Seizure Phases Explained: What Happens Before, During, and After a Seizure
On this episode of Epilepsy Explained, Dr. Kristen Park identifies the various phases of a seizure and explains what may happen during each of these phases. Dr. Park is a Professor of Pediatrics and Neurology at the University of Colorado and an epileptologist at Children’s Hospital of Colorado.
In this episode Dr. Park answers the following questions:
0:00 Intro
0:16 What is meant by the “phases of a seizure”?
1:34 What is the prodromal phase and what happens during this phase?
3:37 What is an aura and what happens during this phase?
5:19 What is the ictal phase?
6:44 What is the postictal phase and what happens during this phase?
10:25 How long can it take a person to recover from a seizure?
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Episode Transcript
What is meant by the “phases of a seizure”
Dr. Kristen Park:
If you think of seizures kind of like telling a story, it kind of has a beginning, a middle, and an end. And so that translates into these different parts of the seizure and the time surrounding the seizure.
So seizure may start for some people with what’s called a prodromal phase, which can begin hours to even days before the seizure starts. Some people can then have an aura, which usually starts seconds to minutes before the bigger seizure. Then there’s the ictus, which is the actual seizure itself. And then there is often a postictal phase where the person is no longer having a seizure, but they’re not fully recovered. And then kind of in between seizures would be the interictal phase. And sometimes people can still have some symptoms during that time. So if you kind of put that all together, there are multiple phases. And not all seizures have or people with epilepsy have all of those phases, especially when the seizures are very brief like an absence seizure or a myoclonic seizure.
What is the prodromal phase and what happens during this phase?
Dr. Kristen Park:
So the prodromal phase is kind of the first. And again, not everyone has that phase. There have been some studies that have surveyed people with epilepsy, and the range of people that experience a prodrome is anywhere from as low as 6% to as high as 40% of people who have seizures. And that phase can last for hours or it can even last for days. The most common symptoms are being irritable or having some mood changes. Sometimes people have headaches. Sometimes people have confusion. There was another study that I read that said that up to 2% of the people who did have a prodrome were actually having a small seizure during that time or a period of what’s called non-convulsive status epilepticus. So kind of back-to-back seizures that led to them being confused and not able to function normally during that period of time. But I think that’s the majority of people with a prodrome. Most people just have some sense that a seizure is going to happen soon. We don’t actually know what’s happening, but we think that this is the kind of thing that seizure dogs may be able to pick up on. And the experiments with seizure dogs have shown that there may be a change in the, what are called, volatile organic compounds that our body secretes to make up our own personal metabolic profile and our scent and our response to stress and all sorts of other things. That kind of changes in the time leading up to a seizure. And there are actually people working on figuring out what specific compounds are common to all people with epilepsy so that perhaps we could have a better prediction tool to help people with epilepsy identify that this day is going to be a day with a seizure and maybe I should get a ride to wherever I’m going or maybe I should cancel that meeting or work from home today or what have you.
What is an aura and what happens during this phase?
Dr. Kristen Park:
So an aura is actually a very small seizure. It typically occurs right before the person’s usual seizure that they associate with their epilepsy. And it’s typically pretty short, less than a minute or so. Most auras are associated with focal onset seizures, although about 20% of people with generalized epilepsies report that they have an aura before a seizure. It’s just, I think, a little less well understood what that means. But for focal seizures, the symptoms of the aura typically depend on where the seizure is starting. So some of the most common ones for temporal lobe epilepsy are a rising sensation in the stomach, a feeling of deja vu, meaning that you’ve done this before, or a feeling of jamais vu, which is, “I’ve never been here before,” even though you’re in a familiar place. Sometimes people can hear things like ringing in their ear or the voices sound far away. Sometimes people can see things. So it’s a variety of different symptoms depending on what part of the brain is activated. And sometimes I think the challenging thing is that auras are often not visible on EEG because they are such a small part of the brain firing abnormally. They may not be picked up. But if you can reliably associate those symptoms with then having another seizure that’s easier to recognize, then that can be used as a warning by people with epilepsy that maybe they should sit down or maybe they should alert someone next to them that they’re about to have a seizure.
What is the ictal phase?
Dr. Kristen Park:
So the ictal phase is actually the seizure itself that the person experiences that has given them the diagnosis of epilepsy. And seizures can be quite different, meaning that there can be some that are very brief and last only seconds, while there can be others that are more dramatic and last up to minutes. The person can experience internal sensations, so feelings, being scared, being an impending sense of doom. They can feel tingling in various parts of their body. They can see things. They can also have movements, so twitching or jerking of different parts of the body. They can lose awareness of what’s going on around them and their ability to communicate with people in their environment. All of those things are possible with different types of seizures. The ictal phase usually lasts no more than a few minutes. The average duration of most seizures is a couple minutes. And we typically think that if that phase goes on for longer period of time, five minutes or more, that’s when it becomes a little bit more concerning and dangerous. And that’s when we typically tell families or patients to implement kind of rescue protocols that we may require some medication to stop the seizure.
What is the postictal phase?
Dr. Kristen Park:
So the postictal phase is after the seizure has ended. And again, not every seizure type has a postictal phase. Some of the shorter seizures like myoclonic or absence seizures, people may just recover and be back to normal, but some longer seizures like focal unaware seizures or tonic-clonic seizures may have this period of time where people don’t feel quite like themselves. And that can last anywhere from a few minutes to hours to even a day.
And we think that the EEG… Or we know that the EEG during that period is kind of not back to where it looks normally. It can be slow, it can be a bit disorganized as the person is recovering. And people can experience a variety of different symptoms, sometimes again, related to where the seizure started and how the seizure progressed. So if the seizure affected that person’s language area on the left side, they may have trouble talking, they may slur their words or not make as much sense as they usually do. Sometimes if the seizure is affecting our motor function, someone may not be able to use their arm after a seizure. That particular thing is called a Todd’s paralysis, and that can last for hours. And people may even think that they’ve had a stroke, but it’s really just that brain portion after having the seizure and those neurons firing over and over repetitively is just really exhausted and it just can’t function as well as it usually does. So that’s where those symptoms come from.
So more general symptoms, sometimes people can be tired, their muscles can be sore again from contracting during a convulsion. They can have a headache, they can be kind of cranky or have trouble staying awake or be a bit confused about what’s going on. Sometimes, especially people with temporal lobe seizures can even become a bit aggressive or agitated after their seizure. And that may be, again, because they’re confused. That has led unfortunately to a lot of interactions of people with epilepsy with the police who think that they are schizophrenic or that they’re endangering others and try to arrest them.
And so the Epilepsy Foundation has actually done a lot of education with first responders and emergency personnel to say, “These are the signs and symptoms that someone may have had a seizure and you should not be trying to arrest them. You should just be supporting and helping them.” And that’s what we want to kind of convey, that just like you don’t restrain someone during a seizure, you shouldn’t restrain them in the postictal period either. You should try to reassure them that everything is okay. You can gently guide them away from situations that may be dangerous to them. You can speak to them in a calm voice, try to reassure them that everything is going to be okay until they kind of recover.
There are actually also people who experience something more serious called postictal psychosis, where after they recover from the initial seizure, maybe hours to a day later, they can actually start experiencing hallucinations or delusions, hearing voices, become very paranoid, and can have full-blown psychosis that lasts for several days and may require treatment. That’s a minority of people with epilepsy, but something that is pretty serious and should be discussed with their neurologist.
How long can it take a person to recover from a seizure?
Dr. Kristen Park:
So I think that can, again, can be quite variable depending on the person, depending on the seizure type. As we’ve talked about, some of the briefer seizures like myoclonic or absence seizures, people don’t really experience any recovery time. They’re back to doing whatever they were doing right beforehand. But things like focal unaware seizures or convulsions or status epilepticus can take a much longer time to recover from. Most people will come out of that kind of acute postictal or recovery phase within a few minutes to a couple of hours and should be back to at least functioning pretty normally. But some people have told me in clinic that they experience several days or even up to a week of not feeling quite right after a bigger seizure has occurred. And I think that’s important to keep track of and know about one’s own epilepsy so that if you were going to an important meeting, you might ask that it be rescheduled. Or if you were supposed to take a test and you had a seizure the day before, maybe you should have an accommodation to move that test because you might not do your best on it that day. And then if you were to have a recovery period that was out of the range of normal for you, maybe that’s a time again to see your physician or give them a call to say, “I don’t feel like things are back to normal. I feel like something is wrong,” and they can try to help sort that out with you.
