Epilepsy is a chronic neurological disease with recurring, unprovoked seizures. These arise through sudden, excessive electrical discharges in networks of nerve cells in the brain. Epilepsy is not a single uniform disease, but rather an umbrella term for various syndromes with an increased tendency to seizures.
According to the definition of the International League Against Epilepsy (ILAE), epilepsy is generally present when at least two unprovoked seizures have occurred more than 24 hours apart, when a single unprovoked seizure with a clearly increased risk of recurrence is present, or when the diagnosis of an epilepsy syndrome has been made.
In Germany, an estimated 500,000 people live with epilepsy. The disease can in principle begin at any age, but occurs especially often in childhood and from about 60 years. In older people, a stroke is a common cause.¹˒²
Epilepsy is neither contagious nor a sign of personal weakness
With modern therapy, a large proportion of those affected become seizure-free — many lead a largely normal life.¹
2. Understanding seizure types
The ILAE classification distinguishes seizures above all by their site of origin in the brain.⁴
Focal seizures (begin in one brain region)
Focal 1Without impaired awareness (with aura)
The affected person is generally conscious, but experiences uncontrolled symptoms — e.g. twitching of a hand or an arm, tingling, flashes of light, rising sensations in the stomach, déjà-vu, sudden fear or unusual smells. This "aura" is often already the first sign of a beginning seizure.
Focal 2With impaired awareness (automatisms)
Awareness is limited or abolished. Typical are automatisms — e.g. lip-smacking, chewing, fumbling or aimless wandering. Afterwards there is usually a phase of confusion (postictal phase).
Focal 3Focal to bilateral tonic-clonic
A seizure that initially begins focally and then spreads to both brain hemispheres. From the perspective of bystanders, it often looks like a "classic" major seizure.
Generalized seizures (both halves of the brain from the start)
Grand malTonic-clonic seizure
Loss of consciousness, first a stiffening of the musculature (tonic), then rhythmic twitching (clonic). Often a pronounced exhaustion follows. A tongue bite and loss of urine are possible.
AbsenceA brief pause in awareness
Brief pauses in awareness without a fall and generally without pronounced twitching. The affected person "freezes", has a fixed gaze and mostly does not respond. Often occur in children and are sometimes misinterpreted as daydreaming.
MyoclonicLightning-like muscle twitches
Brief, lightning-like muscle twitches, often in the morning shortly after waking (e.g. with juvenile myoclonic epilepsy).
AtonicDrop attacks — a sudden loss of strength
A sudden loss of muscle tension with a risk of falling — often associated with a risk of injury.
3. Causes
The current S2k guideline roughly distinguishes several etiological categories:¹
Structural: e.g. after a traumatic brain injury, stroke (common in older people), brain tumors, cortical malformations or hippocampal sclerosis
Genetic: inherited gene defects or new mutations — e.g. juvenile myoclonic epilepsy, absence epilepsy, Dravet syndrome
Infectious: e.g. in the context of meningitis or encephalitis
Metabolic: e.g. electrolyte disturbances, low blood sugar or metabolic derailments
Autoimmune: e.g. anti-NMDA receptor encephalitis — this group of causes is recognized more often today and can in part be treated well
Unknown: In a not insignificant proportion, no cause can be reliably identified despite extensive diagnostics
A single seizure is not yet epilepsy
So-called occasional seizures can be triggered by sleep deprivation, alcohol withdrawal, fever (in children as a febrile seizure), certain medications or drugs. The distinction is made by a doctor.
4. Symptoms: before, during and after a seizure
Before the seizure: aura and prodromes
Some of those affected report nonspecific changes hours or days before a seizure, such as mood swings, irritability, concentration problems or sleep disturbances (so-called prodromes). Immediately before focal seizures, an "aura" can occur — this is often already the beginning of the seizure itself: a rising sensation in the stomach, déjà-vu, unusual smells, sudden fear or flashes of light.
During the seizure
Loss or impairment of consciousness
Muscle cramps, rhythmic twitching, a possible fall
A lateral tongue bite (rather typical of an epileptic seizure; a bite at the tip of the tongue speaks more often for a syncope)
An uncontrolled loss of urine is possible
A temporary bluish discoloration due to a brief pause in breathing
After the seizure (postictal)
Confusion and disorientation — often over minutes to hours
Deep exhaustion, drowsiness
Headache, muscle soreness (after a tonic-clonic seizure)
A memory gap for the time of the seizure
More rarely: temporary neurological deficits (e.g. Todd's paresis)
5. Diagnosis
History (often the most important element): As precise a description as possible by those affected AND eyewitnesses. A smartphone video of a seizure is often very helpful for the neurology — relatives should, if possible, film seizures.
EEG (electroencephalography): Measures brain waves via electrodes on the scalp and can show epilepsy-typical patterns. In addition to the routine EEG, there are long-term EEG, sleep-deprivation EEG or video-EEG monitoring in specialized centers. Important: an unremarkable EEG does not necessarily rule out epilepsy.¹
MRI of the head: Generally high-resolution following an epilepsy protocol. Can make structural causes such as tumors, scars, malformations or a hippocampal sclerosis visible.
Laboratory: Blood sugar, electrolytes, liver and kidney values, inflammation values. In certain situations additionally a lumbar puncture (with suspected encephalitis) or toxicological investigations.
Common differential diagnoses
Syncope (circulatory collapse), psychogenic non-epileptic seizures, migraine with aura, TIA, panic attacks or parasomnias. The differentiation between syncope and an epileptic seizure is, according to the S2k guideline, often the most important differential diagnosis.¹
A note on terminology: the current S2k guideline uses the term "anti-seizure medications" (ASMs) instead of "antiepileptics", because the medications generally suppress the seizures but do not cure the epilepsy.¹
Monotherapy for focal epilepsy — often the first choice
Lamotrigine
Guideline: A first-choice agent for newly occurring focal epilepsy (S2k guideline)¹ Properties: Generally well tolerated and mood-stabilizing Important: The dose must be increased gradually — with too rapid an increase there is an elevated risk of skin reactions up to Stevens-Johnson syndrome
Levetiracetam
Broadly usable, can be dosed up quickly, few relevant interactions. Possible side effects: tiredness, irritability or mood changes — especially in children. Also works for generalized epilepsies.
Lacosamide
Generally well tolerated, few interactions — increasingly also used in the first line. Possible side effects: dizziness and double vision. With pre-existing heart conditions, medical checks are sensible.
Oxcarbazepine
A further development of carbamazepine with generally fewer interactions. Possible side effect: a lowering of sodium (hyponatremia) — laboratory values are usually checked regularly.
Carbamazepine
A classic anti-seizure medication, today somewhat less often the first choice. Compared with newer active ingredients, it has more interactions. More: Drug interactions.
For generalized epilepsies
Valproate
Considered particularly effective for certain generalized epilepsies.¹ ⚠ Important — strict pregnancy prevention program: Due to a high risk of malformations and developmental disorders with exposure during pregnancy, valproate is subject to very strict regulatory requirements across the EU. In women and girls of childbearing age, its use is strongly restricted and takes place only under the conditions of an official pregnancy prevention program. Other possible side effects: weight gain, tremor, hair loss, changes in liver values.
Add-on therapy for difficult-to-treat epilepsy
Cenobamate — NEW for difficult-to-treat focal epilepsy
A newer anti-seizure medication for adults with difficult-to-treat focal epilepsy. In studies, seizure freedom could be achieved in a relevant proportion of those treated — considerably more than under placebo.⁵ Important: The dose must be increased especially slowly (among other things because of a rare but severe reaction pattern, DRESS). It is generally used in specialized centers.
Further anti-seizure medications
Brivaracetam, perampanel, zonisamide, topiramate, eslicarbazepine acetate, clobazam and others.
Never stop anti-seizure medications on your own
The risk of seizures can rise considerably as a result, up to a life-threatening status epilepticus. A change of preparation (e.g. to a different generic) should also mostly take place only under medical supervision. The S2k guideline recommends reminder apps and pill organizers to improve adherence. More: Stopping medications, Generics vs. brand-name.
7. Further therapies: surgery, VNS, diet
Epilepsy surgery: An option for focal epilepsy with an identifiable seizure focus, when two or more medications do not work sufficiently. Pre-surgical diagnostics in specialized epilepsy centers. The S2k guideline recommends referring patients with difficult-to-treat focal epilepsy to an epilepsy center early.¹
Vagus nerve stimulation (VNS): An implanted stimulation device on the left vagus nerve that delivers electrical impulses at regular intervals. Can reduce the seizure frequency in some patients.
Deep brain stimulation: A newer option for difficult-to-treat epilepsy, when surgery is not an option.
Ketogenic diet: A very fat-rich, strongly low-carbohydrate form of nutrition. Particularly effective in children with difficult-to-treat epilepsies. Always medically supervised. In adults often a modified Atkins diet.
8. First aid during an epileptic seizure
The most important message: stay calm
Most seizures generally end on their own after a few minutes. Look at the clock and measure the duration — that is the most important basis for the decision about an emergency call.
What you can do
Look at the clock and measure the seizure duration
Remove dangerous objects from the immediate surroundings
Protect the head, e.g. by placing something soft underneath
After the seizure: the recovery position, to avoid aspiration
Stay calm, speak to the person in a reassuring way and do not leave them alone
If possible: film the seizure with a smartphone — very helpful for the neurology
What you should NOT do
Do not put anything between the teeth — no bite block, no fingers, no spoon
Do not hold the person down or restrain them — this can cause injuries
Do not give anything to drink or eat as long as the person is not fully conscious again
Call 112 (in the US: 911) when:
The seizure lasts longer than about 5 minutes (a sign of status epilepticus — an emergency) · The person does not regain consciousness after the seizure · Injuries occurred during the seizure · It is a first-ever seizure · Seizures occur in a series · The seizure happened in water · A known heart condition or another risk situation is present.¹˒⁶
Emergency medications
Many people with epilepsy have a doctor-prescribed emergency medication (e.g. a benzodiazepine as a nasal or buccal spray). Relatives should be trained in its use — the use and dosage are always determined individually by the treating neurology.
9. SUDEP — knowing the risk
SUDEP stands for "Sudden Unexpected Death in Epilepsy" — a sudden, unexpected death in epilepsy without another explainable cause of death. SUDEP is among the common epilepsy-related causes of death. The individual risk per seizure is generally very low, but the topic should be addressed openly.⁶
Possible risk factors
Uncontrolled tonic-clonic seizures (considered the most important factor), nighttime seizures, sleeping alone, young adulthood and difficult-to-treat epilepsy.
What can protect, according to professional societies
As good a seizure control as possible through consistent medication intake, avoidance of known triggers (e.g. sleep deprivation), not sleeping alone in risk situations as well as seizure-alarm or sensor systems (e.g. mattress sensors, smartwatches). After a seizure, the recovery position is generally recommended.⁶
The S2k guideline recommends informing all patients and relatives early — ideally already at the time of diagnosis — about SUDEP.¹
10. Living with epilepsy
Driving licence: Driving a motor vehicle is generally possible again after a defined seizure-free interval. For professional drivers, considerably stricter regulations apply. The details are always determined by a traffic-medicine assessment in the individual case.
Work: Most jobs are generally possible with epilepsy. Restrictions apply to activities with a risk of falling, lone working at dangerous machines or passenger transport. The S2k guideline recommends individual counseling — blanket occupational bans should be avoided.¹
Sport: Sport is in principle allowed and is generally recommended. For water sports (especially swimming), climbing or diving, special precautions apply. The guideline expressly advises avoiding overly cautious restrictions.¹
Sleep: Sleep deprivation is considered one of the most common seizure triggers. A regular sleep rhythm is mostly advisable — also at the weekend. Avoid night shifts where possible.
Alcohol: Alcohol can lower the seizure threshold and interact with anti-seizure medications. Occasional small amounts are possible in many cases with a stable adjustment — the decision should always be discussed with the neurology. Alcohol withdrawal is a known seizure trigger. More: Medications and alcohol.
Seizure diary: A structured documentation of every seizure (date, time, type, duration, possible triggers, medication intake) is generally very helpful for the neurology appointment.
Epilepsy ID card: Should ideally always be carried — with the diagnosis, current medications, an emergency contact and, if applicable, the emergency medication. Templates are provided by, for example, the German Epilepsy Association.
How brite helps you with epilepsy
Taking anti-seizure medications on time is decisive for seizure control. brite supports you with that — and with everything around it.
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Health history — document seizures, possible triggers and side effects in a structured way — helpful for the neurology appointment. Track your history
Digital medication plan — all medications clearly organized for the neurology, GP and emergency department. Go to medication plan
In the classic sense, epilepsy is generally not curable — medications can suppress the seizures, but not cure the disease. With a suitable therapy, however, a large proportion of those affected become seizure-free. After a longer phase without seizures, a controlled attempt to discontinue can be considered in individual cases — always under medical supervision. In suitable cases, surgery for focal epilepsy can lead to lasting seizure freedom.¹
Driving a motor vehicle is often possible again after a defined seizure-free interval and a traffic-medicine assessment. For professional drivers, stricter rules apply. The exact requirements are always determined by the medical assessment in the individual case.
Stay calm, protect the head, do not push objects into the mouth and do not hold the person down. Pay attention to the duration of the seizure. After the seizure: the recovery position, speak reassuringly. Call 112 (in the US: 911) with a seizure lasting more than about 5 minutes, a failure to regain consciousness afterwards, injuries, a series of seizures or a first-ever seizure.¹
Status epilepticus is generally a seizure that lasts longer than about five minutes, or a sequence of seizures without recovery in between. This is a medical emergency — call 112 (in the US: 911) immediately.⁶
SUDEP stands for "Sudden Unexpected Death in Epilepsy" — a sudden, unexpected death in epilepsy without another explainable cause. The most important risk factor is considered to be uncontrolled tonic-clonic seizures. As good a seizure control as possible through consistent medication intake is considered the most important protective factor. The current guideline recommends informing patients early.¹˒⁶
Yes — sport is generally possible with epilepsy and is often even recommended. For certain activities (e.g. swimming, climbing, diving), special precautions apply. The guideline emphasizes that overly cautious restrictions should mostly be avoided.¹
Cenobamate is a newer anti-seizure medication for adults with difficult-to-treat focal epilepsy. In studies, seizure freedom could be achieved in a relevant proportion of those treated — considerably more than under placebo. It must be increased especially slowly and is generally used in specialized centers.⁵
Medical disclaimer: This article is for general information and does not replace medical advice, diagnosis or treatment. The choice and dosage of anti-seizure medications, the indication for surgical therapy or neuromodulation as well as the planning of individual treatment goals are always determined individually by the treating neurology. With a first-ever seizure, a seizure lasting longer than about 5 minutes, a seizure with injury or a series of seizures, call 112 (in the US: 911) immediately. Anti-seizure medications must generally not be stopped on one's own. Last updated: April 2026.
