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  • Updated 05.08.2023
  • Released 04.03.2004
  • Expires For CME 05.08.2026

Seizures presenting in childhood



Epilepsy is one of the most common neurologic disorders of childhood. It can be subdivided into focal epilepsy with or without impaired awareness, in which seizures arise from a particular region of the cortex, and generalized epilepsy. Unique to seizures in children, some childhood epilepsy syndromes are known to cease before adulthood. However, there are still many children who do not “outgrow” their epilepsy. In fact, although two thirds of people with epilepsy will achieve seizure freedom with the first or second antiseizure medication, one third of people with epilepsy still develop medically intractable epilepsy (seizure freedom is not achieved despite adequate trials of at least two antiseizure medications), despite the development of over 30 antiseizure medications. There are also several other paroxysmal events that are commonly seen in childhood that may mimic seizures. Recognition of these common seizure mimics is also important to ensure appropriate evaluation, diagnosis, and treatment plans are put into place.

Key points

• Diagnosis of a seizure is a clinical one and requires a thorough history that includes a detailed description of the event and details surrounding the event.

• EEG is the most useful diagnostic test in cases in which the history is not diagnostic, particularly if the event is captured on EEG.

• In the absence of signs or symptoms of infection or trauma, MRI is the preferred imaging modality for those patients with new-onset afebrile seizures who require imaging.

• Classification of a patient’s epilepsy as being generalized or focal in onset, or whether the presentation fits a particular childhood epilepsy syndrome, is important for the selection of appropriate treatment and for counseling regarding prognosis.

Historical note and terminology

The childhood years represent a time of high seizure incidence. The wide variation in seizure type and epilepsy syndromes makes diagnosis challenging for the treating physician. With up to 4% of children experiencing at least one seizure during childhood, physicians caring for children are likely to encounter patients with seizures or epilepsy (32; 15; 110).

Seizures during childhood have been described since ancient times and were often attributed to mystical causes. Nonepileptic syndromes were frequently misidentified as seizures or epilepsy. Following the advent of the electroencephalogram (EEG) in the early 1900s by Dr. Hans Berger, researchers identified a variety of EEG findings that, in combination with neuroimaging, have been invaluable in confirming, classifying, localizing, and identifying the etiologies of childhood seizures and epileptic syndromes (55; 87).

The International League Against Epilepsy (ILAE) developed an updated seizure type classification in 2017 based on whether seizures were of focal, generalized, or unknown onset (30). Focal seizures were then further subdivided as aware versus impaired awareness, replacing the prior terminology of simple partial versus complex partial, respectively. All three categories (focal, generalized, unknown onset) were also subdivided based on motor versus nonmotor features. The term “secondary generalization” to indicate focal-onset seizures that spread to become generalized was replaced by the term “focal to bilateral tonic-clonic.” Thus, overall, this classification emphasized seizure type classification based on the first manifestation rather than the most prominent one.

In 2022, the ILAE Task Force on Nosology and Definitions produced a revised classification of childhood epilepsy syndromes. The term “benign” was no longer recommended given the known comorbidities that can exist with childhood epilepsy syndromes, even if the seizures themselves remit. Instead, the term “self-limited” is preferred (106). Additionally, the term “idiopathic” would only be used when referring to “idiopathic generalized epilepsy,” which consists of four specific syndromes: childhood absence epilepsy, juvenile absence epilepsy, juvenile myoclonic epilepsy, and epilepsy with generalized tonic-clonic seizures alone (50). Details on these various epilepsy syndromes are reviewed in this article.

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