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  • Updated 03.12.2021
  • Released 06.19.2006
  • Expires For CME 03.12.2024

Alcohol withdrawal seizures

Introduction

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, alcohol withdrawal 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 (30), as well as by the Romans, who even put a name to it, morbus convivialis, or “disorder related to partying” (27). Centuries later, Magnus Huss introduced the term “alcoholismus chronicus” in 1851 and showed that after prolonged intoxication, alcoholics may have seizures (21). He also established that patients with epilepsy who drink must be differentiated from alcohol abusing patients having epileptic seizures during withdrawal (22). In 1953 the first systematic article describing alcohol withdrawal syndrome appeared (59), and later an article exploring the nature of alcohol withdrawal seizures (60). 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 (39). Acute intoxication with alcohol is not a proven cause of seizures (26). 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 (39). For a comprehensive discussion of seizure types related to alcohol, see McMicken and Liss (33). This article deals only with seizures occurring during alcohol withdrawal in adults.

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