First Adult Seizure Differential Diagnoses

  • Author: Eissa Ibrahim AlEissa, MBBS, MD; Chief Editor: Selim R Benbadis, MD   more...
 
Updated: Jun 8, 2011
 
 

Diagnostic Considerations

The diagnosis of epilepsy refers to recurrent seizures and cannot be made on the basis of a single episode, even if anticonvulsant treatment is administered. This is especially important because of the serious medical, social, economic, and legal consequences surrounding the diagnosis of epilepsy.

The wrong diagnosis of epilepsy is common; 20-30% of cases seen at epilepsy centers are misdiagnosed.[27, 32] The annual cost of misdiagnosis of nonepileptic spells as epileptic seizures has been reported to be between $650 million and $4 billion.[33]

Disease states and conditions often misdiagnosed as epilepsy include the following:

  • Convulsive syncope: Decreased cardiac output causes reduced cerebral perfusion with loss of consciousness and convulsive motor activity. Scheepers et al reported that cardiovascular disease was the most common diagnosis among patients whose conditions were initially misdiagnosed as epilepsy.[1] Using a comprehensive battery of cardiovascular tests in a population of patients diagnosed with epilepsy, Zaidi et al reported alternative diagnoses in 41%.[34]
  • Transient ischemic attack
  • Transient global amnesia
  • Paroxysmal vertigo
  • Panic attacks
  • Migraine
  • Sleep disorders, parasomnias, non–rapid-eye movement (REM) parasomnias (eg, night terrors, sleepwalking, and confusional arousals), REM behavior disorder, cataplexy (part of the narcolepsy tetrad, consisting of an abrupt loss of tone), hypnic jerks (ie, benign myoclonic jerks)
  • Paroxysmal movement disorders, including acute dystonic reactions, hemifacial spasms, and nonepileptic myoclonus
  • Psychogenic nonepileptic attacks: These are the most common conditions at epilepsy monitoring units, comprising more than 90% of misdiagnosed adult cases and more than 50% of cases in children.[32]
  • Malingering

Other conditions that may be considered in the evaluation of a new-onset seizure in an adult include the following:

  • Chorea gravidarum
  • Essential tremor
  • Hemifacial spasm
  • Hyperammonemia
  • Juvenile myoclonic epilepsy
  • Restless legs syndrome

Differential Diagnoses

Proceed to Workup
 
 
Contributor Information and Disclosures
Author

Eissa Ibrahim AlEissa, MBBS, MD  Consultant Neurologist, Prince Salman Hospital, Saudi Arabia

Eissa Ibrahim AlEissa, MBBS, MD is a member of the following medical societies: American Academy of Neurology and American Epilepsy Society

Disclosure: Nothing to disclose.

Coauthor(s)

Selim R Benbadis, MD  Professor, Director of Comprehensive Epilepsy Program, Departments of Neurology and Neurosurgery, Tampa General Hospital, University of South Florida College of Medicine

Selim R Benbadis, MD is a member of the following medical societies: American Academy of Neurology, American Academy of Sleep Medicine, American Clinical Neurophysiology Society, American Epilepsy Society, and American Medical Association

Disclosure: UCB Pharma Honoraria Speaking, consulting; Lundbeck Honoraria Speaking, consulting; Cyberonics Honoraria Speaking, consulting; Glaxo Smith Kline Honoraria Speaking, consulting; Pfizer Honoraria Speaking, consulting; Sleepmed/DigiTrace Honoraria Speaking, consulting

Specialty Editor Board

Anthony M Murro, MD  Professor, Laboratory Director, Department of Neurology, Medical College of Georgia

Anthony M Murro, MD is a member of the following medical societies: American Academy of Neurology and American Epilepsy Society

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Jose E Cavazos, MD, PhD, FAAN  Associate Professor with Tenure, Departments of Neurology, Pharmacology, and Physiology, Program Director of the Clinical Neurophysiology Fellowship, University of Texas School of Medicine at San Antonio; Co-Director, South Texas Comprehensive Epilepsy Center, University Hospital System; Director of the San Antonio Veterans Affairs Epilepsy Center of Excellence and Neurodiagnostic Centers, Audie L Murphy Veterans Affairs Medical Center

Jose E Cavazos, MD, PhD, FAAN is a member of the following medical societies: American Academy of Neurology, American Clinical Neurophysiology Society, American Epilepsy Society, and American Neurological Association

Disclosure: GXC Global, Inc. Intellectual property rights Medical Director - company is to develop a seizure detecting device. No conflict with any of the eMedicine articles that I wrote or edited.

Chief Editor

Selim R Benbadis, MD  Professor, Director of Comprehensive Epilepsy Program, Departments of Neurology and Neurosurgery, Tampa General Hospital, University of South Florida College of Medicine

Selim R Benbadis, MD is a member of the following medical societies: American Academy of Neurology, American Academy of Sleep Medicine, American Clinical Neurophysiology Society, American Epilepsy Society, and American Medical Association

Disclosure: UCB Pharma Honoraria Speaking, consulting; Lundbeck Honoraria Speaking, consulting; Cyberonics Honoraria Speaking, consulting; Glaxo Smith Kline Honoraria Speaking, consulting; Pfizer Honoraria Speaking, consulting; Sleepmed/DigiTrace Honoraria Speaking, consulting

Acknowledgments

The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous author William J Nowack, MD, to the development and writing of the source article.

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An electroencephalogram (EEG) recording of a temporal lobe seizure. The ictal EEG pattern is shown in the rectangular areas.
An electroencephalogram (EEG) recording from a patient with primary generalized epilepsy. A burst of bilateral spike and wave discharge is shown in the rectangular area.
An electroencephalogram (EEG) recording of a seizure from a subdural array in a patient evaluated for epilepsy surgery. The subdural electrodes record from the left anterior temporal (LAT), left middle temporal (LMT), and left posterior temporal (LPT) regions. The EEG seizure pattern is seen best in bipolar EEG channels LAT 3-4 and LMT 3-4 (rectangular areas).
 
 
 
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