More than 50% of seizures have no known aetiology. Causes that are well elucidated are post-infection, inherited syndromes, congenital brain malformation and syndromes. These aetiologies are interwoven with syndromes occurring due to chromosomal, metabolic, mitochondrial and single gene mutations. Common genetic syndromes manifesting with seizure disorder include tuberous sclerosis, Sturge weber, Rett, Prader Willi etc. Some mutations such as SCN1A, SCN2A, SCN1B have been associated with febrile seizures. Complex types of febrile seizures have the risk of resulting in epilepsy. In low and middle income countries (LMICs) neonatal conditions such as severe perinatal asphyxia, bilirubin encephalopathy, severe acute malnutrition and acute febrile illnesses (severe malaria, meningitis etc) all predispose to cerebral palsy with seizure disorders.

History taking is very important and identifying whether seizure occurred or not is important. History also on nature of seizure and complications associated with it. All these information are best given by eye witness and not only the caregiver. Children above 5 years will assist with information regarding history of aura, preservation of consciousness and postictal state. Other important history include what precipitated seizure, its duration and interventions during and after seizure. Physical examination for neuro-cutaneous disorders and other disorders is equally important.

Seizure classification was first done in 1970 by the International classification of epileptic seizures (ILAE), it was updated in 1981 and 1989. The most recent update was in 2017 and this is presented below (Table I):

Epilepsy syndromes also occur, some examples are juvenile myoclonic epilepsy, benign neonatal familial convulsions, Ortahara syndrome, west syndrome, Dravet syndrome, Lennox-Gastaut syndrome, benign Rolandic epilepsies and status epilepticus.

Identifying some conditions such as breath-holding spells, narcolepsy, cataplexy, syncope, benign paroxysmal vertigo, panic attack, tics, spasmus nutans, benign paroxysmal torticollis, migraine with visual aura and jitteriness usually limit confusing these conditions with epilepsy.

Fig: This is ILAE 2017 classification of seizures.

Specific investigations aim to identify focal lesions and properly classify the seizure type. A high index of suspicion will allow quick identification of seizure aetiology and other investigations that are appropriate. Neuro-imaging is necessary when there are focal or lateralizing signs. The investigations applicable in this regard are:

Brain magnetic resonance image (MRI)

Brain computer tomography scan (CT-Scan)

They may show lesions in the brain that may benefit from surgical intervention. This may just relieve seizures.

Electroencephalogram helps in identifying type of seizure. It also helps in prognosticating, guides selection of medications and when to discontinue medications. Findings on EEG may include:

• Abnormal epileptiform discharge
• Diffuse background slowing
• Focal slowing
• Intermittent diffuse intermixed slowing.
• Hypsarrhythmia
• Polyspikes and wave discharge.

Treatment for seizure disorder requires multi-specialist care. With family Physicians, Paediatric Neurologist, Neurosurgeons, Psychologist, Mental Health Physicians and Physiotherapist all having a role to play. Early identification of seizure and its proper classification enhances appropriate treatment for epilepsy. Anticonvulsant is the mainstay of epilepsy treatment, the seizure type/ syndromes helps in deciding which antiepileptic is most appropriate. Monotherapy is preferred because it is less expensive, it limits adverse events and drug-drug interactions. Below is a table of common anti-epileptic medications (Table II).

Ketogenic diet: This aims at achieving ketosis and ketonuria which will result in control of seizure. It could be applied in children 3-15years but common side effects are abdominal pains, vomiting and diarrhea.

Surgical treatment: This is of use in intractable seizures. It becomes a prominent mode of management when seizure is refractory. Certain conditions are usually fulfilled before considering this option.

Table I: Common antiepileptic agents for children

No single approach will prevent epilepsy. However, general healthy living and implementing policies that strengthen health systems especially those relating to public health may contribute in reducing epilepsy burden. Some recognized interventions include:

• Preventing head injury by using head gears / helmets and seat belts
• Staying healthy during pregnancy
• Ensuring strict compliance to the vaccination regimen in children.
• Hand and food hygiene
• Strengthening primary health care services.