Type of seizureDifferential diagnosisGeneral historyExamination findingsSeizure-specific history
Nonepileptic
Psychogenic
  • Childhood trauma

  • High frequency of seizures

    History of self-harm

    Medically unexplained symptoms

    Physical or sexual abuse

    Posttraumatic stress disorder

    Psychiatric disease

    Resistance to antiepileptic drugs

  • Electroencephalography shows no abnormal brain activity during a typical event

    No abnormal physical examination findings

  • Consistent triggers unusual for epilepsy (e.g., stress, pain, particular sounds)

    Duration longer than two minutes

    Eyes closed during event

    Gradual seizure onset

    Pelvic thrusting

    Sobbing, moaning, or coughing during event

    Usually occurs in public

Syncope
  • Cardiogenic syncope (cardiac arrhythmias, congestive heart failure)

    Carotid sinus hypersensitivity

    Orthostatic hypotension

    Vasovagal syncope

  • Cardiomyopathy

    Coronary artery disease

    Episodes of chest pain

    Family history of sudden death

    Hypertension

    Lower extremity edema

    Peripheral vascular disease

  • Arrhythmias (electrocardiography, Holter monitoring)

    Carotid bruit or heart murmur

    Male sex

    Middle to older age

    Positive tilt table test

    Precipitated by carotid massage

  • Preceded by lightheadedness, diaphoresis, or palpitations

    Precipitated by exercise, urination, stress, blood draws, or prolonged sitting or standing

Epileptic
Provoked (acute symptomatic; caused by underlying disease or event)
  • Acute hemorrhagic stroke

    Acute ischemic stroke

    Acute venous thrombosis

    Central nervous system infection or tumor

    Drug intoxication or withdrawal

    Intracranial hematoma

    Medication use

    Metabolic derangements

    Newly diagnosed brain lesion (abscess, tumor, or vascular malformation)

    Recent head trauma

    Toxic exposures

  • Alcohol use

    Diabetes mellitus

    Drug use

    Focal transient motor or sensory symptoms

    Human immunodeficiency virus infection or hepatitis

    Hyperlipidemia

    Liver or kidney disease

    Personality disturbances

    Prior or active cancer

    Prior transient ischemic attack or stroke

    Progressive headaches

    Recent new medication

    Recent toxic exposures

    Recent trauma

    Severe dehydration

  • Age younger than one year or older than 65 years

    Male sex

    Physical examination may show confusion, fever, signs of infection, neck stiffness, pupil asymmetry, speech difficulties, unilateral sensory loss, unilateral weakness, nausea, vomiting

  • Duration less than two minutes

    Eyes open during event

    Focal seizure with or without secondary generalization

    Head turning

    Ictal cry (preseizure stereotypical shout)

    Occurs during sleep

    Synchronous bilateral movements

Unprovoked
  • Remote symptomatic (caused by previous static brain disease)

  • Perinatal injury

    Remote stroke

    Remote trauma

  • Cerebral palsy

    Family history of seizure

    Maternal preeclampsia

    Mental retardation

    No suggestive history

    Old head injury

    Perinatal stroke or ischemia

    Prior transient ischemic attack or stroke

  • Age younger than one year or older than 65 years

    Focal neurologic deficit (new or chronic)

    Male sex

    Physical examination may show minor injuries, scalp lacerations, subgaleal bruising, lateral tongue lacerations, evidence of incontinence

  • Duration less than two minutes

    Eyes open during event

    Focal seizure with or without secondary generalization

    Head turning

    Ictal cry (preseizure stereotypical shout)

    Occurs during sleep

    Synchronous bilateral movements

  • Progressive symptomatic (caused by progressive brain disease)

  • Degenerative disorder

    Movement disorder

    Tumor

  • Alzheimer disease

    Multiple sclerosis

    Parkinson disease

    Recurrent progressive brain tumor

  • Cognitive impairment (new or chronic)

    Global developmental delay