FP Essentials™ #568 Seizure Disorders in Adults

This edition of FP Essentials is particularly salient for me as one of my long-time adult patients recently received a diagnosis of a seizure disorder. My patient was first evaluated in the clinic by one of my astute family medicine colleagues, who listened carefully to the story from both patient and spouse, recognized that the patient could be having recurring focal seizures with impaired awareness, and ordered the testing that confirmed the diagnosis. She then did a rapid e-consultation with neurology to obtain their advice on initial management and next steps.

Section One provides guidance for evaluating individuals who have experienced a first seizure. I appreciated the authors’ emphasis on the importance of accurate recognition of seizure type during the initial evaluation, as well as their helpful tip that a normal electroencephalogram does not exclude epilepsy. And we all need to remember that driving and other high-risk activities must be paused for safety after an unprovoked seizure, with regulations varying by state, but with a 6-month seizure-free interval required in many states.

Section Two covers the various types of epileptic seizures and several common conditions that can mimic epilepsy. Current terminology allows clinicians to classify seizures in a practical way, using where the seizure begins (focal, generalized, or unknown), level of consciousness, and whether manifestations are observable or nonobservable. The authors point out several ways to distinguish epileptic seizures from seizure mimics. They note that misdiagnosis can lead to unnecessary treatment, inappropriate restrictions, and delayed care for the true underlying condition.

Section Three focuses on epilepsy treatment, including strategies for choosing an appropriate antiseizure medication based on seizure type, dose titration, and monitoring. The various classes of antiseizure medications are reviewed, as are nonmedication approaches to treatment, including neuromodulation and epilepsy surgery. Complete freedom from seizures is the ideal outcome, and it was reassuring to read that 60% to 70% of adults with epilepsy will achieve this outcome with an appropriate antiseizure medication.

Section Four addresses the role of primary care in the longitudinal management of patients with epilepsy. Nonadherence to medication treatment increases the risk of seizure recurrence, whereas seizure freedom is the best way to prevent sudden unexpected death in epilepsy. Other important parts of a comprehensive treatment plan include counseling on pregnancy planning, lifestyle modifications, and workplace accommodations.

We hope you find this edition of FP Essentials to be practical and helpful. When you have finished studying it and are ready to submit your answers to the test questions, please use the comment section to tell us what was most useful and what we can do to improve. We always appreciate your recommendations for topics you would like us to cover in future editions.

Finally, we encourage you to give careful attention to the joint editorial being published simultaneously in several family medicine journals. You can access it here or from the FP Essentials home page. The authors have a timely and urgent message: Primary care is essential to improving health, reducing disparities, addressing chronic disease, and controlling costs, yet it continues to be under-resourced and strained. Please review the evidence and recommendations presented and consider how you might strengthen primary care through advocacy, investment, and renewed commitment.

Karl T. Rew, MD, Associate Medical Editor
Clinical Professor
Departments of Family Medicine and Urology
University of Michigan Medical School, Ann Arbor, Michigan

Kiran Mullur, MD, CAQSM, is an assistant professor in the Department of Family Medicine at Atrium Health Wake Forest Baptist in Winston-Salem, North Carolina. He is a graduate and undergraduate medical educator with roles in curriculum development, large-group teaching, and small-group clinical skills instruction. He directs educational content in diagnostic reasoning, evaluation of common primary care presentations, and clinical decision-making. Dr. Mullur has authored peer-reviewed publications, national presentations, and institutional curricula focused on improving learner competence in the assessment of acute conditions, patient communication, and evidence-based practice. His academic interests include advancing medical education and strengthening clinical reasoning skills across all training levels.

Kimberly Burbank, MD, is a primary care sports medicine physician and assistant professor in the Department of Orthopaedic Surgery at the University of California, Los Angeles. She completed her family medicine residency at Atrium Health Wake Forest Baptist, where she served as a resident educator and contributed to multiple teaching initiatives in clinical reasoning and ambulatory care. Dr. Burbank has previously authored articles in American Family Physician and has participated in developing educational resources for learners at multiple training levels. Her scholarly efforts center on creating and evaluating educational tools that improve trainees’ diagnostic skills for common and complex presentations in family medicine.

Gina Bertelli, DO, is a sports medicine fellow at Atrium Health Wake Forest Baptist, where she has been active in undergraduate and graduate medical education, including precepting medical students and contributing to departmental teaching conferences. She has participated in research and quality-improvement work focused on enhancing outpatient diagnostic processes and communication skills. Dr. Bertelli’s academic interests include evidence-based ambulatory care, resident teaching development, and advancing educational strategies for common primary care conditions.

No relevant financial relationships.