Diagnosis Hyperventilation Migraine Panic attack Psychogenic seizures Syncope Transient global amnesia Transient ischemic attack Important Clinical Features Anxiety and overbreathing evident; often perioral cyanosis, hand paresthesias, and carpo pedal spasm are present; environmental trigger may be evident Slow progression of neurologic symptoms; visual symptoms prominent; basilar migraine has unusual features, including confusion, stupor, bilateral blindness; headache may be minimal or absent Abrupt onset with intense feeling of dread or fear; often sense of impending death or inability to breathe; prominent autonomic features (e.g., tachycardia, sweating, nausea); lasts longer (5–30 min) than typical seizure; no loss of consciousness Psychiatric history; patient usually motionless with eyes closed at onset; fluttering eye movements and forceful eye closure common; out-of-phase, thrashing limb move- ments and pelvic thrusting common; urinary incontinence unusual; refractory to treatment Precipitating circumstances usually identifiable; prodrome of wooziness but no aura or unilateral symptoms; loss of consciousness brief (<20 sec), with rapid return to nor- mal; a few muscle jerks (“convulsive syncope”) can occur at end because of hypoxia Isolated amnesic syndrome; prolonged duration (several hours); no alteration of con- sciousness; no confusion, weakness, or aphasia; persistent memory gap during period of attack; recurrence unusual Sudden onset without progression of symptoms; variable symptoms related to brain and vascular anatomy; negative features (e.g., weakness, loss of sensation, aphasia) predominate Evaluation The neurologic examination is normal in most pa- tients with epilepsy.
Patients should be discouraged from participating in ac- tivities for which a history of seizures increases the risk of injury or death; these activities include driving, operating high-risk power equipment, n engl j med 359;2 www.nejm.org july 10, 2008 The New England Journal of Medicine Copyright © 2008 Massachusetts Medical Society.
T h e ne w e ngl a nd jou r na l o f m e dicine tively inexpensive phadenopathy; rela- acial features, lym- sutism, coarsened gival hyperplasia, hir- increased risk of gin- Reduces bone density; f netics‡ lead to nonlinear ki- ed; more likely to Not always well tolerat-
How- ever, clinical trials in newly diagnosed epilepsy have not shown any advantage associated with phenytoin,27 and it is generally preferable to initi- ate whichever antiepileptic drug is considered to n engl j med 359;2 www.nejm.org july 10, 2008 The New England Journal of Medicine Copyright © 2008 Massachusetts Medical Society.
* Type of Medication Cardiac Psychiatric Antineoplastic Antiinfective Other Increased Clearance (and Need for Higher Doses) with Phenytoin, Phenobarbital, Carbamazepine Decreased Clearance (and Need for Lower Doses) with Valproic Acid Mexiletine, quinidine, amiodarone, propranolol, meto- prolol, nifedipine, felodipine, nimodipine, digoxin, lovastatin, simvastatin, dicoumarol, warfarin Amitriptyline, nortriptyline, imipramine, desipramine, clomipramine, citalopram, paroxetine, buproprion, haloperidol, chlorpromazine, clozapine, olanzapine, risperidone, quetiapine Cyclophosphamide, busulfan, etoposide, methotrexate, teniposide, some vinca alkaloids Praziquantel, albendazole, doxycycline, nevirapine, efavirenz, delavirdine, indinavir, ritonavir, saquinavir Cyclosporine, tacrolimus, diazepam, alprazolam, prednisone, oral contraceptive pills, theophylline, methadone Nimodipine Amitriptyline, nortriptyline, clomip- ramine, paroxetine Zidovudine, possibly others Lorazepam, diazepam * Data are from Patsalos and Perucca.46 This list is not comprehensive.