Epilepsy is a chronic neurological condition with recurrent, unprovoked seizures. These arise from sudden, excessive electrical discharges in networks of nerve cells in the brain. Epilepsy is not a single condition but rather an umbrella term for various syndromes with an increased tendency to seizures.
According to the International League Against Epilepsy (ILAE) definition, epilepsy is generally diagnosed when at least two unprovoked seizures have occurred more than 24 hours apart, when there has been a single unprovoked seizure with a significantly increased risk of recurrence, or when an epilepsy syndrome has been diagnosed.
An estimated 500,000 people in Germany live with epilepsy. The condition can in principle begin at any age but occurs particularly often in childhood and from around age 60. In older people, 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 largely normal lives.¹
2. Understanding seizure types
The ILAE classification distinguishes seizures primarily by where they originate in the brain.⁴
Focal seizures (begin in one brain area)
Focal 1Without impaired awareness (with aura)
The person is generally conscious but experiences uncontrolled symptoms — e.g. twitching of a hand or arm, tingling, flashes of light, a rising sensation in the stomach, déjà vu, sudden fear or unusual smells. This "aura" is often already the first sign of a starting seizure.
Focal 2With impaired awareness (automatisms)
Awareness is reduced or absent. Typical features 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 begins focally and then spreads to both brain hemispheres. From a bystander's perspective, it often looks like a "classic" grand mal seizure.
Generalized seizures (both hemispheres from the start)
Grand malTonic-clonic seizure
Loss of consciousness, first muscle stiffening (tonic), then rhythmic jerking (clonic). Marked exhaustion often follows. Tongue biting and loss of urine are possible.
AbsenceBrief lapse of awareness
Brief lapses of awareness without a fall and generally without marked jerking. The person "freezes," has a fixed stare and usually does not respond. Common in children and sometimes misinterpreted as daydreaming.
MyoclonicLightning-fast muscle jerks
Brief, lightning-fast muscle jerks, often in the morning shortly after waking (e.g. in juvenile myoclonic epilepsy).
AtonicDrop attacks — sudden loss of muscle tone
Sudden loss of muscle tone with risk of falling — often associated with a risk of injury.
3. Causes
The current S2k guideline broadly distinguishes several etiological categories:¹
Structural: e.g. after 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 decompensation
Autoimmune: e.g. anti-NMDA receptor encephalitis — this category 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 investigation
A single seizure is not yet epilepsy
So-called provoked 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 the seizure
Before the seizure: aura and prodrome
Some people report nonspecific changes hours or days before a seizure, such as mood swings, irritability, problems with concentration or sleep disturbances (so-called prodrome). Immediately before focal seizures, an "aura" can occur — this is often already the start 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 stiffening, rhythmic jerking, possible fall
Lateral tongue bite (more typical of an epileptic seizure; a bite on the tip of the tongue more often suggests syncope)
Possible loss of urine
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
Headaches, sore muscles (after a tonic-clonic seizure)
Memory gap for the time of the seizure
More rarely: transient neurological deficits (e.g. Todd's paresis)
5. Diagnosis
Medical history (often the most important element): As precise a description as possible from the affected person AND witnesses. A smartphone video of a seizure is often very helpful for the neurology team — family members should film seizures when possible.
EEG (electroencephalogram): Measures brain waves through electrodes on the scalp and can show epilepsy-typical patterns. In addition to routine EEG, there are long-term EEG, sleep-deprived EEG and video-EEG monitoring in specialized centers. Important: a normal EEG does not necessarily rule out epilepsy.¹
Brain MRI: Generally high-resolution, following an epilepsy protocol. Can reveal structural causes such as tumors, scars, malformations or hippocampal sclerosis.
Lab tests: Blood sugar, electrolytes, liver and kidney values, inflammatory markers. In certain situations, additional lumbar puncture (if encephalitis is suspected) or toxicology testing.
Common differential diagnoses
Syncope (circulatory collapse), psychogenic non-epileptic seizures, migraine with aura, TIA, panic attacks or parasomnias. The distinction 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 "antiepileptic drugs" because the medications generally suppress seizures but do not cure epilepsy.¹
Monotherapy for focal epilepsy — often first choice
Lamotrigine
Guideline: First-choice drug in newly diagnosed focal epilepsy (S2k guideline)¹ Properties: Generally well tolerated and mood-stabilizing Important: The dose must be increased gradually — too rapid escalation carries an increased risk of skin reactions up to Stevens-Johnson syndrome
Levetiracetam
Broadly usable, can be titrated quickly, few relevant interactions. Possible side effects: fatigue, irritability or mood changes — particularly in children. Also effective in generalized epilepsies.
Lacosamide
Generally well tolerated, few interactions — increasingly used in first-line therapy too. Possible side effects: dizziness and double vision. With pre-existing heart conditions, medical monitoring is advisable.
Oxcarbazepine
A further development of carbamazepine with generally fewer interactions. Possible side effect: sodium lowering (hyponatremia) — lab values are usually monitored regularly.
Carbamazepine
A classic anti-seizure medication, somewhat less often the first choice today. Has more interactions compared with newer agents. Learn more: Medication interactions.
For generalized epilepsies
Valproate
Considered particularly effective in certain generalized epilepsies.¹ ⚠ Important — strict pregnancy prevention program: Because of a high risk of malformations and developmental disorders with exposure during pregnancy, valproate is subject to very strict EU-wide regulatory requirements. In women and girls of childbearing potential, its use is heavily restricted and only takes place 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 hard-to-treat epilepsy
Cenobamate — NEW for hard-to-treat focal epilepsy
A newer anti-seizure medication for adults with hard-to-treat focal epilepsy. In studies, seizure freedom was achieved in a relevant proportion of patients treated — markedly more than under placebo.⁵ Important: The dose must be titrated up particularly slowly (among other reasons, because of a rare but severe reaction pattern, DRESS). Generally used in specialized centers.
Other anti-seizure medications
Brivaracetam, perampanel, zonisamide, topiramate, eslicarbazepine acetate, clobazam and others.
Never stop anti-seizure medications on your own
Doing so can significantly increase seizure risk — up to a life-threatening status epilepticus. A change of preparation (e.g. to a different generic) should usually also only be done under medical supervision. The S2k guideline recommends reminder apps and pill organizers to improve adherence. Learn more: Stopping medication, Generics vs. brand name.
7. Other therapies: surgery, VNS, diet
Epilepsy surgery: An option in focal epilepsy with an identifiable seizure focus when two or more medications do not work sufficiently. Presurgical evaluation in specialized epilepsy centers. The S2k guideline recommends referring patients with hard-to-treat focal epilepsy to an epilepsy center early.¹
Vagus nerve stimulation (VNS): An implanted stimulator on the left vagus nerve that delivers electrical impulses at regular intervals. Can reduce seizure frequency in some patients.
Deep brain stimulation: A newer option in hard-to-treat epilepsy when surgery is not feasible.
Ketogenic diet: A very high-fat, very low-carbohydrate dietary approach. Particularly effective in children with hard-to-treat epilepsies. Always medically supervised. In adults, the modified Atkins diet is often used.
8. First aid during an epileptic seizure
The most important message: stay calm
Most seizures end on their own after a few minutes. Look at the clock and time the duration — that is the most important basis for deciding whether to call emergency services.
What you can do
Look at the clock and time the seizure
Remove dangerous objects from the immediate surroundings
Protect the head, e.g. cushion it with something soft
After the seizure: recovery position, to prevent aspiration
Stay calm, reassure the person and don't leave them alone
If possible: film the seizure with your phone — very helpful for the neurology team
What you should NOT do
Do not put anything between the teeth — no bite block, no fingers, no spoon
Do not hold or restrain the person — this can cause injuries
Do not give anything to drink or eat until the person is fully conscious again
Call 112 if:
The seizure lasts longer than about 5 minutes (suggestive 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 · There is a known heart condition or other risk situation.¹˒⁶
Rescue medications
Many people with epilepsy have a doctor-prescribed rescue medication (e.g. a benzodiazepine as a nasal or buccal spray). Family members should be trained in its use — use and dosing are always determined individually by the treating neurology team.
9. SUDEP — understanding the risk
SUDEP stands for "Sudden Unexpected Death in Epilepsy" — a sudden, unexpected death in epilepsy with no other explainable cause. SUDEP is among the common epilepsy-related causes of death. The risk per individual 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), nocturnal seizures, sleeping alone, young adulthood and hard-to-treat epilepsy.
What, according to professional societies, can offer protection
The best possible seizure control through consistent medication adherence, avoiding known triggers (e.g. sleep deprivation), not sleeping alone in higher-risk situations, and 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 family members about SUDEP early — ideally at the time of diagnosis.¹
10. Living with epilepsy
Driver's license: Driving a motor vehicle is generally possible again after a defined seizure-free interval. Significantly stricter rules apply to professional drivers. The details are always determined by a transport medicine assessment in the individual case.
Work: Most occupations are generally possible with epilepsy. Restrictions apply to activities with a risk of falling, solo work on dangerous machinery or passenger transport. The S2k guideline recommends individual advice — blanket occupational bans should be avoided.¹
Sport: Sport is generally allowed and generally recommended. Special precautions apply to water sports (especially swimming), climbing or diving. The guideline explicitly advises against overcautious restrictions.¹
Sleep: Sleep deprivation is considered one of the most common seizure triggers. A regular sleep rhythm is generally advisable — including at weekends. Avoid night shifts where possible.
Alcohol: Alcohol can lower the seizure threshold and interact with anti-seizure medications. Occasional small amounts are in many cases possible with stable treatment — the decision should always be discussed with your neurology team. Alcohol withdrawal is a known seizure trigger. Learn more: Medication and alcohol.
Seizure diary: 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 be carried at all times — with diagnosis, current medications, emergency contact and any rescue medication. Templates are provided e.g. by the German Epilepsy Association (Deutsche Epilepsievereinigung).
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Digital medication plan — all medications clearly laid out for neurology, GP and the emergency department. Go to medication plan
In the classic sense, epilepsy is generally not curable — medications can suppress seizures but not cure the condition. With appropriate therapy, however, a large proportion of those affected become seizure-free. After a longer seizure-free phase, a controlled withdrawal attempt can be considered in individual cases — always under medical supervision. In suitable cases of focal epilepsy, surgery can lead to lasting seizure freedom.¹
Driving a motor vehicle is often possible again after a defined seizure-free interval and a transport medicine assessment. Stricter rules apply to professional drivers. The exact requirements are always set by the medical assessment in the individual case.
Stay calm, protect the head, do not put anything in the mouth and do not hold the person down. Watch the duration of the seizure. After the seizure: recovery position, speak reassuringly. Call 112 if a seizure lasts more than about 5 minutes, the person does not regain consciousness afterwards, there are injuries, a series of seizures, or a first-ever seizure.¹
Status epilepticus generally refers to a seizure lasting more than about five minutes, or a series of seizures without recovery in between. This is a medical emergency — call 112 immediately.⁶
SUDEP stands for "Sudden Unexpected Death in Epilepsy" — a sudden, unexpected death in epilepsy with no other explainable cause. Uncontrolled tonic-clonic seizures are considered the most important risk factor. The best possible seizure control through consistent medication adherence 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. Special precautions apply to certain activities (e.g. swimming, climbing, diving). The guideline emphasizes that overcautious restrictions should usually be avoided.¹
Cenobamate is a newer anti-seizure medication for adults with hard-to-treat focal epilepsy. In studies, seizure freedom was achieved in a relevant proportion of patients treated — markedly more than under placebo. It must be titrated up particularly slowly and is generally used in specialized centers.⁵
Medical disclaimer: This article is for general information only and is not a substitute for medical advice, diagnosis or treatment. The choice and dosing of anti-seizure medications, the indication for surgical therapy or neuromodulation and the planning of individual treatment goals are always determined individually by your treating neurology team. With a first-ever seizure, a seizure lasting more than around 5 minutes, a seizure with injury, or a series of seizures, call 112 immediately. Anti-seizure medications should generally not be stopped on your own. Last updated: April 2026.
