Alcohol withdrawal seizures

Manuela Ochoa-Urrea MD (

Dr. Ochoa-Urrea of the University of Texas Health Science Center at Houston has no relevant financial relationships to disclose.

)
Samden D Lhatoo MD FRCP (

Dr. Lhatoo of the University of Texas Health Science Center at Houston has no relevant financial relationships to disclose.

)
C P Panayiotopoulos MD PhD, editor. (Dr. Panayiotopoulos of St. Thomas' Hospital has no relevant financial relationships to disclose.)
Originally released June 19, 2006; last updated April 8, 2020; expires April 8, 2023

This article includes discussion of alcohol withdrawal seizures and rum fits. The foregoing terms may include synonyms, similar disorders, variations in usage, and abbreviations.

Overview

Alcohol withdrawal seizures are frequently encountered in the emergency room as a severe manifestation of alcohol withdrawal syndrome. Such seizures comprise acute and serious complications to chronic alcohol abuse that need immediate attention. However, it is often neglected as a possible cause of seizures, and the consequences of misdiagnosis include significant morbidity and mortality as well as missing other potentially catastrophic neurologic complications of chronic alcohol dependence such as Wernicke encephalopathy and Korsakoff psychosis. Thus, in addition to benzodiazepines as the first choice in the pharmacological management of such seizures, all such patients should be given thiamine during hospitalization, regardless of nutritional state. In this article, the authors explain the clinical presentation, pathophysiology, diagnostic work-up, and management of alcohol withdrawal seizures and provide clues to the differentiation of withdrawal seizures from seizures due to epilepsy.

Key points

 

• Alcohol withdrawal is a major seizure-precipitating factor. All adult patients arriving to the emergency room with a seizure should be questioned about alcohol intake history.

 

• Drinking history is essential; biomarkers such as GGT and CDT may be useful ancillary aids to diagnosis.

 

• A history of epilepsy prior to alcohol abuse is suggestive of seizures triggered by alcohol abuse instead of alcohol withdrawal seizures and management may vary accordingly.

 

• Existing alcohol-related liver damage is an important consideration in choice of antiepileptic drug treatment.

 

• Benzodiazepines are safe and effective in alleviating both seizures and general withdrawal symptoms as well as preventing further seizures. High initial doses may be necessary, but treatment should be discontinued within a week. Barbiturates have been shown to be effective in acute severe withdrawal syndrome.

 

• Parenteral thiamine should be given before any carbohydrate-containing fluids or food.

 

• The recommended initial preventive thiamine dose is 200 mg; if Wernicke encephalopathy is suspected, give 200 mg 3 times daily for at least 2 days.

 

• Investigation of first seizures must include neuroimaging.

Historical note and terminology

The relationship between alcohol and seizures was first mentioned by Hippocrates (Lloyd 1978), as well as by the Romans, who even put a name to it, morbus convivialis, or “disorder related to partying” (Lennox 1941). Centuries later, Magnus Huss introduced the term “alcoholismus chronicus” in 1851 and showed that after prolonged intoxication, alcoholics may have seizures (Huss 1851). He also established that patients with epilepsy who drink must be differentiated from alcohol abusing patients having epileptic seizures during withdrawal (Jellinek 1943). In 1953 the first systematic article describing alcohol withdrawal syndrome appeared (Victor and Adams 1953), and later an article exploring the nature of alcohol withdrawal seizures (Victor and Brausch 1967). These have remained landmark articles, forming a basis for our current knowledge.

“Alcohol-related seizures” describes all types of interrelationships between seizures and chronic alcohol abuse in adults (Rathlev et al 2006). Acute intoxication with alcohol is not a proven cause of seizures (Leach et al 2012). On the other hand, situations that are consequent to alcohol abuse and acute withdrawal are where seizures are most often encountered. Alcohol withdrawal seizures are caused by abrupt cessation of heavy alcohol consumption (Rathlev et al 2006). For a comprehensive discussion of seizure types related to alcohol, see McMicken and Liss (McMicken and Liss 2011). This article deals only with seizures occurring during alcohol withdrawal in adults.

The content you are trying to view is available only to logged in, current MedLink Neurology subscribers.

If you are a subscriber, please log in.

If you are a former subscriber or have registered before, please log in first and then click select a Service Plan or contact Subscriber Services. Site license users, click the Site License Acces link on the Homepage at an authorized computer.

If you have never registered before, click Learn More about MedLink Neurology  or view available Service Plans.

Find out how you can join MedLink Neurology