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This is a clinician-written, evidence-based summary aligned to the 2026 MLA Content Map. It is intended for medical students and junior doctors preparing for the UKMLA. Always cross-reference with NICE guidance, local protocols, and clinical judgement.
The Bottom Line
- Epilepsy = ≥2 unprovoked seizures OR 1 seizure + high recurrence risk (e.g. structural lesion on MRI)
- Classification: focal (aware/impaired awareness), generalised (tonic-clonic, absence, myoclonic), unknown onset
- First-line AEDs: focal = lamotrigine or levetiracetam; generalised tonic-clonic = sodium valproate (men) or lamotrigine (women of childbearing age)
- Sodium valproate is TERATOGENIC — Pregnancy Prevention Programme mandatory for women of childbearing potential
- Status epilepticus: seizure >5 min or recurrent seizures without recovery. IV lorazepam → IV phenytoin → GA
Overview
Epilepsy is a chronic neurological disorder defined by a tendency to recurrent unprovoked seizures. It affects approximately 600,000 people in the UK. Seizures are classified by the 2017 ILAE classification into focal onset (originating in one hemisphere), generalised onset (involving both hemispheres from onset), and unknown onset. Focal seizures may be further classified by whether awareness is retained or impaired. Generalised seizures include tonic-clonic, absence, myoclonic, tonic, atonic, and clonic subtypes.
Epidemiology
Epilepsy has a UK prevalence of approximately 1%. Incidence is bimodal — highest in children <1 year and adults >65 years. Causes vary by age: genetic/idiopathic in young patients; structural (stroke, tumour, TBI) in older adults. Other causes include hippocampal sclerosis (mesial temporal sclerosis), cortical malformations, infections (encephalitis, meningitis), and metabolic disorders. In approximately 60% of cases, no structural cause is identified. SUDEP (Sudden Unexpected Death in Epilepsy) causes approximately 600 deaths per year in the UK.
Clinical Features
Symptoms
Tonic-clonic seizure: loss of consciousness, tonic stiffening then clonic jerking, tongue biting (lateral), urinary incontinence, post-ictal confusion/drowsiness
Absence seizure: brief (5–15 s) staring episodes with arrest of activity, no post-ictal phase — childhood absence epilepsy
Focal aware seizure: preserved consciousness with motor, sensory, or autonomic symptoms (e.g. déjà vu, epigastric rising, limb jerking)
Focal impaired awareness seizure: altered consciousness, automatisms (lip-smacking, fumbling) — temporal lobe epilepsy
Myoclonic seizures: brief shock-like jerks, typically on waking — juvenile myoclonic epilepsy
Prolonged seizure >5 min or recurrent seizures without recovery (status epilepticus)
Signs
Often normal between seizures
Lateral tongue bite (highly specific for tonic-clonic seizure vs syncope)
Post-ictal confusion, Todd paresis (transient focal weakness post-seizure)
Signs of underlying cause: focal neurological deficit (structural lesion), neurocutaneous stigmata (tuberous sclerosis)
Investigations
First-line
Detailed history + witness accountMost important diagnostic tool — characterise seizure type, triggers, prodrome, post-ictal features
EEGSupports diagnosis and classification. Interictal EEG may be normal in up to 50%. Generalised spike-and-wave in generalised epilepsy; focal discharges in focal epilepsy. 3 Hz spike-and-wave = absence epilepsy
MRI brainStandard structural imaging — identifies tumours, hippocampal sclerosis, vascular malformations, cortical dysplasia
Second-line
BloodsGlucose, calcium, magnesium, U&Es, LFTs — exclude metabolic causes, baseline before AEDs
ECGExclude cardiac causes of collapse (long QT, Brugada, arrhythmia) — essential to distinguish seizure from syncope
Prolonged EEG / video telemetryIf diagnostic uncertainty — capture habitual events to classify seizure type
Specialist
Neuropsychological assessmentPre-surgical evaluation to lateralise language and memory function
PET/SPECTFunctional imaging for surgical planning in drug-resistant focal epilepsy
Management
NICE NG217 (Epilepsy), updated 20241
First-line AEDs by seizure type
- Focal seizures: lamotrigine or levetiracetam (first-line); carbamazepine, oxcarbazepine as alternatives
- Generalised tonic-clonic: sodium valproate (first-line in men and non-childbearing women) or lamotrigine
- Absence: sodium valproate or ethosuximide
- Myoclonic (JME): sodium valproate or levetiracetam
- Women of childbearing age: AVOID sodium valproate (teratogenic) — use lamotrigine or levetiracetam
2
Sodium valproate and pregnancy
- Valproate Pregnancy Prevention Programme is MANDATORY for all women/girls of childbearing potential
- Up to 40% risk of developmental disorders and ~10% risk of major congenital malformations
- Annual specialist review, signed risk acknowledgement form, effective contraception
- If already on valproate and planning pregnancy: plan switch with specialist ≥6 months before conception
- High-dose folic acid 5 mg/day if on any AED in pregnancy
3
Status epilepticus protocol (seizure >5 min)
- ABCDE approach, high-flow oxygen, check blood glucose
- First-line: IV lorazepam 4 mg (repeat once after 10 min if still seizing). Pre-hospital: buccal midazolam or rectal diazepam
- Second-line: IV phenytoin 20 mg/kg (or IV levetiracetam if already on phenytoin, or sodium valproate)
- Third-line (refractory): rapid sequence induction and general anaesthesia with thiopentone/propofol — ITU admission
4
Lifestyle and driving
- DVLA: must be seizure-free for 12 months to hold Group 1 (car) licence. Group 2 (HGV/bus): seizure-free for 10 years off medication
- Avoid known triggers: sleep deprivation, alcohol excess, missed medication
- Reasonable precautions: supervised bathing/swimming, avoid working at heights or with unguarded machinery
- Discuss SUDEP risk honestly — risk reduced by good seizure control and medication adherence
Complications
- SUDEP: Sudden Unexpected Death in Epilepsy — ~1 in 1,000 per year. Risk factors: frequent tonic-clonic seizures, nocturnal seizures, poor adherence, young adults
- Status epilepticus: Seizure >5 min — medical emergency with ~20% mortality
- Injury: Falls, burns, drowning during seizures
- Cognitive and psychiatric comorbidity: Depression, anxiety, memory impairment — screen regularly
- Teratogenicity: AEDs (especially valproate) cause congenital malformations and neurodevelopmental disorders
- Osteoporosis: Enzyme-inducing AEDs (carbamazepine, phenytoin) increase vitamin D metabolism
UKMLA Exam Tips
- 1Lateral tongue bite = seizure. Tip of tongue bite = more likely syncope/non-epileptic attack
- 2Status epilepticus: lorazepam → phenytoin → GA. Know the doses
- 3Sodium valproate: NEVER first-line in women of childbearing age — up to 40% developmental risk
- 4Carbamazepine can WORSEN absence and myoclonic seizures — contraindicated in generalised epilepsy
- 53 Hz spike-and-wave on EEG = absence epilepsy. Hypsarrhythmia = infantile spasms (West syndrome)
- 6DVLA: seizure-free for 12 months for Group 1. 10 years OFF medication for Group 2
- 7First seizure: do NOT start AEDs. Investigate and counsel. Start AEDs after ≥2 unprovoked seizures (or high recurrence risk)
practicetest your knowledge on epilepsyApply what you've learnt with UKMLA-style questions from the iatroX Q-Bank — neurology and beyond.
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