Epilepsy differential diagnosis

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Fahimeh Shojaei, M.D.

Overview[edit | edit source]

Epilepsy must be differentiated from: Psychogenic nonepileptic attacks (PNEAs), syncope, hypoglycemia, panic attacks, acute dystonic reactions, hemifacial spasm, nonepileptic myoclonus, parasomnias, cataplexy, hypnic jerks, transient ischemic attacks, migraines and transient global amnesia.

Differentiating epilepsy from other Diseases[edit | edit source]

Epilepsy must be differentiated from:

• Psychogenic nonepileptic attacks (PNEAs):
  • Psychogenic non epileptic attacks most commonly happens in young women and is the most common disease misdiagnosed with epilepsy.^[1][2][3]
  • There are some features which can help us differentiate PNEAs from epilepsy:
    • These patients are resistance to anti-epileptic drugs.^[4]
    • PNEAs rarely happens in sleep and mostly happens in the present of an audience.^[5]
    • In physical examination of PNEAs patients we can observe histrionic features.^[6]
    • Tongue biting, urine incontinence and postictal confusion are in favor of epilepsy.^[6]
    • In PNEAs we have normal EEGs.^[7]

• Syncope:
  • Syncope is another misdiagnosed disease with epilepsy. The reason for this misdiagnosis is that syncope attacks happens in a convulsive manner and patients may have body jerks and clonic movement.^[8]
  • Syncope also cause EEG changes and make it more difficult to differentiate it from epilepsy.^[9]
  • There are some presyncope symptoms such as sweating, dizziness, nausea and malaise which helps us differentiate it from epilepsy.^[10]
• Hypoglycemia
• Panic attacks: Panic attacks mostly resemble PNEAs rather than epilepsy.^[11][12] In mesiotemporal epilepsy the patient experience fear as an aura and it can be mistaken with panic attack specially if the typical seizure doesn’t happen after aura.^[13]
• Acute dystonic reactions: Drugs such as anti-dopaminergic, anti-emetics, carbamazepine, lithium and trazodone can cause twisting movements of craniopharyngeal and cervical muscles for seconds to hours. This condition response very well to anticholinergic treatment.^[14]

• Hemifacial spasm: Hemifacial spasm (HFS) can be mistaken with simple partial seizure or facial clonic seizure. There are some features which helps us to differentiate it from epilepsy:
  • HFS is a progressive and chronic condition and it’s not a paroxysmal phenomenon.
  • In partial epilepsy we have involvement of perioral muscle but HFS mostly involves periorbital muscles.^[15]
• Nonepileptic myoclonus
• Parasomnias: Non-REM parasomnias such as night terrors and sleepwalking can misdiagnosed with epilepsy specially because they are paroxysmal and can cause amnesia and unresponsiveness. These patients have normal EEG and their attacks mostly starts in a specific stage of sleep.^[16][17]
• Cataplexy: Cataplexy commonly misdiagnosed with atonic seizures (drop attacks) These attacks mostly trigger by emotion such as laughter.^[18][19]
• Hypnic jerks: Hypanic jerk is a very common condition which happens at the beginning of sleep resembles myoclonic seizures.^[20]
• Transient ischemic attacks: The key difference between TIA and seizure is TIA attacks have negative symptoms instead of positive symptoms we observe in seizures.^[21]
• Migraines
• Transient global amnesia: Patients with this condition experience periods of anterograde amnesia for few hours which resolves on its own.^[22]

A quick algorithm to differentiate epilepsy from other causes of altered mental status is demonstrated below:

Abbreviations: SCD: Sudden cardiac death;T-LOC: Transient-Loss of consciousness.

References[edit | edit source]

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