Differential Diagnosis of Epilepsy

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The diagnostic possibilities of an episode of altered consciousness are vast. It is therefore essential that all relevant information be obtained before a diagnosis of epilepsy is made, including the identification of potential triggers and provoking factors. The clinical history must include a full past medical history, specifically previous significant head injury, meningitis or encephalitis, a birth history, any history of febrile convulsions, and any family history of epilepsy.

The diagnosis of epilepsy is clinical and relies on accurate personal and eye-witnessed accounts, concentrating on the circumstances of episode, the preceding aura, the interictal state, and postictal events. A diagnosis of epilepsy is a life-changing event with potential psychological consequences; the diagnosis should be given and relevant treatment begun only when the there is reasonable certainty. On first contact with the patient all the relevant information may not be at hand; the passage of time can be an important diagnostic tool in avoiding misdiagnosis. The conditions most commonly mistaken for epileptic seizures are syncope (vasovagal and cardiac), nonepileptic attacks, and sleep disorders. Table 2.1 outlines other conditions to be considered in the differential diagnosis of epilepsy.

Table 2.1 Differential diagnosis of epilepsy

Syncope

Vasovagal (see text)

Orthostatic (autonomic failure)

Cardiac (arrhythmia or structural)

Psychogenic

Panic attacks

Dissociative attacks

Vascular

Migraine (especially basilar artery migraine)

Transient ischemic attacks (especially brainstem)

Transient global amnesia

Sleep disorders

Parasomnias

Narcolepsy

Metabolic

Hypoglycemia and insulinoma

Hypocalcemia

Toxic

Drugs

Alcohol

Table 2.2 Seizures versus

syncope

Seizure

Syncope

Precipitating factor

Rare

Common

Situation

Anywhere

Bathroom

Dances

Pubs

Queues

Prodrome

Aura

Nausea, sweating

Visual blurring

Hearing fades

Onset

Sudden

Gradual

Duration

Minutes

Seconds

Consciousness

Lost

Briefly uncon-

scious

May recall falling

Jerks

Common

Briefly

Incontinence

Common

Rarely

Lateral tongue bite

Common

Rarely

Color

Pale, blue, cyanosis

Very pale, white

Recovery

Slow

Rapid

Confusion

Common

Rarely

Adapted from Smith.5

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