Epilepsy differential diagnosis

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Fahimeh Shojaei, M.D.


Epilepsy must be differentiated from: Psychogenic nonepileptic attacks (PNEAs), syncope, hypoglycemia, panic attacks, acute dystonic reactions, hemifacial spasm, nonepileptic myoclonus, parasomnias, cataplexy, hypnic jerks, transient ischemic attacks, migraines and transient global amnesia.

Differentiating epilepsy from other Diseases

Epilepsy must be differentiated from:

  • Psychogenic nonepileptic attacks (PNEAs):
    • Psychogenic non epileptic attacks most commonly happens in young women and is the most common disease misdiagnosed with epilepsy.[1][2][3]
    • There are some features which can help us differentiate PNEAs from epilepsy:
      • These patients are resistance to anti-epileptic drugs.[4]
      • PNEAs rarely happens in sleep and mostly happens in the present of an audience.[5]
      • In physical examination of PNEAs patients we can observe histrionic features.[6]
      • Tongue biting, urine incontinence and postictal confusion are in favor of epilepsy.[6]
      • In PNEAs we have normal EEGs.[7]

A quick algorithm to differentiate epilepsy from other causes of altered mental status is demonstrated below:

Clinical presentation
Loss of conscoiusness
• Transient?
• Rapid onset?
• Short duration?
• Spontaneous recovery?
Altered consciousnes
Aborted SCD
Epileptic seizure
Rare causes
• Reflex syncope
Orthostatic hypotension
Cardiac syncope
• Tonic
• Clonic
• Tonic-clonic
• Atonic
• Pseudo-epileptic
• Pseudo-syncopal

Abbreviations: SCD: Sudden cardiac death;T-LOC: Transient-Loss of consciousness.

The above algorithm adopted from ESC guideline [23]


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