of bad smell (e.g. burning rubber), bad taste (e.g. metallic taste), or a feeling that the unfamiliar is familiar (déjà vu—I have seen it before) or the opposite (jamais vu—the familiar is unfamiliar—I have not seen it before). The patient may be able to identify flashing lights as a photic stimulation that provoked the seizure, but this only occurs in approximately 10% of people with epilepsy.⁴ Stress, fatigue, sleep deprivation, drugs, alcohol or even sleep itself can provoke seizures. Menstruation and hormonal changes may cause seizures. Most of this information is readily available from the patient if the right questions are asked (see Table 7.1).

TABLE 7.1 Questions and answers that help diagnose epilepsy

Question	Answers pointing to epilepsy
When and where did the seizure occur?	• when asleep • when sleep deprived • with excess alcohol • with alcohol withdrawal • at times of stress • related to menstrual cycle • at time of flashing lights (e.g. at a dance or while playing video games)

Were there any warning symptoms or signs that occurred before the seizure? What do you recall from the seizure? What have others told you about your seizure? How did you feel after the seizure? Is there a family history? Were there febrile convulsions? Is there a history of brain trauma?

The patient will know if they bit their tongue, buccal mucosa or injured themselves in a seizure. Similarly, they can report if they were incontinent of urine or faeces. The patient will also know how they felt in the post-ictal period, whether they were confused, disoriented, exhausted and had to sleep, or if they had a headache. Thus the history from the patient is very helpful (see Table 7.1).

In addition, a history from any eyewitness will help the doctor to ascertain a word picture of what occurred during the seizure. Questions should include: did the patient appear absent; were there automatisms (automatic behaviour such as smacking lips, fiddling with clothing, involuntary behaviour or apparently purposeful activity for which the patient has no recall); did the patient turn the head to one or the other side; where, if identified, did the seizure start (such as in one hand or in the face to then move throughout the body); were the eyes open or shut (often used to differentiate non-epileptic, pseudo-seizures from truly epileptic phenomena where eyes are open); did the patient shake, twitch, talk, writhe, flail or do anything else during the episode? (See Table 7.2.)

TABLE 7.2 Description of seizures

Seizure type	Description
Simple partial seizure (SPS)	Consciousness retained but focal features determined by site of seizure, such as perception of a smell, a sound or a vision. Uncontrolled movement or twitching of a part of the body, such as a thumb or hand, without loss of consciousness, which may spread (such as Jacksonian march in focal motor seizure).
Complex partial seizure (CPS)	Differentiated from SPS by altered state of consciousness. Patient may be unaware or poorly relate to the surrounding environment as with déjà vu (false memory) or jamais vu (blocked real memory). The patient, while non-responsive, may have automatisms—automatic behaviour that can be quite complex—such as driving a car. The appearance may be of a patient on automatic pilot. The patient has post-ictal features of fatigue, headache or confusion. ‘Absence’ with post-ictal features may be CPS rather than generalised absence.
Secondarily generalised seizure	This is a convulsive seizure that follows focal onset. A convulsion in which the patient reports an aura (representing a focal seizure) is experiencing secondary generalisation (2° gend) throughout the brain.
Typical absence	The patient has generalised absence that is short lived and often multiple, possibly provoked by hyperventilation. There is often no post-ictal feature.
Atypical absence	Similar to typical absence but may have automatisms. Differentiation from CPS may be difficult. EEG with typical 3 Hz spike and wave pattern may be necessary to differentiate from CPS, which will have more focal, often temporal lobe abnormality.
Tonic seizure	Drop attacks with hands and arms often coming up in front of the body and the head dropping forward as the patient becomes stiff and falls down, usually forward.
Myoclonic seizure	Sudden jerking of limbs and head—often first thing in the morning after waking. A form of generalised seizure without focal features.
Tonic clonic seizure	Primarily generalised convulsive seizure starting abruptly without focal features. Similar features to 2° gend but without focality—no aura at onset.

After spending considerable effort to define the seizure the next step is to determine if there are precipitating factors, such as illness, genetic influences (with family history), or exposure to toxins. An obstetric history looking for birth trauma is important, as is any other history of brain damage from accidents, assaults or trauma. An educational history gives a clue regarding poor cognition and possible impaired function. A past history of febrile convulsions is worth seeking as is the detailed past medical and surgical history.

After history taking the patient should undergo a full medical examination, particularly a neurological assessment. In general, the patient with only epilepsy and an otherwise unremarkable history will have no focal neurological signs. If signs are found then further questions seeking cause for focal cerebral damage must be asked. The doctor must accept that seizures, and hence epilepsy, are the physical manifestation of what is occurring in the brain and must question what that might be, such as a space-occupying lesion, congenital abnormality, ischaemic lesion, cerebral bleed or site of infection, such as an abscess.

Investigation of the Patient with Epilepsy