Epilepsy in PLAB 2: Key History, Differentials, and Management
- Ann Augustin
- Jun 9
- 5 min read
Epilepsy is a common PLAB 2 topic and may appear as a first seizure, known epilepsy with poor medication compliance, driving concerns, medication side effects, pregnancy counselling, or a worried relative seeking advice.
The key to scoring well is obtaining a structured before–during–after history, identifying red flags, differentiating seizures from mimics, and providing clear safety-netting and management advice.
What is Epilepsy?
Epilepsy is a condition characterized by recurrent unprovoked seizures due to abnormal electrical activity in the brain.
A single seizure does not automatically mean epilepsy. Seizures caused by hypoglycaemia, alcohol withdrawal, severe infection, or electrolyte disturbances are considered provoked seizures.
Data Gathering
1. Before the Seizure
Important Questions
"What were you doing when it happened?"
"Was there anything that might have triggered it, such as lack of sleep, stress, alcohol, illness, or missed medication?"
"Did you notice anything unusual before the attack started?"
Why?
You need to determine whether the event was:
Provoked
Unprovoked
Triggered by medication non-compliance
Provoked seizures do not necessarily indicate epilepsy.
Common provoking factors:
Sleep deprivation
Alcohol withdrawal
Recreational drugs
Severe infection
Hypoglycaemia
Electrolyte abnormalities
Head injury
Look for Aura Symptoms: Did They Have Any Warning Signs?
Strange smells or tastes
Déjà vu
Flashing lights
Tingling sensations
Sudden fear or anxiety
A rising sensation in the stomach
Questions
"Did you notice anything unusual before the attack started?"
"Did you experience strange smells, tastes, flashing lights, or a feeling of déjà vu?"
Why Ask?
Aura symptoms suggest a focal onset seizure and help distinguish epilepsy from other causes of collapse.
2. During the Seizure
A witness history is often more valuable than the patient's account.
Important Questions
"Did you lose consciousness?"
"Did your body become stiff?"
Witness history is often more reliable than the patient's account because patients frequently have no memory of the event.
"Were your arms or legs jerking?"
"Did you bite your tongue?"
Lateral tongue biting strongly suggests an epileptic seizure.
"Did you lose control of your bladder?"
"How long did the episode last?"
Most generalized tonic-clonic seizures last:
1–3 minutes
Seizures lasting more than 5 minutes raise concern for status epilepticus.
Features Suggestive of Epilepsy
Sudden loss of consciousness
Tonic (stiffening) phase
Clonic (jerking) movements
Lateral tongue biting
Urinary incontinence
Eyes open during the event
No response during the attack
3. After the Seizure
Important Questions
"How did you feel afterwards?"
"Were you confused?"
"Did you need to sleep?"
"How long did it take before you felt back to normal?"
Typical Post-Ictal Features
Confusion
Drowsiness
Headache
Muscle aches
Fatigue
Temporary weakness (Todd's paresis)
Why Ask?
Post-ictal confusion is one of the strongest clues that the episode was an epileptic seizure.
4. Previous Episodes
Questions
"Has this happened before?"
"How many seizures have you had?"
"How often do they occur?"
Why?
Determines seizure control and severity.
Differentiating Epilepsy from Dissociative (Psychogenic) Non-Epileptic Seizures (PNES)
In PLAB 2, examiners often expect you to consider this differential.
Feature | Epileptic Seizure | PNES (Pseudoseizure) |
Trigger | Often none | Often emotional stress |
Tongue biting | Common (especially side of tongue) | Rare |
Urinary incontinence | May occur | Less common |
Eye position | Usually open | Often tightly closed |
Movements | Rhythmic and stereotyped | Variable, asynchronous |
Duration | Usually 1–3 minutes | Often prolonged |
Post-ictal confusion | Common | Usually absent or brief |
Injury during seizure | Common | Less common |
Important Note
Avoid using the term "pseudoseizure" with patients. It can sound dismissive.
A better phrase is:
"Sometimes people can experience seizure-like episodes that are not caused by abnormal electrical activity in the brain. We may need further tests to determine the exact cause."
Other Important Differentials
Syncope (Fainting)
Ask:
"Did you feel hot, sweaty, dizzy, or lightheaded before collapsing?"
Features favouring syncope:
Standing for prolonged periods
Pallor
Sweating beforehand
Quick recovery
Features favouring seizure:
Tongue biting
Post-ictal confusion
Todd's paresis
Prolonged unconsciousness
Additional History
Medication Compliance
"Are you taking your anti-epileptic medication regularly?"
"Have you missed any doses recently?"
Driving
"Do you currently drive?"
Why? This has major legal implications.
Occupation
"Do you work at heights, operate machinery, or drive for work?"
Why?
Particularly important if:
Driving professionally
Operating machinery
Working at heights
Management
If the Patient is Currently Stable
Acknowledge Concerns
"I understand that this experience can be frightening."
"Let's discuss what may have happened and the next steps."
Your management plan should therefore focus on addressing the underlying cause, arranging appropriate investigations or specialist referral, optimizing seizure control, providing safety advice, discussing the impact on daily activities such as driving and work, addressing medication-related concerns, and offering clear explanations and reassurance to both the patient and their relatives.
If This Is a First Seizure
Explain Referral
"Because you've had a seizure-like episode, I'd like to refer you to a First Seizure Clinic for further assessment."
Investigations may include:
Blood tests
MRI brain
EEG
If Known Epilepsy
Address Compliance
"Taking your medication regularly is one of the most important ways to prevent future seizures."
Explore:
Missed doses
Side effects
Recent illness
Sleep deprivation
Lifestyle and Safety Advice
Driving
"You should not drive until you've been assessed and advised by the specialist team."
Sleep
"Lack of sleep can trigger seizures, so maintaining a regular sleep routine is important."
Alcohol
"Avoid excessive alcohol consumption as it can increase seizure risk."
Water Safety
"Avoid swimming alone and consider showers rather than baths."
Advice for Relatives
"If a seizure occurs, keep them safe by moving nearby hazards away, do not restrain them, do not put anything in their mouth, and place them on their side once the seizure has stopped."
When to Call an Ambulance
Seek urgent help if:
The seizure lasts longer than 5 minutes
Repeated seizures occur without recovery
Significant injury occurs
Breathing does not return to normal
It is the person's first seizure
Driving Advice
A frequently tested PLAB 2 topic.
Communication Phrase
"For your safety and the safety of others, you should not drive until you have been assessed and advised by the specialist team."
Pregnancy and Pre-Conception Counselling
Pregnancy counselling is an important aspect of epilepsy management. The key message is:
"Do not stop your anti-epileptic medication without specialist advice, as uncontrolled seizures can be harmful to both you and your baby."
Key Points
Discuss pregnancy plans with a neurologist or GP before conception.
Take high-dose folic acid 5 mg daily before conception and during the first trimester.
Arrange a medication review, as some anti-epileptic medications are safer in pregnancy than others.
If already pregnant, continue medication and seek specialist review promptly.
Good seizure control is important for the safety of both mother and baby.
Important PLAB 2 Point
Sodium Valproate carries a significant risk of birth defects and developmental problems and requires specialist review in women of childbearing age.
Useful Communication Phrase
"If you're planning a pregnancy or become pregnant, please let us know as early as possible so we can review your medication and ensure you receive appropriate support throughout the pregnancy."
Interesting Clinical Pearl
Many anti-epileptic drugs, such as Carbamazepine, are also used for conditions like Trigeminal Neuralgia because they reduce abnormal electrical firing in nerves. They do not "boost" brain function; instead, they stabilize overactive nerve activity.
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