---
title: "Seizures"
url: https://mghmclean.org/residents/handbk/part2b/seiz.htm
description: "during seizure: behavior during seizure, tongue-biting, incontinence"
published: 2026-08-10
updated: 2026-08-10
---

# Seizures

Published 2026-08-10

PART 3 / CH 32

On this page

1. Acute management
2. Elements of history
3. Differential Diagnosis
4. “Pseudoseizures”
5. Temporal Lobe Epilepsy (complex or simple partial sz.)**:**
6. Seizure Risk from Antidepressants and Antipsychotics

Paul Hammerness

## Acute management

ABC’s, neuro exam, EKG, IV access/labs.

lorazepam 2mg IV q2min x5 (ativan 0.1 mg/kg)

or diazepam 5mg IV q3min x4.

## Elements of history

prior to seizure: aura

during seizure: behavior during seizure, tongue-biting, incontinence

postictal: length/nature of postictal period, including confusion or focal deficits (Todd’s paralysis)

past history/precipitants: prior seizures, febrile seizures as child, head trauma, recent illness, recent alcohol or drugs, sleep deprivation, relation to menses.

## Differential Diagnosis

Young children: breathholding, syncope, parasomnia, benign vertigo, tics/habits, rage.

Adolescent/Adult: myoclonus, migraine, syncope/CV, panic, narcolepsy/apnea, hypoglycemia, amnesia, acute confusional state, pseudoseizure

## “Pseudoseizures”

(often occur in patients with “true” seizures as well)

Characteristics: gradual onset, nonspecific warning period, bizarre/unusual behaviors, asynchronous limb thrashing, side-to-side head movements, speech during episode. Rarely associated with tongue biting, incontinence or injury. No postictal state. No abnormal neuro signs in sleep, rare night sz. EEG, CPK,PRL all normal.

## Temporal Lobe Epilepsy (complex or simple partial sz.)**:**

Interictal changes are controversial (hyperreligious, hypergraphic, hyposexual, viscous)

Source: Flaherty A (1998) MGH Handbook of Neurology.

## Seizure Risk from Antidepressants and Antipsychotics

Antidepressants

| High Risk | Intermediate Risk | Low Risk |
|---|---|---|
| Bupropion (HD) | (MD to LD) |  |
| Clomipramine (HD) | (MD to LD) |  |
| Maprotiline (HD) | (MD to LD) |  |
|  | FluvoxamineVenlafaxine |  |
|  | TCA (HD to MD) | (LD) |
|  |  | FluoxetineMAO-IMirtazipineParoxetineSertralineTrazodone |
| *HD=high dose* | *MD=moderate dose* | *LD=low dose* |

Antipsychotics

| High Risk | Intermediate Risk | Low Risk |
|---|---|---|
| Chlorpromazine (HD) | (MD to LD) |  |
| Clozapine (HD - MD) | (LD) |  |
|  | OlanzapineQuetiapineThioridazine |  |
|  |  | FluphenazineHaloperidolMolindonePimozideRisperidoneTrifluoperazine |
| *HD=high dose* | *MD=moderate dose* | *LD=low dose* |

source: Allredge BK (1999) Neurology 53 (suppl 2): S68-S75.