A careful history of the details of the attack should be obtained from the patient, if possible, and from any bystanders who actually witnessed the attack. Only a physical description of the attack should be sought as witnesses, even physicians, may mislabel the activity or even mistake nonseizure activity as a seizure.

Important avenues of inquiry include preceding aura, abrupt or gradual onset, progression of motor activity, loss of bowel or bladder control, and whether the activity was local or generalized, symmetrical or not. Finally, the duration of the attack and any postictal confusion or lethargy should be sought. The patient should be asked whether he or she has any recollection of the attack.

Next, the clinical context in which the attack occurred should be determined. If the patient is a known epileptic, the baseline seizure pattern should be established. In patients presenting with an attack consistent with their previously documented seizures, the history should be directed toward factors that may have precipitated epileptic activity. Missed doses of antiepileptics or recent alterations in medication, including dosage change or conversion from brand name to generic formulation, may be the inciting element. Other possible factors that might provoke a seizure include sleep deprivation, alcohol withdrawal, infection, and use or cessation of other drugs.

If there is no previous history of seizures, a more detailed history is needed. Symptoms that might suggest previous unwitnessed or unrecognized seizures, such as blank or staring spells in school, involuntary movements, unexplained injuries, nocturnal tongue biting, and enuresis, may be clues to a more long-standing problem. A history of recent or remote head injury should be sought. Persistent, severe, or sudden headache should prompt a search for intracranial pathology. Concurrent pregnancy or recent delivery suggests the possibility of eclampsia. A history of metabolic derangements or electrolyte abnormalities, hypoxia, systemic illness (especially cancer), coagulopathy or anticoagulation, drug ingestion or withdrawal (licit and illicit), and alcohol use, may help identify factors that predispose patients to seizures (Table . . .224-2.).

TABLE 224-2 Causes of Secondary Seizures

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