Seizures in Adults and Children: Symptoms, Causes, and Treatment

What are Seizures?

Seizures are a medical condition characterized by a series of rapid, violent, involuntary contractions of one or more muscle groups, sometimes followed by relaxation, repeating multiple times and producing uncontrolled body movements.

They can consist of:

• A sustained spasm (tonic seizures),
• Rhythmic contractions alternating with relaxation (clonic seizures).

The term “seizure” is often used as a synonym for epilepsy, a disease responsible for a significant proportion of seizure episodes. However, epilepsy has its own distinct characteristics and cannot explain all forms of seizure. Importantly, some forms of epilepsy manifest without convulsions.

Seizures are not a disease in themselves, but rather a symptomatic manifestation of an underlying pathological process. They are caused by irritation of the central nervous system areas responsible for controlling muscle movement: an uncontrolled burst of electrical activity in a group of adjacent neurons generates a nerve signal that triggers contraction of the corresponding muscles.

There is wide variability across seizure types, both in terms of the severity of the underlying pathology and the most appropriate therapeutic approach. Some seizures are considered near-physiological phenomena, such as febrile convulsions in children, which commonly occur in the context of infectious illness.

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Causes

Seizures occur when uncontrolled, disorganized electrical activity is generated in the brain, producing repeated contractions of the muscles controlled by the affected cortical areas. The neurons controlling movement activate synchronously, generating specific wave patterns visible on an electroencephalogram (EEG) recorded during the seizure.

Seizures can be provoked by:

• Localized brain lesions: tumors, trauma, or vascular damage affecting a specific brain area,
• Generalized processes disrupting global brain function: hypoglycemia, intoxication, high fever, uremia.

The cause may be chronic and persistent (e.g., tumor or ischemic damage) or transient and correctable (e.g., electrolyte imbalance or hypoglycemic episode).

Main Causes

The principal causes of seizures in both adults and children include:

• Epilepsy, the most common chronic cause,
• Brain tumors (primary or metastatic)
• High fever, particularly in children (for example, febrile seizures)
• Hypoglycemia: dangerously low blood sugar
• Electrolyte imbalances: hyponatremia, hypocalcemia, hypomagnesemia
• Vascular events: stroke, cerebral hemorrhage
• Acute alcohol intoxication or withdrawal in chronic alcoholics,
• Recreational drugs, such as cocaine, amphetamines, and synthetic cannabinoids
• Certain medications, such as neuroleptics, some antibiotics, and tramadol (at high doses)
• Poisoning or intoxication: carbon monoxide, heavy metals, organophosphates
• Liver failure or renal failure due to toxic metabolite accumulation
• Phenylketonuria: metabolic disorder
• Eclampsia: hypertensive crisis of pregnancy
• Head trauma or brain surgery,
• Meningitis and encephalitis: CNS infections
• Brain malformations and other neurological conditions,
• Perinatal brain injury: hypoxic-ischemic encephalopathy in newborns
• Sleep deprivation or severe psychophysical stress

Classification of Seizures

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Accompanying Symptoms

The characteristics of a seizure and its accompanying symptoms depend on which brain areas are involved and the underlying pathology. A typical episode lasts a few minutes and may include:

• Muscle contractions and spasms
• Involuntary body movements
• Sudden falling
• Loss of consciousness
• Teeth grinding
• Temporary alteration of breathing
• Vocalizations or crying out
• Loss of sphincter control: urinary or fecal incontinence
• Foaming at the mouth
• Vomiting

The Aura: Warning Signs Before a Seizure

Many seizures, particularly in epilepsy, are preceded by an aura: a set of neurological warning symptoms that the patient experiences moments before the seizure begins. These may include:

• Visual phenomena: flashing lights (scintillating scotomas), dark spots, or visual distortions
• Unusual sensory experiences such as auditory or olfactory hallucinations
• Automatic movements or myoclonus
• Numbness or tingling in a body part
• Anxiety, irritability, insomnia
• Nausea
• Vertigo

The aura is clinically valuable: it warns the patient that a seizure is imminent, allowing them to move to safety, and it provides diagnostic information about the brain region of origin.

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What to Do During a Seizure

Witnessing a seizure can be frightening, but the most important principle is to stay calm and not attempt to physically intervene in the seizure itself. Let it run its natural course. Attempting to restrain or stop the movements risks causing muscle tears, bone fractures, or other injuries.

During the Seizure

Do:

• Stay with the person and remain calm,
• Time the duration of the seizure; this is important information for emergency responders
• Clear the area of hard or sharp objects,
• Cushion the head gently with something soft,
• If the person is in a dangerous location (near stairs, water, or traffic), move them to safety as this is the one instance where gentle repositioning is appropriate

Do NOT:

• Try to restrain or hold down the person.
• Put anything in their mouth: it is a dangerous myth that people can swallow their tongue during a seizure.
• Give water, food, or medication during the seizure.

After the Seizure

Once the convulsions have stopped:

• Place the person in the recovery position (lateral decubitus, on their side), particularly if vomiting has occurred, to prevent aspiration and facilitate oral drainage.
• Stay with them while they regain consciousness: this may take several minutes.
• Speak reassuringly: they may feel confused, exhausted, frightened, or disoriented after the episode. (This post-ictal phase is normal.) Maintain a calm, quiet environment.

When to Call Emergency Services

Call emergency services immediately if:

• The seizure lasts more than 5 minutes (status epilepticus risk),
• A second seizure begins shortly after the first without recovery between them,
• The person does not regain consciousness after the seizure ends,
• The person is injured during the seizure,
• The person is pregnant,
• The seizure occurs in water (drowning risk),
• It is the person’s first known seizure,
• The person has diabetes or another serious condition.

Status Epilepticus: A Medical Emergency

Status epilepticus, defined as continuous or repeated seizures without recovery of consciousness lasting more than 20 minutes, is a life-threatening medical emergency. Unlike a typical self-limiting seizure, status epilepticus requires immediate hospitalization and aggressive pharmacological treatment. Prolonged status epilepticus can cause permanent brain damage due to sustained neuronal excitotoxicity and hypoxia.

Diagnostic Investigations

To identify the precipitating cause, the physician relies on clinical history, physical examination, and targeted investigations:

• Electroencephalogram (EEG): non-invasive recording of brain electrical activity via scalp electrodes. If recorded during a seizure, it shows pathognomonic patterns. Between seizures, the EEG may appear entirely normal.
• Brain MRI: detailed soft tissue imaging for structural lesions (tumors, cortical dysplasia, vascular malformations).
• Brain CT scan: rapid imaging for acute intracranial events (hemorrhage, large infarcts).
• Blood and urine tests: electrolytes, glucose, renal and hepatic function, and toxicological screening.
• Lumbar puncture (spinal tap): if CNS infection (such as meningitis or encephalitis) is suspected.

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Treatment and Therapy

Lifestyle Precautions

Patients at risk of recurrent seizures (particularly those with uncontrolled epilepsy) should avoid activities that could be dangerous in the event of a sudden seizure:

• Rock climbing or working at heights,
• Unsupervised swimming,
• Cycling on public roads,
• Driving motor vehicles (regulations vary by country; most require a seizure-free period of 6–12 months before resuming driving).

Acute Management of a Seizure

Most seizures self-terminate within 1–5 minutes. By the time medical assistance arrives, the episode has usually already ended. If the seizure is still ongoing when emergency services arrive:

• Diazepam intravenously: to terminate the acute episode.
• Supplemental oxygen: to prevent hypoxia.

Status epilepticus management requires hospitalization with:

• Diazepam IV (or midazolam buccal/IM in community settings) as first-line
• Phenytoin or sodium valproate IV if benzodiazepines fail (second-line)
• Levetiracetam IV: increasingly used as an alternative to phenytoin
• Anaesthetic agents (propofol, thiopental) in refractory status epilepticus in the ICU

Febrile Seizures in Children

For children with febrile seizures that do not self-resolve within 4 minutes:

• Rectal diazepam administered by parents or caregivers at home.
• Buccal midazolam: increasingly used as an alternative with equivalent efficacy and greater parental acceptance.

Parents should be educated about:

• Administering paracetamol early during future febrile episodes to prevent temperature spikes that trigger seizures,
• How to recognize and respond to a seizure,
• When to seek emergency care.

Long-Term Anticonvulsant Therapy

Since seizures are a symptom of an underlying condition, treatment must address the root cause first:

• Correctable causes (hypoglycemia, electrolyte imbalance, intoxication): once the precipitant is corrected, seizures should not recur, and long-term anticonvulsant therapy is not needed.
• Permanent structural causes (epilepsy, tumors, ischemic damage) require chronic anticonvulsant pharmacotherapy.

The main antiepileptic drugs (AEDs) available include:

Each drug has a distinct efficacy profile for specific seizure types, as well as a unique side effect and interaction profile. The choice of medication is individualized by the treating neurologist based on seizure type, patient characteristics, comorbidities, and reproductive considerations.

The Importance of Adherence

Consistent adherence to the prescribed antiepileptic regimen is critical. Therapy must be maintained for a sufficient duration. In epilepsy, this is generally at least two years from the last seizure episode. Premature discontinuation substantially increases the risk of seizure recurrence, which can have serious consequences for the patient’s safety and driving ability. Any dose adjustments or discontinuation should only be performed under close neurological supervision.

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Sources and Bibliography

• Kasper DL, Fauci AS, Hauser SL, Longo DL, Jameson JL, Loscalzo J. Harrison’s Principles of Internal Medicine, 19th edition. McGraw-Hill, New York, 2015.
• Potestà P. Manuale-Prontuario di diagnostica e terapia medica, 9th edition. Verducci Editore, 2018.
• Pazzaglia P. Clinica neurologica, 7th edition. Casa Editrice Esculapio, 2008.
• National Institute for Health and Care Excellence (NICE). Epilepsies in children, young people and adults. NICE Guideline NG217, 2022.
• Fisher RS et al. “ILAE Official Report: A practical clinical definition of epilepsy”. Epilepsia, 2014; 55(4):475–482.
• Glauser T et al. “Updated ILAE evidence review of antiepileptic drug efficacy and effectiveness as initial monotherapy for epileptic seizures and syndromes”. Epilepsia, 2013; 54(3):551–563.
• Brophy GM et al. “Guidelines for the Evaluation and Management of Status Epilepticus”. Neurocritical Care, 2012; 17(1):3–23.