Epilepsy – The Path to Diagnosis

Epilepsy can be difficult to diagnose, in part because doctors rarely witness seizures firsthand. Epilepsy can also be challenging to distinguish from other conditions, including meningitis, schizophrenia, migraines, sleep disorders, heart problems, multiple sclerosis (MS), attention deficit hyperactivity disorder (ADHD), and transient ischemic attacks – temporary low blood flow to part of the brain, sometimes called a “mini-stroke.” It is possible to have one or more of these conditions in addition to epilepsy, further complicating diagnosis.

It is also important to note that not all seizures are caused by epilepsy. Epilepsy is defined as a neurological disorder that involves recurrent seizures caused by abnormal electrical activity in the brain. Nonepileptic seizures do not originate from abnormal electrical activity and may require different treatment than epileptic seizures.

Typically, a neurologist diagnoses epilepsy, but it may also be diagnosed by a pediatrician, emergency room physician, or general practitioner.

How is epilepsy diagnosed?

There is no single test to diagnose epilepsy. Instead, the doctor will consider your medical history and may perform a variety of diagnostic tests.

Medical history

The doctor will take a thorough history, asking detailed questions about what happens during seizures, how long they last, and how often they occur. The physician may ask about a history of head injuries, infections, or other neurological symptoms. The doctor will likely ask about family history of seizures. A clear picture may emerge from the medical history to help the doctor assess risk factors that strengthen the suspicion of epilepsy or rule out other conditions.

Electroencephalography (EEG)

EEG is a test that visualizes brainwaves to monitor seizure activity. For an EEG, the technologist will place electrodes on your scalp. The electrodes pick up the tiny electrical charges resulting from brain activity. Most EEGs take one to one-and-a-half hours to set up and complete the test. Receiving an EEG is painless and cannot harm you.

About half of EEGs performed on people who have seizures produce normal results. Even if you have frequent seizures, your EEG may be normal if you are not having a seizure during the test. You may be asked to rapidly blink your eyes, stare at blinking lights, or breathe deeply for several minutes to provoke seizure activity.

Ambulatory EEGs record brainwaves for a longer period of time, usually 24 hours or three days, to increase the chances of recording seizure activity. Ambulatory EEGs may be performed at home, at an outpatient clinic, or as an inpatient at a hospital.

During a video EEG, video and audio of your movement, behavior, and sounds are recorded along with brainwave patterns. Video EEGs allow the neurologist to see what is happening in your brain during specific seizure behavior. Video EEGs can be done on an inpatient or outpatient basis.

When EEGs do capture seizure activity, they are very valuable tools. Some brainwave patterns are distinctive indicators of certain types of epilepsy, types of seizures, or other neurological disorders. Sometimes, EEG results can even indicate where in the brain the seizures originate.

If your EEG results are normal, it is not conclusive whether or not you have epilepsy. Further tests will be performed.

Brain imaging

Imaging tests are performed to evaluate brain function and structure. The most common neuroimaging procedures are magnetic resonance imaging (MRI) and computed tomography (CT or sometimes CAT) scans. Neuroimaging scans can detect potential causes of seizures including tumors, scar tissue, abnormal blood vessel formations, or hydrocephalus (an excess of spinal fluid).

Other tests

Blood or saliva tests may be ordered to check for genetic causes of epilepsy.

Some people with epilepsy may have speech or auditory processing problems, so tests may be performed to measure processing ability. Assessment tests may be performed by audiologists (hearing specialists) or speech and language pathologists.

The doctor may order a test to quantify cognitive (related to thinking, memory, and reasoning) abilities in relation to normal or abnormal brain structures. Cognitive assessments may be performed by doctors, psychologists, educators, or other specialists.

What is the prognosis for epilepsy?

Roughly 60 percent of people diagnosed with epilepsy who receive appropriate treatment will become seizure-free within a few years. Some people never have another seizure, while others have sporadic seizures or uncontrolled seizures despite being on anti-epileptic drugs (AEDs).

What is remission?

Some doctors define remission from epilepsy as 10 years without having a seizure, and being off of AEDs for the past five years. Other doctors consider someone in remission after two years without seizures (the last year off AEDS), or five years without seizures (the last two off AEDs). The chances for remission are higher if the cause of epilepsy is unknown, seizures are few and far between, seizures are responsive to AEDs, and there are no underlying neurological problems.

Age at diagnosis

The age at which a person receives an epilepsy diagnosis varies widely and is often correlated to the cause of epilepsy. Some forms of epilepsy, especially those that are caused by birth trauma or a genetic mutation, are diagnosed in infancy or early childhood. Other types of epilepsy don’t develop until adolescence or adulthood.

Resources

External resources

• Diagnosing Seizures and Epilepsy – Johns Hopkins Medicine
• What is Epilepsy – Epilepsy Action (UK)
• Diagnosing Epilepsy – Epilepsy Foundation
• What Tests are Needed? – Epilepsy Foundation
• Conditions Commonly Misdiagnosed as Epilepsy – Epilepsy Foundation
• Will I Always Have Seizures? – Epilepsy Foundation
• Remission in epilepsy: How long is enough? – Epilepsia

MyEpilepsyTeam resources

• Finding a New Normal: Living With Epilepsy (Infographic)
• Age at diagnosis (Q+A)
• Clear diagnosis (Q+A)
• How do you deal with the anniversary of your diagnosis? (Q+A)
• Incorrect diagnosis (Q+A)

FAQ

Is it possible to have seizures without having epilepsy?

Yes, it is possible to have seizures that are not caused by epilepsy. Nonepileptic seizures can look and feel like epileptic seizures, but they do not involve abnormal electrical activity in the brain. Nonepileptic seizures can have several different causes. Febrile seizures, caused by high fever, are very common in children. Another type of nonepileptic seizure is the psychogenic seizure. Psychogenic seizures are caused by psychological stress, sometimes related to an anxiety disorder. Nonepileptic seizures can also be caused by heart problems and metabolic conditions such as diabetes. Women are at a higher risk for nonepileptic seizures. It is possible for someone who has epilepsy to experience one or more nonepileptic seizures.