How to diagnose and manage epilepsy in primary care, and when to refer?

Diagnosis of epilepsy in primary care:

• Take a detailed history from the person after a first suspected seizure, including eyewitness accounts and video footage if possible, and carry out a physical examination ².
• Use a 12-lead ECG to help identify cardiac conditions that could mimic seizures ².
• Offer brain neuroimaging tests, preferably an MRI scan within 6 weeks of referral, to identify structural causes unless idiopathic generalised epilepsy or self-limited epilepsy with centrotemporal spikes are suspected ².
• Consider an EEG to support diagnosis and provide information about seizure type or epilepsy syndrome, ideally within 72 hours of the seizure, but do not use EEG to exclude epilepsy ².

Management in primary care:

• Undertake a routine review at least once a year, assessing seizure control, medication adherence, and impact on daily life ¹.
• Provide information and support to the person and their family or carers, including how to recognize and manage further seizures, first aid, and safety advice ¹.
• Assess for mental health issues such as anxiety and depression, and cognitive problems, and manage appropriately ¹.
• Ensure the person is aware of driving regulations and has contacted the DVLA if they wish to drive ¹.
• Check adherence to antiepileptic drugs, monitor for adverse effects, and consider blood level testing if toxicity or non-compliance is suspected ¹.

Referral to specialist services:

• Refer all suspected or confirmed epilepsy cases to a tertiary epilepsy service if there is uncertainty about diagnosis, drug resistance, or need for specialized assessment or treatment, to be seen within 4 weeks ².
• Children under 3 years, or those with specific features such as deterioration in behaviour, speech, or learning, should be referred urgently within 2 weeks ².
• Ensure access to epilepsy specialist nurses for information, education, and support, with regular reviews, especially for those with ongoing seizures ².