Epilepsy affects millions of people worldwide. Most seizures stop within two to three minutes without intervention but some do not. Prolonged seizures, repeated seizures without recovery between them, and first seizures in adults can all be medical emergencies. Status epilepticus (a seizure lasting more than five minutes, or two or more seizures without full recovery between them) carries a higher complications risk and must be treated as urgently as a cardiac arrest. At CARE Hospitals, the emergency neurology team manages seizure emergencies with tiered drug protocols from arrival.

What is Epilepsy?

Epilepsy is a neurological disorder characterised by recurrent unprovoked seizures occurring without an immediate identifiable cause like fever or low blood sugar. Two unprovoked seizures more than 24 hours apart, or one unprovoked seizure with high recurrence risk need a diagnosis.

Seizures are classified as:

Focal: Beginning in one brain hemisphere
Generalised: Involving both from the outset
Tonic-clonic seizures (formerly called grand mal): The most recognised type and characterised by stiffening (tonic phase) followed by rhythmic jerking (clonic phase), loss of consciousness, and post-ictal confusion (the period of reduced consciousness and fatigue after a seizure).

Common Causes of Epilepsy

Cause varies with age of onset and guides treatment.

Structural abnormalities: Cortical dysplasia (abnormal brain development), brain tumours, cavernomas (blood vessel abnormalities) and prior stroke alter brain electrical properties
Head trauma: Significant brain injury disrupts neural circuits. Sometimes post-traumatic epilepsy can develop weeks to years after injury
Infections: Bacterial meningitis, viral encephalitis (brain inflammation), cerebral malaria, and neurocysticercosis (brain infection from the pork tapeworm Taenia solium) are leading causes in India
Genetic causes: Ion channel mutations (proteins controlling nerve electrical signals) underlie many childhood epilepsies including Dravet syndrome, Lennox-Gastaut syndrome, and juvenile myoclonic epilepsy
Autoimmune encephalitis: The immune system attacks brain proteins such as NMDA receptors, causing seizures alongside psychiatric symptoms
Metabolic causes: Chronic low sodium (hyponatraemia), low calcium (hypocalcaemia), or liver failure causing hepatic encephalopathy (brain dysfunction from toxins) can cause recurrent seizures
Idiopathic: No cause found in many cases despite thorough investigation.

Signs and Symptoms of Epilepsy

Seizures vary in appearance depending on type and brain region:

Generalised tonic-clonic seizure: Loss of consciousness, body goes rigid (tonic, 10 to 20 seconds) then rhythmic jerking (clonic, 30 to 60 seconds) and may also include a cry at onset, brief blueness from breath-holding, and loss of bladder control
Absence seizure: A brief (5 to 15 second) blank stare with no response and is most common in children. The person resumes activity immediately without post-ictal confusion
Focal aware seizure: Aabnormal sensation, smell, taste, or movement confined to one limb or body side but the person remains conscious throughout
Focal impaired awareness seizure: Blank stare and repetitive movements (automatisms such as lip-smacking) and lasts one to three minutes followed by post-ictal confusion
Myoclonic seizure: Brief, sudden limb or whole-body jerks, often on waking and consciousness maintained
Atonic seizure (drop attack): Sudden muscle tone loss causing an unwarned fall
Aura: A warning sensation before a seizure (a smell, rising stomach sensation, déjà vu, or visual disturbance). It is itself a focal seizure in the generating brain area.

First Aid for Epilepsy (Before Reaching Hospital)

Correct first aid limits injury and allows the seizure to end safely:

Stay calm and time the seizure: Note when the seizure started. If it exceeds five minutes, call emergency services.
Protect from injury: Clear hard or sharp objects from the area. Place something soft under the head. Do not restrain the person and let the movements run their course.
Turn onto the side: Once convulsive movements stop roll the person gently onto the side (recovery position). This prevents aspiration of saliva or vomit and keeps the airway clear.
Do not put anything in the mouth: The tongue cannot be swallowed. Objects placed in the mouth during a seizure injure both the person and the first aider bitten fingers and broken teeth are common consequences.
Do not give water or food: Swallowing is impaired during and after a seizure and offering fluids risks aspiration.
Give rescue medication if prescribed: Many people carry their seizure medicine, give it as directed and call emergency services.
Stay with the person until fully recovered: Post-ictal confusion can last 15 to 30 minutes. Speak calmly, reorient as awareness returns, and do not leave until the person is fully conscious.

When to Seek Emergency Care for Epilepsy

A typical seizure stopping within two to three minutes in a known epileptic may not need emergency transport, but in some situations, emergency interventions may be needed. They are:

Seizure lasting more than five minutes
Two or more seizures without full recovery between them
First seizure in any adult
Seizure in a person with diabetes
Seizure in a pregnant woman
Seizure after a head injury
Seizure followed by prolonged confusion, one-sided weakness, or speech difficulty
Seizure with fever
Injury sustained during a seizure like head wound, suspected fracture, or aspiration.

Emergency Treatment at the Hospital for Epilepsy

Hospital treatment follows a step by step protocol:

Assessment: Blood glucose first; oxygen saturation; vital signs; electrolytes (sodium, calcium, magnesium); renal and liver function; antiepileptic drug levels; toxicology screen if overdose is suspected.
First-line: benzodiazepine: IV benzodiazepine stops seizures in the majority of patients within five minutes. Where IV access is unavailable buccal or IM medications are equally effective and faster to administer.
Second-line: IV antiepileptic: After two benzodiazepine doses, IV lantiepileptic medicne is the preferred second-line agent and usually well tolerated with no cardiac side effects.
Third-line: anaesthesia: Refractory status epilepticus is treated with general anaesthesia with intubation and mechanical ventilation. EEG monitoring confirms cessation of electrical seizure activity even when clinical movements have stopped.
Cause-specific treatment:
- Hypoglycaemia: 50 ml of IV dextrose 50% immediately.
- Eclampsia: IV magnesium sulphate 4 g loading dose.
- Meningitis or encephalitis: IV antibiotics and antivirals before CT.
- Tumour or stroke: urgent neurosurgical or stroke review.

What Not to Do

These actions cause harm or delay treatment.

Do not restrain the person during convulsive movements
Do not put anything in the mouth
Do not give water or food until the person is fully conscious and aware
Do not leave until full consciousness returns
Do not assume a brief seizure needs no review. A first seizure, seizure after head injury or seizure with fever needs emergency assessment regardless of duration.

Conclusion

Most seizures end within two to three minutes and the person recovers fully. The exceptions like status epilepticus, first seizures in adults, seizures after head injury, and seizures with fever or neurological deficit require immediate hospital assessment. At CARE Hospitals, the tiered status epilepticus protocol is followed from arrival, the seizure cause is investigated, and neurology follow-up is arranged for medication optimisation.

FAQs

1. What should I do during an epilepsy emergency?

Stay calm; note the time; clear hazards; place something soft under the head; do not restrain or put anything in the mouth; turn onto the side when jerking stops; give prescribed rescue medication if the seizure exceeds five minutes; call emergency services.

2. Can stress or lack of sleep trigger epilepsy?

Yes sleep deprivation is the most reliably documented trigger. Stress, alcohol, missed medication, flashing lights (photosensitive epilepsy), and illness are other well-recognised triggers. Identifying and managing personal triggers is core to epilepsy self-management.

3. How is epilepsy diagnosed?

Diagnosis combines clinical history (an eyewitness account is essential), EEG, and MRI (to identify structural causes) and blood tests exclude metabolic causes. A single normal EEG does not exclude epilepsy.

4. Can epilepsy be cured permanently?

In some forms, yes epilepsy from a resectable (surgically removable) lesion such as a cavernoma or cortical dysplasia is cured by surgery in many patients. Most patients are managed with antiepileptic drugs and the majority become seizure-free on medication.