Tonic-clonic (grand mal) seizure

Overview

A tonic-clonic seizure, previously known as a grand mal seizure, causes a loss of consciousness and violent muscle contractions. It's the type of seizure most people picture when they think about seizures.

During a seizure, there's a burst of electrical activity in the brain that causes changes in behavior and movements. Seizures can be focal, meaning the burst of electrical activity happens in one area of the brain. Or seizures can be generalized, in which they result in electrical activity in all areas of the brain. Tonic-clonic seizures may begin as focal seizures in a small area of the brain and spread to become generalized seizures that involve the whole brain.

Focal and generalized seizures have different symptoms. People who have generalized seizures usually lose consciousness. But people who have focal seizures may or may not lose consciousness. In tonic-clonic seizures, the muscles become stiff, causing the person to fall. Then the muscles alternately flex and relax.

Usually, a tonic-clonic seizure is caused by epilepsy. But sometimes this type of seizure can be triggered by other health problems, such as a high fever or damage to the brain.

Some people who have a tonic-clonic seizure don’t have another one and don't need treatment. But someone who has recurrent seizures may need treatment with daily anti-seizure medicines to control and prevent future tonic-clonic seizures. Surgery and dietary changes also may be options to manage your seizures.

Causes

The brain's nerve cells typically communicate by sending electrical and chemical signals across the synapses that connect the cells. A synapse is the area between cells that allows them to send messages. Tonic-clonic seizures occur when there's a surge of electrical activity over the surface of the brain. Many nerve cells fire at once, much faster than usual. Exactly what causes these changes often is not known.

However, tonic-clonic seizures are sometimes caused by other health problems, such as:

• Injury or infection. Severe head injuries can cause tonic-clonic seizures. Other possible causes include infections, such as encephalitis or meningitis, or having these infections in the past. Stroke and dementias that cause degeneration in the brain, such as Alzheimer's disease, also can cause tonic-clonic seizures.
• Congenital or developmental factors. These can include blood vessels that don't form properly in the brain and brain tumors.
• Metabolic issues. Very low blood levels of glucose, sodium, calcium or magnesium can cause tonic-clonic seizures.
• Withdrawal syndromes. These can include using or withdrawing from drugs, including alcohol.

Complications

Having a seizure at certain times can be dangerous for you or others. You might be at risk of:

• Falling. If you fall during a seizure, you can injure your head or break a bone.
• Drowning. If you have a seizure while swimming or bathing, you're at risk of accidental drowning.
• Car accidents. A seizure that causes either loss of awareness or control can be dangerous if you're driving a car or operating other equipment.
• Pregnancy complications. Seizures during pregnancy pose dangers to both mother and baby. And certain anti-seizure medicines increase the risk of birth defects. If you have epilepsy and plan to become pregnant, talk with a healthcare professional. Your medicines may need to be adjusted. A healthcare professional likely will monitor your pregnancy.
• Emotional health issues. People with seizures are more likely to have depression and anxiety. Children with seizures may be more likely to develop attention deficit hyperactivity disorder, also called ADHD. Emotional health issues may be a result of dealing with the condition itself or as a result of medicine side effects.

Treatment

Not everyone who has one seizure has another one. Because a seizure can be an isolated incident, you may not start treatment until you've had more than one. Treatment usually involves the use of anti-seizure medicines.

Medications

Many medicines are used in the treatment of epilepsy and seizures. These are usually taken daily by mouth to help prevent seizures. Different medicines may be prescribed based on factors such as your specific seizure type and how often you have them, and your personal considerations such as your age and whether or not you're pregnant.

Finding the right medicine and dosage can be challenging. A healthcare professional likely will prescribe a single medicine at a relatively low dosage, then may increase the dosage gradually until your seizures are well controlled.

Many people with epilepsy are able to prevent seizures with just one medicine. But others need more than one. If you've tried two or more single-drug regimens without success, you may need to try a combination of medicines.

For the best seizure control possible, take medicines exactly as prescribed. Ask a healthcare professional before adding other medicines or stopping your medicine. This includes prescription medicines, medicines available without a prescription or herbal remedies.

Mild side effects of anti-seizure medicines can include:

• Fatigue.
• Dizziness.
• Weight gain.

More-troubling side effects need to be brought to the attention of a healthcare professional right away. They include:

• Mood changes.
• Skin rashes.
• Loss of coordination.
• Speech problems.
• Extreme fatigue.
• Swollen lymph nodes.
• Swelling of the face or eyes, or painful sores in the mouth or around the eyes.
• Trouble swallowing or breathing, including during exercise.
• Discoloration of the skin or eyes such as a yellowing.
• Bruising and bleeding that's not typical.
• Fever and muscle pain.

In rare cases, the medicine lamotrigine has been linked to an increased risk of aseptic meningitis. Aseptic meningitis is an inflammation of the protective membranes that cover the brain and spinal cord. The disease is similar to bacterial meningitis but isn't caused by bacteria.

The U.S. Food and Drug Administration has warned that two anti-seizure medicines can cause a serious reaction, although it happens rarely. Levetiracetam and clobazam can cause inflammation and symptoms that include a rash, fever, swollen lymph nodes, and swelling of the face or eyes. Without quick treatment, the reaction can lead to organ damage, including to the liver, kidneys, lungs, heart or pancreas. It also can lead to death.

These symptoms can begin 2 to 8 weeks after starting levetiracetam or clobazam, but symptoms also may occur earlier or later. Get emergency medical attention if you take these medicines and experience a reaction or any of these serious symptoms.

Talk to your healthcare professional before stopping these medicines. Suddenly stopping the medicines can cause seizures to return.

Surgery and other therapies

When anti-seizure medicines aren't effective, other treatments may be an option:

• Surgery. The goal of surgery is to stop seizures from happening. It may be an option if you have tried two different medicines and they don't prevent your seizures. Surgeons locate and remove the area of your brain where seizures begin. Surgery works best for people who have seizures that originate in the same place in their brains.
• Vagus nerve stimulation. A device placed underneath the skin of your chest stimulates the vagus nerve in your neck. This sends signals to your brain that stop seizures. With vagus nerve stimulation, you may still need to take medicine, but you may be able to lower the dose.
• Responsive neurostimulation. During responsive neurostimulation, a device implanted on the surface of your brain or within brain tissue can detect seizure activity. The device can deliver an electrical stimulation to the detected area to stop the seizure.
• Deep brain stimulation. For this therapy, a surgeon implants electrodes within certain areas of the brain. The electrodes produce electrical impulses that regulate brain activity. The electrodes attach to a pacemaker-like device placed under the skin of your chest. This device controls the amount of stimulation produced.
• Dietary therapy. A diet that's high in fat and protein and low in carbohydrates, known as a ketogenic diet, can improve seizure control. Variations on a ketogenic diet are less effective but may provide benefit. They include the low glycemic index diet and modified Atkins Diet.

Pregnancy and seizures

Women who've had previous seizures usually are able to have healthy pregnancies. Birth defects related to certain medicines can sometimes occur.

In particular, valproic acid has been associated with cognitive deficits and neural tube defects, such as spina bifida. The American Academy of Neurology recommends that women don’t use valproic acid during pregnancy because of risks to the baby.

You may want to talk about these risks with a healthcare professional. Planning before getting pregnant is particularly important for women who've had seizures. In addition to the risk of birth defects, pregnancy can alter medicine levels.

In some cases, it may be appropriate to change the dose of anti-seizure medicine before or during pregnancy. In rare cases, your healthcare professional may consider changing your medicines.

Contraception and anti-seizure medications

It's also important to know that some anti-seizure medicines can make oral contraceptives — a form of birth control — less effective. Also, some oral contraceptives can speed up the metabolism of anti-seizure medicines. Check with a healthcare professional to evaluate whether your medicine interacts with your oral contraceptive. Ask if other forms of contraception need to be considered.

Coping and support

It can be stressful to live with a seizure disorder. Stress can affect your mental health, so it's important to talk with a healthcare professional about your feelings, who can suggest ways you can find help.

At home

Your family can provide much-needed support. Tell them what you know about your seizure disorder. Let them know they can ask you questions, and be open to conversations about their worries. Help them understand your condition by sharing any educational materials or other resources.

At work

Meet with your supervisor and talk about your seizure disorder and how it affects you. Discuss what you need from your supervisor or co-workers if a seizure happens while at work. Consider talking with your co-workers about seizure disorders. This may help you widen your support system. It also may bring about acceptance and understanding.

You're not alone

Remember, you don't have to go it alone. Reach out to family and friends. Ask your healthcare professional about local support groups or join an online support community. Don't be afraid to ask for help. Having a strong support system is important to living with any medical condition.