Seizures and Epilepsy – Awareness, Overview and Role of the Primary Care or Family Physician – Dr. Praveen Gupta, Dr. Varsha Narayanan

ABSTRACT

Seizures and epilepsy are not uncommon, and can present very subtly or dramatically depending on the type. It is very important for the primary care or family physician to be aware and updated on the types of seizure and epilepsy, and their signs to enable them make a timely diagnosis and neurology referral for best patient management and outcomes. In addition, the physician can be instrumental in holistic epilepsy care by interacting regularly with the patient and family to counsel, prevent undue panic or alarm, ensure regularity of medicines, explain appropriate precautions, and help build good support for the wellbeing of the patient.

Keywords: Seizure, Epilepsy, Family Physician, Primary Care, Anti-Seizure Medicines (ASM)

INTRODUCTION

World Epilepsy Day (International Epilepsy Day), celebrated on February 9^th in 2026, raises awareness, reduces stigma and highlights the challenges faced by millions with epilepsy. Epilepsy is a neurological condition in which the brain activity becomes abnormal causing episodes of unusual sensations, muscle activity, and awareness called seizures.¹ 

The manifestation of a seizure ranges from staring blankly or rolling of eyes, twitching, stiffening up or jerky movements, confusion, and anxiety, to loss of awareness or consciousness. Convulsions refer to rapid and rhythmic shaking and involuntary muscle contractions.  Epilepsy often may not have a definite identifiable cause. Some of the known causes include head trauma, stroke, vascular abnormalities in the brain, infections (meningitis, encephalitis, HIV), brain tumors, and brain damage before/around birth. Genetic predisposition, family history, and some conditions like autism or dementia are associated with epilepsy.

Epilepsy is a common condition worldwide, with approximately 50 million people suffering from it, of which 10 million may be in India.² A single seizure does not mean epilepsy, and almost 10% of the population can have a seizure during their lifetime, as there are many other central nervous system disorders other than epilepsy in which seizures occur, either transiently or as a comorbid condition. At least one of the following criteria are needed to call it epilepsy:²

• 2 seizures without a known trigger (unprovoked) occurring at least 24 hours (or more) apart.
• 1 unprovoked seizure with >60% recurrence risk (based on brain scans, EEG, genetics).
• Diagnosis of an epilepsy syndrome (identified by a specific seizure type/types and EEG findings).

The impact of seizures and epilepsy is, widespread and easily underestimated, but about 70% of patients with epilepsy could be seizure-free if correctly diagnosed and treated, bringing in the importance of primary care and family physicians as the pivot for diagnosis and timely referral.⁴ The role of primary care physicians is to be able to identify a current/past seizure or symptoms suggesting epilepsy, and refer to a neurologist for timely assessment and treatment. At the same time, it is important to work in collaboration with the neurologist for holistic management of the patient and the family.

TYPES OF SEIZURES

Seizures are classified as focal (abnormal activity in just one area of the brain) or generalized (involving the whole brain), and in some cases – unknown or unclassified.⁵

Focal seizures

Also called partial seizures earlier, these are mainly of 2 types:

• Simple Partial or Focal seizures with preserved consciousness (FBC): These manifest as altered sensory perceptions (tingling, flashes, and abnormal smell/taste, sound or appearance), sometimes a sense of de ja vu, and twitching/jerking of one body part (like arm or leg). However, consciousness or awareness is preserved.
• Complex Partial or Focal seizures with impaired consciousness (FIC): There is an actual change in the state of awareness (staring, not responding, feeling dream-like) or loss of consciousness, with abnormal and repetitive movements (walking in circles, chewing, smacking, swallowing, hand rubbing movements, etc.)

FBTC (Focal to Bilateral Tonic-Clonic) seizure is a type of seizure that begins in a limited, specific area on one side of the brain (focal) and subsequently spreads to involve both sides of the brain (bilateral). This spread causes a loss of consciousness and the characteristic stiffening (tonic) and jerking (clonic) movements.

Generalized Seizures

These are of the following types:

• Absence seizures (earlier called petit mal): These are brief blank spells that manifest as staring into space, sometimes with mild movements like blinking or lip smacking, and may cause loss of awareness, all for a few seconds. These are more common in children and can occur on any single day several times. It is important for physicians to pick up these seizures, as parents may often describe these as blanking/zoning out, having poor attention, performance deficiency, etc. Neurologists may further classify these seizures as typical, atypical, or myoclonic.
• Tonic-clonic seizures (earlier called grand mal): These are pronounced and abrupt causing loss of consciousness, muscle stiffening, shivering/twitching, convulsions, and sometimes tongue bites or even urination. 
• Tonic seizures: These cause muscles (arms, back, legs) to stiffen, and can cause one to lose balance or fall down, and lose awareness in some cases.
• Atonic seizures: These manifest as loss of muscle tone and control, causing the person to suddenly collapse or drop to the ground.
• Clonic seizures: These are rhythmically repetitive, jerking muscle movements, generally of the face, neck and arms.
• Myoclonic seizures: These appear as sudden short muscle twitches or jerks of the trunk, arms and legs. Neurologists may further classify them as myoclonic atonic seizures or negative myoclonic seizures.
• Generalized epileptic spasms: These are brief, sudden muscle contractions affecting both sides, often occurring in clusters, especially upon waking, and involve quick flexing or extending of arms, legs, and trunk, sometimes subtler signs like head nodding. These are more common in infants but can occur in older patients as well.

Status epilepticus

It refers to continuous or recurrent seizures without gaining consciousness in between for more than 5 minutes. This significantly increases the risk of permanent brain damage and danger to life.

Febrile Seizures

High fevers in childhood can sometimes be associated with seizures. But this generally does not develop into epilepsy unless there is a definite family history or other predispositions. 

Seizures and Pregnancy

Seizures during pregnancy pose dangers to both mother and baby. Pregnant women with epilepsy are often on anti-epileptic medications that can increase the risk of birth defects, so regular monitoring is necessary. Eclampsia is a condition where there are seizures due to a severe complication of high blood pressure during pregnancy (preeclampsia). It puts the life of both mother and baby at very high risk and needs to be immediately controlled and treated.⁶

DIAGNOSIS

Symptoms of focal seizures may sometimes be confused with other neurological disorders, such as migraine, sleep disorders like narcolepsy, or psychological disorders. Often focal seizures may just be dismissed as day dreaming, being inattentive, poor focus in studies, or a behavioural issue. Therefore, an astute primary care physician can play an important role in clinical suspicion, referral and diagnosis.

A neurological referral and examination is the cornerstone for all seizure episodes that includes neuropsychological tests to assess thinking, memory and speech skills, and an EEG (electroencephalogram) to assess brain activity. EEG may be video-EEG, ambulatory EEG (recording over 24 hours while one continues with normal activities) and high-density EEG (closer spacing of electrodes).

Imaging of the brain with CT/MRI and/or PET scans may also be performed. Some newer combination diagnostic techniques include statistical parametric mapping (SPM) that compares areas of the brain that have increased blood flow during seizures to indicate seizure origin site, electrical source imaging (ESI) that projects EEG data onto a brain MRI to identify seizure sites, and magnetoencephalography (MEG) that measures the magnetic fields produced by brain activity to identify potential seizure origin sites.⁷

Blood investigations also are ordered for screening associated conditions.

MANAGEMENT

Antiepileptic Drugs

Antiseizure medications (ASM) are drugs that help to control seizures by blocking ionic channels in the brain (sodium or potassium channels), or modifying neurotransmitters by potentiating inhibitory neurotransmitter GABA (targets – GABA A receptors, GABA T, GAT1, calcium channels) or reducing the excitatory neurotransmitter glutamate (targets – AMPA and NMDA receptors and SV2A synaptic vesicle protein or vesicular glutamate transporter 2A).⁸ Some drugs can act by both of these, as well as additional mechanisms like lamotrigine, topiramate, valproate/divalproex, and zonisamide.

The older group of antiepileptic drugs includes barbiturates (phenobarbital), phenytoin, carbamazepine, ethosuximide, and valproate. The newer antiepileptics drugs are topiramate, lamotrigine, oxcarbazepine, zonisamide, tiagabine, vigabatrine, and levetiracetam. These drugs can be used to prevent all kinds of seizures, while the drug ethosuximide is used for absence seizures.

Gabapentinoid drugs like pregabalin and gabapentin are used mainly for partial seizures. Benzodiazepine drugs like diazepam, lorazepam and clonazepam are used to control active seizures and status epilepticus.

Antiepileptic drugs are very effective and have helped most people with epilepsy lead a fulfilled life. However, these medicines can have side effects like nausea, abdominal pain, indigestion, dizziness, fatigue, sleepiness, irritability, anxiety or mood changes, weight gain, and blurry vision. These medicines should be taken strictly under medical guidance and monitoring. They are also known to affect the fetus during pregnancy, so all information of one’s epilepsy condition and treatment should be shared with the treating obstetrician when pregnant.

Table 1: Antiseizure medications (ASM) based on target mechanism of action (MOA)

GABA (Gamma-aminobutyric acid), GAT1 (GABA Transporter 1 – reuptake of GABA from synapses), GABA-T (gamma-aminobutyric acid transaminase- breaks down GABA), AMPA (α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid) and NMDA (N-methyl-D-aspartate) glutamate receptors, SV2A synaptic vesicular glutamate transporter 2A.

*Valproate/Divalproex also has additional action of stimulating glutamic acid decarboxylase (GAD) to convert glutamate to GABA, and Histone Deacetylase (HDAC) Inhibition contributing to neuroprotective and mood-stabilizing effects. 

Procedures and Surgery

Epilepsy surgery is indicated in 30% to 40% of patients with refractory seizure disorders despite being on one year of therapy with an adequate dosage of two antiepileptic therapy (drug resistant epilepsy -DRE).⁹ It is considered in those patients who show well-defined small seizure origin sites which do not interfere with vital functions like vision, speech, hearing, or motor function. Procedures include minimally invasive like MRI-guided stereotactic laser ablation or ultrasound, and open surgery if the risk is not high. Anti-epileptic drugs, possibly at a lower dose may still be needed post-surgery. Rarely cognitive abilities may be impacted after surgery that may need appropriate rehabilitation.

Other non-invasive options include transcutaneous vagus nerve stimulation (tVNS), and trigeminal nerve stimulation (TNS), deep brain stimulation, repetitive transcranial magnetic stimulation (rTMS), transcranial direct current stimulation (tDCS), transcranial alternating current stimulation (tACS), low-intensity focused ultrasound (LI-FUS), continuous subthreshold stimulation of the seizure onset zone, and neurostimulation with implantable pacemaker-like devices.¹⁰

PRECAUTIONS

The available medicines to prevent and manage seizures, help most people with epilepsy have a very good quality of life. A few precautions are important that the primary care physician can emphasize and monitor for his patients:

• Instruct patients to be regular with their medicines. Also always carry at least one dose for managing an active seizure with them when outside the home. It also helps to carry an info card about one’s condition and medicine to be taken in the patient’s bag/wallet.
• Family and close friends should know how to recognize an impending seizure, and about the risk of falling and sometimes serious injuries during a seizure. The primary care physician plays a crucial role in this education and building awareness.
• Extreme care while driving is needed, especially if the seizure can cause a lack of awareness or consciousness. It is important to check one’s country’s or state’s policy on driving about seizure-free intervals and control for driving eligibility.
• If a seizure occurs when in water (swimming or tub bathing), the risk of drowning is greatly increased. Caution has to be strictly advised while indulging in sports.
• Overall meticulous care should be taken with all associated health problems. People with epilepsy especially those with generalized tonic-clonic type and not well controlled on medications have a small risk of sudden unexpected death in epilepsy (SUDEP), possibly due to cardio-respiratory problems.
• Positive emotional support and reinforcement are very helpful to reduce the occurrence of anxiety, depression and other psychological problems in people who get seizures.

CONCLUSION

It is very important for the primary care or family physician to be well versed with the types of seizure and epilepsy, and their presentation to develop clinical suspicion, and timely referral and diagnosis for improving outcomes. In addition, the physician can be a crucial team player in holistic epilepsy management by interacting regularly with the patient and family to ensure regularity of medicines, appropriate precautions, and building a good support system of awareness and care.

REFERENCES:

1. Stafstrom CE, Carmant L. Seizures and epilepsy: an overview for neuroscientists. Cold Spring Harb Perspect Med. 2015 Jun 1;5(6):a022426.
2. Santhosh NS, Sinha S, Satishchandra P. Epilepsy: Indian perspective. Ann Indian Acad Neurol. 2014 Mar;17(Suppl 1):S3-S11.
3. Manole AM, Sirbu CA, Mititelu MR, Vasiliu O, Lorusso L, Sirbu OM, Ionita Radu F. State of the Art and Challenges in Epilepsy-A Narrative Review. J Pers Med. 2023 Apr 1;13(4):623.
4. Çelik Ö, Apaydın Kaya Ç. Challenges and needs of epilepsy management in primary care (from the perspective of family physicians/general practitioners): A cross-sectional study. Epileptic Disord. 2023 Oct;25(5):739-748.
5. Beniczky S, Trinka E, Wirrell E, Abdulla F, Al Baradie R, Alonso Vanegas M, et al. Updated classification of epileptic seizures: Position paper of the International League Against Epilepsy. Epilepsia. 2025 Jun;66(6):1804-1823.
6. Meador KJ. Seizures in pregnancy and child outcomes. Journal of Neurology, Neurosurgery & Psychiatry 2025;96:619-620.
7. Shih JJ. Combining Electrical and Magnetic Fields for Source Analysis: A(n) Attractive or Repelling Thought. Epilepsy Currents. 2019;19(5):291-293.
8. Sánchez JD, Gómez-Carpintero J, González JF, Menéndez JC. Twenty-first century antiepileptic drugs. An overview of their targets and synthetic approaches. Eur J Med Chem. 2024 Jun 5;272:116476.
9. Munakomi S, Das JM. Epilepsy Surgery. [Updated 2023 Aug 14]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK562151/
10. Premaratne S, Zoghi M, Antonic-Baker A, Chen Z, Chen L, Hamer R, et al. Non-invasive neuromodulation for the treatment of drug-resistant epilepsy: Protocol for a systematic review and meta-analysis investigating efficacy, safety, and optimal stimulation parameters. Syst Rev2025; 14, 214.

¹Chairman of Marengo Asia International Institute of Neuro and Spine (MAINS), Gurugram

Corresponding author: ²Chief Editor, The Indian Practitioner, and Medical Director, Dr Varsha’s Health Solutions, Mumbai Email: info@drvarsha.com