Medicine — Seizures and Headache, NMC MBBS licence examination syllabus (Nepal Medical Council).
Seizures and headache: two problems solved by the history
In both, the diagnosis is usually made by asking, not by scanning.
Epilepsy and headache have something unusual in common. In both, the examination is frequently normal, the investigations are frequently normal, and the diagnosis rests almost entirely on a carefully taken history. A normal CT does not exclude epilepsy and does not exclude a dangerous headache. What separates the benign from the serious is the story — how it started, how fast, what came before, what came after, and what a witness saw.
That makes these topics genuinely learnable, because the discriminating features are a finite list. It also makes them high-yield for examinations, which test exactly this kind of structured questioning.
🩺 Where this lives: A wrong diagnosis of epilepsy is a serious harm in its own right. It brings years of unnecessary medication with real side effects, restrictions on driving and employment, and considerable stigma — and in many communities that stigma affects marriage prospects and schooling. A substantial proportion of people labelled with epilepsy turn out not to have it, most often because brief jerking during a faint was misread as a convulsion. Taking ten more minutes over the history is a genuine intervention here.
💡 A note on doses. This chapter gives none. Status epilepticus is treated by timed protocol steps, antiepileptic dosing is titrated to the individual, and migraine treatment follows national formularies. Learn the sequence and the reasoning; take every number from your local protocol.
Seizure or faint?
The single most useful correction here: brief jerking during a faint is common and does not mean epilepsy. A syncopal patient held upright — in a chair, or by well-meaning bystanders — becomes more hypoxic and may jerk for a few seconds. Witnesses describe "a fit", and a lifelong diagnosis follows. The features that actually discriminate are the circumstances (upright with prodrome versus any position without), the duration of jerking, and above all the recovery: syncope recovers orientation in seconds to a minute, while a generalised convulsion leaves prolonged postictal confusion.
GETTING THE HISTORY THAT ACTUALLY DECIDES IT
FROM THE PATIENT — before and after:
What were you doing? Standing, lying, exercising?
Any warning at all? Light-headed, hot, nauseated
(syncope) — or a smell, taste, déjà vu, rising
sensation in the abdomen (focal seizure aura)?
What is the first thing you remember afterwards?
Bitten tongue — and if so, WHERE? The SIDE of the tongue
is much more suggestive of a seizure than the tip.
Aching muscles or headache the next day?
FROM A WITNESS — this is the crucial part, and it is worth
telephoning someone who was there:
Colour: PALE before (syncope) or blue during (seizure)?
How long did the jerking last — seconds, or minutes?
Did the jerking start at the beginning, or after they
had already collapsed?
How long until they could hold a normal conversation?
ALWAYS ASK ABOUT PROVOKING FACTORS: sleep deprivation,
alcohol, drug withdrawal, and missed medication in someone
already treated.
AND CHECK THE GLUCOSE. Hypoglycaemia causes seizures, is
instantly treatable, and is missed embarrassingly often.
Classifying seizures
💡 Exam angle: an aura is itself a focal seizure — it is the electrical event before it spreads, which is why it has localising value. A rising epigastric sensation, an unpleasant smell or intense déjà vu points to a temporal lobe onset. That matters because a focal onset implies a structural cause and prompts imaging, whereas a generalised epilepsy syndrome starting in childhood often does not.
A first seizure is not epilepsy
Two distinctions carry a great deal of weight. First, a provoked seizure — from hypoglycaemia, hyponatraemia, alcohol withdrawal, drugs or eclampsia — is treated by correcting the provocation, not by starting lifelong antiepileptic medication. Second, epilepsy is a tendency to unprovoked recurrent seizures, which is a diagnosis with major implications for driving, employment and pregnancy, and should not be applied casually after a single event.
STATUS EPILEPTICUS — WHY THE CLOCK MATTERS
A seizure that continues, or repeated seizures without
recovery in between, becomes progressively:
HARDER TO STOP — receptor changes make benzodiazepines
less effective as time passes
MORE DAMAGING — prolonged seizure activity causes
neuronal injury independent of hypoxia
So the management is defined by TIME, not by response:
Airway, oxygen, position, and monitor
CHECK THE GLUCOSE — always
First-line benzodiazepine at the protocol time point
Second dose, then escalate to the next agent at the next
time point, rather than waiting hopefully
Look for the CAUSE throughout — glucose, sodium, alcohol
withdrawal, infection, head injury, missed medication,
ECLAMPSIA in a pregnant or recently pregnant woman
In pregnancy or the postpartum period, a seizure is
ECLAMPSIA until proven otherwise, and the treatment is
magnesium sulphate per obstetric protocol rather than the
standard epilepsy pathway.
All doses and intervals come from your local protocol.
Headache: finding the dangerous ones
💡 Exam angle: speed of onset is the highest-value question in headache. A thunderclap headache — maximal within seconds to a minute — is subarachnoid haemorrhage until excluded, and the classic wrong answer is to treat it as migraine because the patient has migraines. Note the investigation sequence: CT first, and if the CT is negative but suspicion remains, lumbar puncture after an interval to look for breakdown products of blood.
The primary headaches
A neat bedside discriminator: the migraine patient lies still in the dark; the cluster patient paces. Migraine is worsened by movement, so the sufferer withdraws and keeps still. Cluster headache produces agitation and restlessness, along with autonomic features on the same side as the pain — a red watering eye, drooping lid, blocked nostril. Watching what the patient does with the pain is genuinely diagnostic.
Clinical reasoning: four presentations
🔍 Case 1 — "he had a fit at the wedding"
PresentationA 19-year-old collapsed while standing in a hot crowded hall. He felt hot, nauseated and grey-visioned first. Witnesses describe a few seconds of jerking while he was held upright in a chair. He was talking normally within half a minute. An antiepileptic is proposed.
Key cluesUpright position, clear prodrome, brief jerking, rapid full recovery.
ReasoningThis is vasovagal syncope with secondary jerking — very common, and very commonly misread. Prolonged postictal confusion, the hallmark of a generalised convulsion, is absent.
AnswerNo antiepileptic. Explain the mechanism, advise on triggers and on lying down at the first warning, examine the cardiovascular system and check an ECG to exclude a cardiac cause of syncope.
🔍 Case 2 — the worst headache of her life
PresentationA 44-year-old with a history of migraine describes a headache that reached maximum intensity within seconds while she was lifting a box. It is severe but she has no focal signs. Migraine treatment is given.
TrapLetting a known diagnosis explain a new pattern.
ReasoningInstantaneous onset is a thunderclap headache, which is subarachnoid haemorrhage until excluded — regardless of a migraine history. Migraine builds over minutes to hours, not seconds.
AnswerUrgent CT head. If negative and suspicion persists, lumbar puncture after the appropriate interval. Never let a previous headache diagnosis explain away a new and different one.
🔍 Case 3 — a seizure that will not stop
PresentationA man has been convulsing for several minutes without regaining awareness. A benzodiazepine has been given once and the team is waiting to see whether it works before doing anything further.
Two errorsWaiting rather than escalating, and not yet checking the glucose.
ReasoningStatus epilepticus is managed by the clock. Seizures become harder to terminate as they continue, so escalation occurs at fixed time points rather than on impression. Hypoglycaemia is an instantly reversible cause that must be excluded in every seizure.
AnswerAirway and oxygen, check glucose immediately, proceed through the timed protocol steps without delay, and search actively for the precipitant.
🔍 Case 4 — headache worse in the mornings
PresentationA 58-year-old has six weeks of headache, worse on waking and when coughing, with recent vomiting. Fundoscopy is not performed and simple analgesia is advised.
PatternRaised intracranial pressure.
ReasoningHeadache worse on lying flat and on straining, with vomiting and a progressive course in a patient over 50, fits raised intracranial pressure and demands imaging rather than analgesia.
AnswerFull neurological examination including fundoscopy for papilloedema, and urgent imaging. In this age group also consider giant cell arteritis, which is a separate treatable cause of new headache.
Commonly confused
Confusion
The distinction
Why it matters
Syncope vs seizure
Prodrome, position, and speed of recovery
Brief jerking in a faint is not epilepsy.
Jerking vs convulsion
Seconds versus minutes, and what follows
Postictal confusion is the discriminator.
Provoked seizure vs epilepsy
Epilepsy means unprovoked and recurrent
Avoids lifelong treatment for a correctable cause.
Focal vs generalised onset
An aura indicates focal onset
Focal onset implies a structural cause.
Waiting vs escalating in status
Management is by the clock
Seizures get harder to stop with time.
Thunderclap vs migraine
Seconds to peak versus minutes to hours
A migraine history does not explain a new pattern.
Migraine vs cluster
Lies still versus paces; autonomic features
Behaviour separates them at the bedside.
Chronic vs new headache over 50
New headache in this group needs explanation
Giant cell arteritis and tumour both present this way.
Rapid revision
MUST-KNOW FACTS
1. The diagnosis in both seizures and headache is made by HISTORY.
2. A WITNESS account is the most valuable investigation in a blackout.
3. Syncope: upright, prodrome of light-headedness, pallor, rapid recovery.
4. Seizure: any position, aura, cyanosis, PROLONGED POSTICTAL CONFUSION.
5. BRIEF JERKING IN A FAINT IS COMMON AND IS NOT EPILEPSY.
6. Tongue biting on the SIDE suggests a seizure.
7. Speed of recovery of orientation is the best discriminator.
8. Misdiagnosed epilepsy causes medication, restriction and stigma.
9. Classification starts with ONSET: focal, generalised or unknown.
10. An AURA is itself a focal seizure and has localising value.
11. Focal onset implies a structural cause — image it.
12. Childhood absence: brief blank spells, no aura, no postictal confusion.
13. CHECK THE GLUCOSE IN EVERY SEIZURE.
14. Provoked causes: hypoglycaemia, hyponatraemia, alcohol withdrawal, drugs, infection.
15. A provoked seizure is treated by removing the provocation.
16. Epilepsy = a tendency to UNPROVOKED RECURRENT seizures.
17. In pregnancy or postpartum, a seizure is ECLAMPSIA until excluded.
18. Status epilepticus is managed BY THE CLOCK, not by impression.
19. Seizures become harder to stop the longer they continue.
20. Escalate at fixed time points; search for the cause throughout.
21. HEADACHE: speed of onset is the highest-value question.
22. THUNDERCLAP headache = subarachnoid haemorrhage until excluded.
23. CT first; lumbar puncture after an interval if CT is negative.
24. A migraine history never explains a NEW headache pattern.
25. Red flags: fever and neck stiffness, focal signs, seizure, papilloedema.
26. Raised ICP: worse in the morning and on lying, straining and coughing.
27. New headache over 50 — consider GIANT CELL ARTERITIS.
28. Migraine: unilateral, throbbing, nausea, PHOTOPHOBIA, worse on movement.
29. Tension-type: bilateral, band-like, not worsened by activity.
30. Cluster: severe, unilateral, around the eye, with autonomic features.
31. MIGRAINE LIES STILL · CLUSTER PACES.
💡 Exam angle: three questions do most of the work in this chapter — how fast did the headache reach its peak?, how long until they were talking normally again?, and what was the glucose? Each takes seconds to ask and each changes the answer completely.
Syllabus points
Why the history decides both diagnoses
Seizure versus syncope
Why jerking in a faint is not epilepsy
The witness account and what to ask
Classification by onset
The aura as a focal seizure
Provoked seizures and checking the glucose
Status epilepticus managed by the clock
Eclampsia as a cause of seizure
Headache red flags
Thunderclap headache and subarachnoid haemorrhage
The raised intracranial pressure pattern
Migraine, tension-type and cluster headache
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