Generalized Tonic-Clonic Seizures (ages 2 months and above)
The generalized tonic-clonic seizure (GTCS) is a dramatic and frightening seizure for parents to watch. This type of seizure occurs with a number of conditions and is not always a sign of epilepsy. It is rarely life threatening.
GTCSs are uncommon in infants but are often seen in toddlers and children . GTCSs in epilepsy most often occur with other seizure types as part of a defined epilepsy syndrome. GTCSs are the predominant seizure type in only one syndrome, the syndrome of generalized tonic-clonic seizures upon awakening.
Generalized tonic-clonic seizures often begin with the child contracting his arm muscles, turning his head and eyes to the side and falling. His A chest muscles may tighten and force air from his lungs so he makes a sound before the fall. Additionally, his jaw might tighten, he might stop breathing , his limbs might jerk, and his lips might turn blue.He’ll lose consciousness and you might fear that he is dying.
GTCSs typically last two to three minutes and are sometimes followed by periods of confusion or sleep. The child may have sore muscles and a headache afterward but will have no memory of the seizure itself.
GTCSs in very young children often result from breath-holding spells, which are not an indication of epilepsy. These spells are preceded by stressful situations, such as tantrums . Age on onset is between 6 and 18 months, although breath-holding spells can occur in the first week of life and after age two. Medical treatment is not needed and the spells will eventually go away.
Generalized tonic-clonic seizures are almost always self-limiting. But a prolonged seizure (status epilepticus) is potentially life threatening and requires immediate medical attention. Experts recommend that emergency medical assistance be summoned when seizures last more than five minutes or if seizures follow one another in a series. Children who are known to have these prolonged episodes may be prescribed an oral or rectal medication for use in emergencies.
Injuries during GTCSs are common. The tongue, cheeks or lips may be bitten. Head and facial cuts and bruises, broken teeth, and rarely, broken bones, may result from falls and hitting objects. Many of these injuries can be prevented by providing a seizure-safe environment and assuring that all caregivers are familiar with the proper first aid for convulsive seizures.
Generalized tonic-clonic seizures on awakening syndrome
Epilepsy with generalized-tonic-clonic seizures on awakening is characterized by GTCSs that mainly occur shortly after waking up . Hallmarks of this syndrome are:
- Seizures that occur within one hour of awakening from sleep or nap
- No sign of structural brain damage
- A family history of epilepsy
- Presence of myoclonic or absence seizures as well
- Muscle jerks on both sides of the body at seizure onset
GTCS on awakening may be preceded in time by a series of staring seizures or muscle jerks while the child is awake. The GTCS itself is similar to GTCSs that occur in all forms of epilepsy. The syndrome of seizures on awakening is more common in boys than in girls.
A second peak in seizure activity in GTCS on awakening occurs in periods of relaxation, usually in the evening. The seizures occasionally may also happen during sleep and at other times of day. The episodes are frequently brought on by sleep deprivation. Flashing light also provokes seizures in many children with this syndrome.
The evaluation for generalized tonic-clonic seizures on awakening will include the child’s medical history and family history of epilepsy. Whether the seizure happened during sleep or after awakening may be unclear because the child might have no memory of awakening before the episode. The observation of family members will be important in resolving this question.
An EEG brain-wave analysis will be conducted, including a sleep EEG if the routine EEG tracing is negative for epilepsy. The evaluation will likely include the flicker test, an indicator of sensitivity to flashing light. Video-EEG monitoring may also be conducted if doubt remains about whether the seizure is a primarily generalized seizure or one that is a partial or focal seizure that has spread within the brain. Neuroimaging normally is not required unless the other tests are inconclusive.
GTCS on awakening syndrome is typically controlled with medication. Among medications most commonly used for this syndrome are valproate, lamotrigine, carbamazapine and phenytoin.
Treatment is most effective when known triggers, including sleep deprivation and flashing lights are avoided.
Surgery is not an option for this syndrome.
Seizures in GTCS on awakening syndrome respond well to medication therapy, but the reduction or withdrawal of medication results in a high rate of relapse. Lifelong treatment is recommended.
Most children who have this syndrome will have a normal life when compliance with therapy and appropriate lifestyle accommodations are observed. The se may include getting enough sleep, avoiding flashing lights and images like those produced by videogames, and whenever possible, limiting exposure to stressful situations.