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

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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

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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:

| Clinical presentation|

|
|
|
|
|
|
|
|
|
|
|
|
|
|

| Loss of conscoiusness|

| No|

| Yes

| • Transient?
• Rapid onset?
• Short duration?
• Spontaneous recovery?

Falls|

| Altered consciousnes|

| Yes|

| No

| Coma|

| Aborted SCD|

| Others

| T-LOC|

| Non-Traumatic|

| Traumatic|

Syncope|

| Epileptic seizure|

| Psychogenic|

| Rare causes|

• Reflex syncope
• Orthostatic hypotension
• Cardiac syncope|

| • Tonic
• Clonic
• Tonic-clonic
• Atonic|

| • Pseudo-epileptic
• Pseudo-syncopal|

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

The above algorithm adopted from ESC guideline [23]

## References

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1. ↑ Benbadis SR, O'Neill E, Tatum WO, Heriaud L (September 2004). "Outcome of prolonged video-EEG monitoring at a typical referral epilepsy center". Epilepsia. 45 (9): 1150–3. doi:10.1111/j.0013-9580.2004.14504.x. PMID 15329081.
2. ↑ Behrouz R, Heriaud L, Benbadis SR (May 2006). "Late-onset psychogenic nonepileptic seizures". Epilepsy Behav. 8 (3): 649–50. doi:10.1016/j.yebeh.2006.02.003. PMID 16531122.
3. ↑ Duncan R, Oto M, Martin E, Pelosi A (June 2006). "Late onset psychogenic nonepileptic attacks". Neurology. 66 (11): 1644–7. doi:10.1212/01.wnl.0000223320.94812.7a. PMID 16769934.
4. ↑ Benbadis SR (1999). "How many patients with pseudoseizures receive antiepileptic drugs prior to diagnosis?". Eur. Neurol. 41 (2): 114–5. doi:10.1159/000008015. PMID 10023117.
5. ↑ Benbadis SR, Lancman ME, King LM, Swanson SJ (July 1996). "Preictal pseudosleep: a new finding in psychogenic seizures". Neurology. 47 (1): 63–7. PMID 8710126.
6. ↑ 6.0 6.1 Benbadis SR, Wolgamuth BR, Goren H, Brener S, Fouad-Tarazi F (November 1995). "Value of tongue biting in the diagnosis of seizures". Arch. Intern. Med. 155 (21): 2346–9. PMID 7487261.
7. ↑ Davis BJ (2004). "Predicting nonepileptic seizures utilizing seizure frequency, EEG, and response to medication". Eur. Neurol. 51 (3): 153–6. doi:10.1159/000077287. PMID 15017116.
8. ↑ Aminoff MJ, Scheinman MM, Griffin JC, Herre JM (June 1988). "Electrocerebral accompaniments of syncope associated with malignant ventricular arrhythmias". Ann. Intern. Med. 108 (6): 791–6. PMID 3369769.
9. ↑ Sheldon RS, Koshman ML, Murphy WF (June 1998). "Electroencephalographic findings during presyncope and syncope induced by tilt table testing". Can J Cardiol. 14 (6): 811–6. PMID 9676166.
10. ↑ Sheldon R, Rose S, Ritchie D, Connolly SJ, Koshman ML, Lee MA, Frenneaux M, Fisher M, Murphy W (July 2002). "Historical criteria that distinguish syncope from seizures". J. Am. Coll. Cardiol. 40 (1): 142–8. PMID 12103268.
11. ↑ Merritt TC (May 2000). "Recognition and acute management of patients with panic attacks in the emergency department". Emerg. Med. Clin. North Am. 18 (2): 289–300, ix. PMID 10767885.
12. ↑ Vein AM, Djukova GM, Vorobieva OV (1994). "Is panic attack a mask of psychogenic seizures?--a comparative analysis of phenomenology of psychogenic seizures and panic attacks". Funct. Neurol. 9 (3): 153–9. PMID 7988943.
13. ↑ Biraben A, Taussig D, Thomas P, Even C, Vignal JP, Scarabin JM, Chauvel P (February 2001). "Fear as the main feature of epileptic seizures". J. Neurol. Neurosurg. Psychiatry. 70 (2): 186–91. PMC 1737203. PMID 11160466.
14. ↑ Dressler D, Benecke R (November 2005). "Diagnosis and management of acute movement disorders". J. Neurol. 252 (11): 1299–306. doi:10.1007/s00415-005-0006-x. PMID 16208529.
15. ↑ Colosimo C, Bologna M, Lamberti S, Avanzino L, Avanzino L, Marinelli L, Marinelli L, Fabbrini G, Abbruzzese G, Defazio G, Berardelli A (March 2006). "A comparative study of primary and secondary hemifacial spasm". Arch. Neurol. 63 (3): 441–4. doi:10.1001/archneur.63.3.441. PMID 16533973.
16. ↑ Derry CP, Davey M, Johns M, Kron K, Glencross D, Marini C, Scheffer IE, Berkovic SF (May 2006). "Distinguishing sleep disorders from seizures: diagnosing bumps in the night". Arch. Neurol. 63 (5): 705–9. doi:10.1001/archneur.63.5.705. PMID 16682539.
17. ↑ Iranzo A, Santamaría J, Rye DB, Valldeoriola F, Martí MJ, Muñoz E, Vilaseca I, Tolosa E (July 2005). "Characteristics of idiopathic REM sleep behavior disorder and that associated with MSA and PD". Neurology. 65 (2): 247–52. doi:10.1212/01.wnl.0000168864.97813.e0. PMID 16043794.
18. ↑ Guilleminault C, Gelb M (1995). "Clinical aspects and features of cataplexy". Adv Neurol. 67: 65–77. PMID 8848983.
19. ↑ Krahn LE, Boeve BF, Olson EJ, Herold DL, Silber MH (April 2000). "A standardized test for cataplexy". Sleep Med. 1 (2): 125–130. PMID 10767653.
20. ↑ Montagna P, Liguori R, Zucconi M, Sforza E, Lugaresi A, Cirignotta F, Lugaresi E (August 1988). "Physiological hypnic myoclonus". Electroencephalogr Clin Neurophysiol. 70 (2): 172–6. PMID 2456194.
21. ↑ Han SW, Kim SH, Kim JK, Park CH, Yun MJ, Heo JH (October 2004). "Hemodynamic changes in limb shaking TIA associated with anterior cerebral artery stenosis". Neurology. 63 (8): 1519–21. PMID 15505181.
22. ↑ Quinette P, Guillery-Girard B, Dayan J, de la Sayette V, Marquis S, Viader F, Desgranges B, Eustache F (July 2006). "What does transient global amnesia really mean? Review of the literature and thorough study of 142 cases". Brain. 129 (Pt 7): 1640–58. doi:10.1093/brain/awl105. PMID 16670178.
23. ↑ Moya, A.; Sutton, R.; Ammirati, F.; Blanc, J.-J.; Brignole, M.; Dahm, J. B.; Deharo, J.-C.; Gajek, J.; Gjesdal, K.; Krahn, A.; Massin, M.; Pepi, M.; Pezawas, T.; Granell, R. R.; Sarasin, F.; Ungar, A.; van Dijk, J. G.; Walma, E. P.; Wieling, W.; Abe, H.; Benditt, D. G.; Decker, W. W.; Grubb, B. P.; Kaufmann, H.; Morillo, C.; Olshansky, B.; Parry, S. W.; Sheldon, R.; Shen, W. K.; Vahanian, A.; Auricchio, A.; Bax, J.; Ceconi, C.; Dean, V.; Filippatos, G.; Funck-Brentano, C.; Hobbs, R.; Kearney, P.; McDonagh, T.; McGregor, K.; Popescu, B. A.; Reiner, Z.; Sechtem, U.; Sirnes, P. A.; Tendera, M.; Vardas, P.; Widimsky, P.; Auricchio, A.; Acarturk, E.; Andreotti, F.; Asteggiano, R.; Bauersfeld, U.; Bellou, A.; Benetos, A.; Brandt, J.; Chung, M. K.; Cortelli, P.; Da Costa, A.; Extramiana, F.; Ferro, J.; Gorenek, B.; Hedman, A.; Hirsch, R.; Kaliska, G.; Kenny, R. A.; Kjeldsen, K. P.; Lampert, R.; Molgard, H.; Paju, R.; Puodziukynas, A.; Raviele, A.; Roman, P.; Scherer, M.; Schondorf, R.; Sicari, R.; Vanbrabant, P.; Wolpert, C.; Zamorano, J. L. (2009). "Guidelines for the diagnosis and management of syncope (version 2009): The Task Force for the Diagnosis and Management of Syncope of the European Society of Cardiology (ESC)". European Heart Journal. 30 (21): 2631–2671. doi:10.1093/eurheartj/ehp298. ISSN 0195-668X.

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