A client with a history of a seizure disorder has a seizure while sitting in a chair

What is a seizure? If someone has a seizure, does that mean they suffer from epilepsy?

A seizure is a a sudden surge of electrical activity in the brain that usually affects how a person appears or acts for a short time. Many different things can occur during a seizure. Whatever the brain and body can do normally can also occur during a seizure. The occurrence of a seizure in the presence of some acute precipitating physiological disturbance does not mean that it will ever happen after the precipitating cause has resolved. When seizures recur without any obvious precipitant or cause, then a person may be considered to have epilepsy.

What happens during a seizure?

Seizures have a beginning, middle, and end. Not all parts of a seizure may be visible or easy to separate from each other. Every person with seizures will not have every stage or symptom described below. The symptoms during a seizure usually are stereotypic (occur the same way or similar each time), episodic (come and go), and may be unpredictable.

Beginning

Some people are aware of the beginning of a seizure, possibly as much as hours or days before it happens. On the other hand, some people may not be aware of the beginning and therefore have no warning.

Prodrome

Some people may experience feelings, sensations, or changes in behavior hours or days before a seizure. These feelings are generally not part of the seizure, but may warn a person that a seizure may come. Not everyone has these signs, but if they do, the signs can help a person change their activity, make sure to take their medication, use a rescue treatment, and take steps to prevent injury.

Aura

An aura or warning is the first symptom of a seizure and is considered part of the seizure. Often the aura is an indescribable feeling. Other times it’s easy to recognize and may be a change in feeling, sensation, thought, or behavior that is similar each time a seizure occurs.

• The aura can also occur alone and may be called a focal onset aware seizure, simple partial seizure or partial seizure without change in awareness.
• An aura can occur before a change in awareness or consciousness.
• Yet, many people have no aura or warning; the seizure starts with a loss of consciousness or awareness.

Common symptoms before a seizure

Awareness, Sensory, Emotional or Thought Changes

• Déjà vu (a feeling of being there before but never have)
• Jamais vu (a feeling that something is very familiar but it isn’t)
• Smells
• Sounds
• Tastes
• Visual loss or blurring
• “Strange” feelings
• Fear/panic (often negative or scary feelings)
• Pleasant feelings
• Racing thoughts

Physical Changes

• Dizzy or lightheaded
• Headache
• Nausea or other stomach feelings (often a rising feeling from the stomach to the throat)
• Numbness or tingling in part of the body

Middle

The middle of a seizure is often called the ictal phase. It’s the period of time from the first symptoms (including an aura) to the end of the seizure activity, This correlates with the electrical seizure activity in the brain. Sometimes the visible symptoms last longer than the seizure activity on an EEG. This is because some of the visible symptoms may be aftereffects of a seizure or not related to seizure activity at all.

Common symptoms during a seizure

Awareness, Sensory, Emotional or Thought Changes

• Loss of awareness (often called “black out”)
• Confused, feeling spacey
• Periods of forgetfulness or memory lapses
• Distracted, daydreaming
• Loss of consciousness, unconscious, or “pass out”
• Unable to hear
• Sounds may be strange or different
• Unusual smells (often bad smells like burning rubber)
• Unusual tastes
• Loss of vision or unable to see
• Blurry vision
• Flashing lights
• Formed visual hallucinations (objects or things are seen that aren’t really there)
• Numbness, tingling, or electric shock like feeling in body, arm or leg
• Out of body sensations
• Feeling detached
• Déjà vu (feeling of being there before but never have)
• Jamais vu (feeling that something is very familiar but it isn’t)
• Body parts feels or looks different
• Feeling of panic, fear, impending doom (intense feeling that something bad is going to happen)
• Pleasant feelings

Physical Changes

• Difficulty talking (may stop talking, make nonsense or garbled sounds, keep talking or speech may not make sense)
• Unable to swallow, drooling
• Repeated blinking of eyes, eyes may move to one side or look upward, or staring
• Lack of movement or muscle tone (unable to move, loss of tone in neck and head may drop forward, loss of muscle tone in body and person may slump or fall forward)
• Tremors, twitching or jerking movements (may occur on one or both sides of face, arms, legs or whole body; may start in one area then spread to other areas or stay in one place)
• Rigid or tense muscles (part of the body or whole body may feel very tight or tense and if standing, may fall “like a tree trunk”)
• Repeated non-purposeful movements, called automatisms, involve the face, arms or legs, such as
  • lipsmacking or chewing movements
  • repeated movements of hands, like wringing, playing with buttons or objects in hands, waving
  • dressing or undressing
  • walking or running
• Repeated purposeful movements (person may continue activity that was going on before the seizure)
• Convulsion (person loses consciousness, body becomes rigid or tense, then fast jerking movements occur)
• Losing control of urine or stool unexpectedly
• Sweating
• Change in skin color (looks pale or flushed)
• Pupils may dilate or appear larger than normal
• Biting of tongue (from teeth clenching when muscles tighten)
• Difficulty breathing
• Heart racing

Ending

As the seizure ends, the postictal phase occurs - this is the recovery period after the seizure. Some people recover immediately while others may take minutes to hours to feel like their usual self. The type of seizure, as well as what part of the brain the seizure impacts, affects the recovery period – how long it may last and what may occur during it.

Common symptoms after a seizure

Awareness, Sensory, Emotional, or Thought Changes

• Slow to respond or not able to respond right away
• Sleepy
• Confused
• Memory loss
• Difficulty talking or writing
• Feeling fuzzy, lightlheaded, or dizzy
• Feeling depressed, sad, upset
• Scared
• Anxious
• Frustrated, embarrassed, ashamed

Physical Changes

• May have injuries, such as bruising, cuts, broken bones, or head injury if fell during seizure
• May feel tired, exhausted, or sleep for minutes or hours
• Headache or other pain
• Nausea or upset stomach
• Thirsty
• General weakness or weak in one part or side of the body
• Urge to go to the bathroom or lose control of bowel or bladder

Types of Seizures

There are three 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.
   • 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.
   • 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.
   As more information is learned, an unknown onset seizure may later be diagnosed as a focal or generalized seizure.

How are different symptoms during a seizure described?

Many different symptoms happen during a seizure. This new classification separates them simply into groups that involve movement.

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, lipsmacking 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.

What should I do if I have a seizure? What should I do if I see someone else have a seizure?

What happens during a seizure may vary from one person to the next. The type of first aid needed can be tailored to what happens during the seizure and the person's safety. It helps to think about whether the person's alertness or awareness is affected, and if any physical movements occur that can place them at risk of injury.

• Always Stay With the Person Until the Seizure Is Over 
  • Seizures can be unpredictable and it’s hard to tell how long they may last or what will occur during them. Some may start with minor symptoms, but lead to a loss of consciousness or fall. Other seizures may be brief and end in seconds.
  • Injury can occur during or after a seizure, requiring help from other people.
• Pay Attention to the Length of the Seizure
  • Look at your watch and time the seizure – from beginning to the end of the active seizure.
  • Time how long it takes for the person to recover and return to their usual activity.
  • If the active seizure lasts longer than the person’s typical events, call for help.
  • Know when to give 'as needed' or rescue treatments, if prescribed, and when to call for emergency help.
• Stay Calm; Most Seizures Only Last a Few Minutes
  • A person’s response to seizures can affect how other people act. If the first person remains calm, it will help others stay calm too.
  • Talk calmly and reassuringly to the person during and after the seizure – it will help as they recover from the seizure.
• Prevent Injury by Moving Nearby Objects Out of the Way 
  • Remove sharp objects.
  • If you can’t move surrounding objects or a person is wandering or confused, help steer them clear of dangerous situations, for example away from traffic, train or subway platforms, heights, or sharp objects.
• Make the Person as Comfortable as Possible
  • Help them sit down in a safe place.
  • If they are at risk of falling, call for help and lay them down on the floor.
  • Support the person’s head to prevent it from hitting the floor.
• Keep Onlookers Away
  • Once the situation is under control, encourage people to step back and give the person some room. Waking up to a crowd can be embarrassing and confusing for a person after a seizure.
  • Ask someone to stay nearby in case further help is needed.
• Do Not Forcibly Hold the Person Down
  • Trying to stop movements or forcibly holding a person down doesn’t stop a seizure. Restraining a person can lead to injuries and make the person more confused, agitated or aggressive. People don’t fight on purpose during a seizure. Yet if they are restrained when they are confused, they may respond aggressively.
  • If a person tries to walk around, let them walk in a safe, enclosed area if possible.
• Do Not Put Anything in the Person's Mouth!
  • Jaw and face muscles may tighten during a seizure, causing the person to bite down. If this happens when something is in the mouth, the person may break and swallow the object or break their teeth!
  • Don’t worry - a person can’t swallow their tongue during a seizure.
• Make Sure Their Breathing is Okay
  • If the person is lying down, turn them on their side, with their mouth pointing to the ground. This prevents saliva from blocking their airway and helps the person breathe more easily.
  • During a convulsive or tonic-clonic seizure, it may look like the person has stopped breathing. This happens when the chest muscles tighten during the tonic phase of a seizure. As this part of a seizure ends, the muscles will relax and breathing will resume normally.
  • Rescue breathing or CPR is generally not needed during these seizure-induced changes in a person’s breathing.
• Do Not Give Water, Pills, or Food by Mouth Unless the Person is Fully Alert
  • If a person is not fully awake or aware of what is going on, they might not swallow correctly.  Food, liquid or pills could go into the lungs instead of the stomach if they try to drink or eat at this time.
  • If a person appears to be choking, turn them on their side and call for help. If they are not able to cough and clear their air passages on their own or are having breathing difficulties, call 911 immediately.
• Call for Emergency Medical Help When
  • A seizure lasts 5 minutes or longer.
  • One seizure occurs right after another without the person regaining consciousness or coming to between seizures.
  • Seizures occur closer together than usual for that person.
  • Breathing becomes difficult or the person appears to be choking.
  • The seizure occurs in water.
  • Injury may have occurred.
  • The person asks for medical help.
• Be Sensitive and Supportive, and Ask Others to Do the Same
  • Seizures can be frightening for the person having one, as well as for others. People may feel embarrassed or confused about what happened. Keep this in mind as the person wakes up.
  • Reassure the person that they are safe.
  • Once they are alert and able to communicate, tell them what happened in very simple terms.
  • Offer to stay with the person until they are ready to go back to normal activity or call someone to stay with them.

Seizures Without Any Change in Awareness

Some people may remain fully awake and alert during a seizure and remember everything that occurs. For example, awareness is not affected during simple partial or myoclonic seizures. During these types of seizures, pay particular attention to the following:

• Usually you don’t need to do anything.
• Stay calm and reassure the person they are safe.
• If the person is frightened or anxious, encourage them to take slow deep breaths or do something that is calming or relaxing.
• Stay with the person until the seizure is over. Make sure that they are fully aware of what is going on before they are left alone.

Seizures with Altered Awareness

Sometimes people may look awake during a seizure, but they really are not aware of part or all of what is going on around them. They may not remember what happens during the seizure or have difficulty talking about it during or after it. The person may walk around during the seizure, but not be in control of where they are going, and they may not be able to protect themselves. These seizure behaviors may be seen with complex partial seizures or clusters of absence seizures. During these episodes, in addition to basic first aid, pay particular attention to the following:

• If the person has a warning before they lose awareness, help them to a safe place.
• Stay with the person and don’t let them wander away. Let them walk in an enclosed area if possible.
• Keep the person away from sharp objects or dangerous places.
• If the person tries to run or is in a dangerous situation, call for help and hold them back if needed to keep them out of danger.
• Do not assume that they can talk or that they can hear you and follow instructions. Assure them they are safe and repeat instructions on what they should do next.
• Make sure that they are alert, oriented and safe after the event before they are left alone.
• Time the seizure – these types of seizures are usually longer than convulsions or tonic clonic seizures. It may be hard to tell when the seizure ended and when the recovery period begins and ends.
• If the seizure turns into a convulsive seizure, follow first aid steps for tonic-clonic seizures.

Seizures with Loss of Consciousness

Some types of seizures can affect a person’s awareness completely – they may be considered ‘unconscious’. They are not able to talk, are not aware of what is going on around them, and may not realize what occurred afterwards. If they have a warning at the start of the seizure, they may be able to get to a safe place – otherwise they are at risk for injury during and after the seizure. Follow the steps for care and comfort first aid with attention to the following:

• Watch how long the seizure lasts – call for emergency medical help if a generalized seizure lasts 5 minutes or longer.
• Protect the person from injury but don’t restrain their movements.
• Watch their breathing – turn them on the side to help keep the airway open. If breathing problems occur, call 911.
• Don’t put anything in their mouth.
• Know when to call for emergency help.
• Stay with the person after the seizure until they are aware and safe.

Posted on BrainLine August 10, 2018.

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