Has anyone in your family had a severe seizure like this? Let's learn about Tonic-Clonic (also known as Grand Mal) seizures!

Have you ever seen someone suddenly jerk and lose consciousness? They may even drool. We all get scared when we see such a scene, right? There are several types of seizures that occur in this way. Today we are going to talk about the Tonic-Clonic (Grand Mal) seizure, which is a slightly more severe but well-known type of seizure among many people. Let's see what it is exactly, why it happens, what are the symptoms, and what we should do in such a situation.

What is a tonic-clonic or grand mal seizure?

Simply put, a tonic-clonic seizure is a severe seizure in which muscles on both sides of our body suddenly become active and twitch. This is the type that most people think of when they hear the word "seizure" and is easily recognized. It used to be called a "Grand Mal." It's a French word that means something like "big illness."

The name "Tonic-Clonic" suggests that this seizure has two main phases.

1. Tonic phase: This is when the muscles of the entire body, especially the arms and legs, suddenly tighten.

2. Clonic phase: This is followed by the jerking of the body, or convulsions.

How is this seizure different from other types of seizures and epilepsy?

There are several types of seizures. Some of them have similar names, which can be confusing. Let's take a look at the main differences:

• Atonic seizures: Also called "drop attacks," these are sudden, involuntary muscle contractions that cause the person to fall to the ground. This increases the risk of injury from falls.
• Tonic seizures: These are similar to tonic-clonic seizures, but the clonic phase, or jerking, does not occur. The person may lose consciousness and become stiff, but there is no jerking.
• Clonic seizures: This is a seizure that occurs without a tonic phase, and suddenly goes into a clonic phase. This means that the body does not stiffen, but instead starts jerking and may even lose consciousness.
• Myoclonic seizures: This is a sudden jerking of a muscle group. It's like being hit by an electric shock. If it affects the legs, you may even fall. (But here's a little something: When we suddenly jerk our bodies when we're going to sleep, it's called a `myoclonic jerk.' It's normal, not a seizure or epilepsy. )
• Epilepsy: Epilepsy is a brain condition that causes frequent, unexplained seizures. Doctors usually diagnose epilepsy if a person has had at least two unprovoked seizures within a 24-hour period, or if they have had one seizure and are at high risk of having another within the next 10 years.

Who is most affected by this condition? How common is it?

Anyone can develop a seizure, but some people are more likely to develop one. Seizures are most common in young children and people over the age of 65.

Overall, about 25% of people who have seizures have tonic-clonic seizures. According to statistics in the United States, about 11% of people will have a seizure in their lifetime, and about 3% of them will be diagnosed with epilepsy. About 1% of patients who come to emergency departments are those who come because of seizures.

How does this seizure affect the body?

A seizure is a change or malfunction in the way our brain cells, called neurons, send electrical signals. During a seizure, these neurons continuously fire uncontrollably, which spreads to other neurons.

A tonic-clonic seizure is a `generalized seizure`. This means that it affects both sides of the brain. This causes loss of consciousness, muscle weakness throughout the body, and uncontrollable movements such as jerking and shaking.

Status Epilepticus - This is dangerous!

Important: If someone has a seizure that lasts longer than five minutes, or if one seizure ends and another one occurs just before they regain consciousness, it is called status epilepticus . This is a life-threatening medical emergency! It can cause permanent brain damage and even death.

About 98% of seizures usually end in less than five minutes. Status epilepticus can occur for any reason that can cause a seizure.

If someone has a seizure that lasts more than 5 minutes while you are there, or if another one occurs before the first one ends, please call 1990 (Sri Lanka's emergency ambulance service) immediately, or take them to the nearest hospital. If status epilepticus lasts longer, it is more difficult for doctors to stop it, and there is a greater chance of brain damage.

What are the symptoms of tonic-clonic seizures?

When most people think of "seizures," they think of tonic-clonic seizures. The symptoms are usually mild and easy to recognize. There are three main stages:

1. Tonic phase (about 10-30 seconds):

• In this case, you suddenly lose consciousness.
• The muscles of the entire body, especially the arms and legs, become tight. It may appear as if the body is bent backwards and the stomach is protruding.
• As the breathing muscles tighten, air escapes from the lungs, making a whistling sound.
• If you fall at this time, or if you clench your teeth and bite your tongue , you could get injured.

2. Clonic phase (30-60 seconds, sometimes longer):

• This is when the whole body starts to shake and tremble (convulsions).
• You can also spit out mucus from your mouth.
• The noises are gradually decreasing, and gradually they stop.
• By the end of this stage, urine and feces may be released, which means they can get on clothes.

3. Recovery phase after a seizure (about 30 minutes):

• Most people gradually regain consciousness after the seizure ends.
• But you may feel confused, have a headache, or experience body aches . These are normal.
• In some severe cases, especially if a condition such as `Status epilepticus` occurs, it may take longer to regain consciousness.

What are focal seizures and aura?

Many people experience a feeling, a foreboding, before a seizure occurs. This is called a `prodrome`. Sometimes this foreboding can be accompanied by an `aura`. An aura is the sensation that certain parts of the brain are affected when a seizure begins.

Generalized seizures, like tonic-clonic seizures, do not have an aura. However, focal seizures – seizures that affect only one side of the brain – can sometimes spread to the entire brain and become a tonic-clonic seizure. The aura that precedes the focal seizure can be a warning sign that a tonic-clonic seizure is coming.

An aura can have the following characteristics:

• Sensory symptoms: If the parts of the brain that control your senses are affected, you may experience false sensations that you are actually seeing or hearing. For example, you may see colored lights, see things moving, hear sounds, experience strange tastes and smells, or feel something moving on your skin.
• Changes in emotions: Some people may experience negative emotions like fear and anxiety. Others may experience positive emotions like happiness and excitement. Some may experience feelings like `déjá vu` (a feeling of familiarity with a new experience) or `jamais vu` (a feeling of familiarity with a new experience).
• Autonomic symptoms: These can affect the things that our body controls automatically. For example, sweating, excessive salivation, pale or red skin, and gastric uprising.

What causes tonic-clonic seizures?

There can be many reasons for this seizure. Let's take a look at the main ones:

• Weaknesses in the blood vessels of the brain (`Aneurysms`).
• Heart rhythm irregularities (`Arrhythmias`), especially when blood flow to the brain is impaired.
• Brain tumors (cancerous and non-cancerous).
• Lack of oxygen to the brain (`Cerebral hypoxia`).
• Injuries caused by a hard blow to the head (concussion and traumatic brain injury).
• Diseases that gradually weaken the brain, e.g. Alzheimer's disease, frontotemporal dementia.
• Drugs and alcohol (this includes not only medications, recreational drugs, but even the caffeine in coffee).
• Conditions that occur after stopping drugs or alcohol.
• Eclampsia (a condition in which pregnant women have seizures due to high blood pressure).
• Imbalances in body salts (especially low sodium - `hyponatremia`, low calcium, magnesium).
• Fever, especially high fever (we have a separate article about febrile seizures in children).
• Bright, flashing beams of light (as seen in TV, movies, video games).
• Congenital genetic diseases (`Genetic disorders`).
• Hormonal changes (e.g., catamenial epilepsy, a condition in which some women experience more seizures during their menstrual cycle).
• Infections (especially encephalitis or meningitis; these can be caused by viruses, bacteria, parasites, or fungi).
• Autoimmune conditions caused by disorders of the immune system.
• Insomnia and other sleep problems.
• Metabolic problems (especially high blood sugar - `hyperglycemia` or low blood sugar - `hypoglycemia`).
• Mental health problems (these are called `psychogenic seizures`, e.g. `conversion disorder`).
• Problems with brain structure (especially due to problems that occur when the brain is developing in the womb).
• Sepsis (a life-threatening condition in which an infection spreads throughout the body and the immune system overreacts).
• Strokes or transient ischemic attacks (TIAs).
• Poisons (e.g. carbon monoxide poisoning, heavy metal poisoning).

Provoked and unprovoked seizures

When doctors diagnose a seizure, they also look at whether it is `provoked` or `unprovoked`.

• Provoked seizures: These occur as a symptom of another medical condition or in response to a specific event (e.g., high fever, low blood sugar, withdrawal from medications, drugs, or alcohol).
• Unprovoked seizures: These are seizures that do not occur as a symptom of a short-term illness or a specific event. Seizures that occur after seven days, such as after a head injury or stroke, also fall into this category.

Are tonic-clonic seizures contagious?

No, tonic-clonic seizures are not contagious. However, some things that cause seizures, such as infections, can be contagious (but not all infections cause seizures). Also, some conditions that cause seizures are genetic (can be passed from parents to children).

How is a tonic-clonic seizure diagnosed ?

Your doctor, usually a neurologist, can often diagnose a tonic-clonic seizure based on the symptoms. Because you lose consciousness during this seizure, you may only remember what you felt before and after the seizure. In such a case, the doctor may ask someone who was with you to explain what happened.

If you see someone having a seizure, especially if they are stiff, twitching, or shaking, a doctor may ask you to describe the symptoms. Telling them what you see can be very helpful in determining the cause.

What kind of tests are done?

There are several tests to determine whether or not you have tonic-clonic seizures. The most common tests are:

• Electroencephalogram (EEG): This measures the electrical activity of the brain.
• Blood tests: These look for things like metabolic disorders, blood chemical imbalances, immune system problems, and toxins.
• Computerized tomography scan (CT scan): Takes cross-sectional images of the brain.
• Magnetic resonance imaging (MRI): This also takes detailed images of the brain.
• Spinal tap (lumbar puncture): To check for things like infections in the brain and spinal cord.

When diagnosing epilepsy, doctors try to find a specific spot in the brain (a `focal point`) where the seizures start. If they can find this spot, it has a big impact on the way the treatment is done.

Tonic-clonic seizures can cause loss of consciousness, jaw clenching, and the risk of injury from jolting or hitting objects. If doctors suspect that there are other injuries or complications from the seizure, they may order additional tests in addition to the ones listed above. Your doctor will be able to tell you which tests are appropriate for your condition and why they are being done.

How are tonic-clonic seizures treated? Can this be cured?

Tonic-clonic seizures usually stop on their own. Therefore, there is no direct treatment for a seizure while it is occurring. However, it is different if you have status epilepticus (a seizure that lasts more than 5 minutes and is followed by another before the previous one is over).

Treatment for seizures depends on what caused them in the first place. If you have a `provoked seizure`, the seizures should stop once the underlying condition that caused them is treated or cured. If the underlying cause cannot be cured, doctors will try to reduce the frequency and severity of the seizures.

Doctors generally do not recommend treating a first unprovoked seizure because there is no way to know for sure whether another seizure will occur, and if so, there is no point in treating it.

Doctors can determine whether you are at risk of having another seizure by looking at your medical history, EEG, CT scan, or MRI scan.

What types of medications or treatments are used?

Like all types of seizures, there are many treatments for tonic-clonic seizures caused by epilepsy. Some people can control their seizures with just one medication. Others may need a combination of medications and other treatments.

Some of the treatments for tonic-clonic seizures caused by epilepsy include:

• Medications: There are IV medications that can be given to stop seizures; however, these are usually only given in cases of status epilepticus. There are also pills that are taken daily to prevent seizures or reduce their frequency. These are the first medications given for seizures caused by epilepsy.
• Epilepsy surgery: If medication doesn't work, sometimes surgery can be done to stop seizures by removing the part of the brain (the focal point) where the seizures start, or by isolating it from other parts of the brain. If seizures continue despite taking two types of anti-seizure medication at the recommended doses, doctors may recommend epilepsy surgery.
• Dietary changes: Low-carb or no-carb diets (`ketogenic diets`) can sometimes stop seizures completely or reduce the frequency of seizures. Although these diets can be difficult to follow, they can be helpful for people who have not responded to medication or who have severe side effects from medication. They are also an option for people who do not want to undergo surgery.
• Brain stimulation: This involves inserting a small device into the brain and delivering an electrical current to the brain. This current disrupts the electrical activity of a seizure and attempts to stop it. There are currently two methods, deep brain stimulation and responsive neurostimulation.
• Vagal nerve stimulation: Our tenth cranial nerve, the vagal nerve, is directly connected to the brain. Electrical stimulation of the left side of this nerve can reduce the frequency of seizures.

Are there any side effects or complications of the treatment?

The side effects and complications of these treatments depend on the treatment, your health history and conditions, and the type of epilepsy you have. Your doctor can tell you more about this. He or she can also tell you what to watch out for and how to minimize their effects.

How do I take care of myself and manage my symptoms?

Never treat a seizure on your own, thinking it's just a seizure. Seizures can often be a symptom of a serious condition that affects the brain. Since tonic-clonic seizures cause loss of consciousness, you may not know what happened during the seizure.

If you or someone close to you has a seizure for the first time, it is extremely important to see a doctor. A qualified doctor can examine the symptoms of the seizure and possible causes.

What if someone has a seizure while I'm there?

If someone has a seizure while you are there, there are some first aid measures you can take. Here are some things to do and things not to do:

Things to do (Dos):

• See if he can breathe. Loosen the clothing around his neck.
• Remove any dangerous objects from around him. Remove any breakable objects or anything that could fall on him. If he is wearing glasses, carefully remove them and set them aside.
• Turn him or her onto his or her side (rescue position). This position makes it easier to breathe and prevents saliva or vomit from entering the airway .
• Try to record the duration of the seizure as much as possible. This information can be very important to a doctor. It can also help determine if emergency medical help is needed.
• Stay with the person after the seizure is over and until they regain consciousness. The person who has had a seizure may feel confused and scared when they regain consciousness. Comfort and encourage them.
• After he regains consciousness, check to see if he is okay. Check to see if he has any injuries from the seizure and if he needs medical attention. If he has hit his head, or if you think he may have an injury to his neck or back, it is safest to seek medical attention. Then we can check for any serious injuries that we cannot see.
• If you have status epilepticus, call for help. If the seizure lasts more than five minutes, or if another one occurs before the first one ends, call 1990 (Sri Lanka's emergency ambulance service) immediately. This is life-threatening!

Don'ts:

• Don't try to hold him or her down or let him move. You or the other person could get hurt.
• Don't put anything in your mouth. There are many myths about seizures. One is that you should put something like a spoon or a belt in your mouth to prevent you from biting your tongue. Please don't do that. It's not a good idea to put anything in the mouth of someone who is having a seizure. You could hurt yourself or someone else.
• Don't worry. Stay calm. If people around you are worried, try to comfort them too.

How soon will I feel better after treatment?

Recovery time depends on what treatment was given and what caused the seizure. Your doctor can tell you more about this, how long it will take, and when you will feel better.

How can I reduce the risk of this? Can seizures be prevented?

Since anyone can have a seizure under the right circumstances, it is impossible to completely prevent seizures. However, some people are more likely to have a seizure. Therefore, there are things you can do to reduce your risk.

The best things you can do to reduce your risk of developing a seizure are:

• Eat a balanced diet and maintain a healthy weight. This can help prevent circulatory system diseases (e.g. stroke) and electrolyte imbalances.
• Don't ignore infections. Treating infections can reduce the risk of seizures, whether caused by an infection or the high fever associated with it.
• Wear safety equipment. Helmets and seat belts can help prevent seizures caused by head injuries.
• Do not abuse alcohol, medications, or drugs. Using or stopping these can cause seizures. If you are addicted to alcohol or drugs, your family doctor can help you find places and specialist services that can help you get rid of them.
• Manage your health conditions. Seizures can be caused directly by chronic illnesses or by other conditions that are associated with seizures. For example, if you have diabetes (Type 1 diabetes or Type 2 diabetes), control your blood sugar levels.
• Avoid things that can trigger seizures. People who have had seizures in the past due to things like bright lights should avoid such things as much as possible.

If I have had one or more tonic-clonic seizures, what should I expect?

About half of people who have had an unprovoked seizure will have another one. About 75% of people who have had a second seizure will have more. That's why doctors diagnose a second unprovoked seizure as epilepsy and start treatment for it.

For those starting medication, it may be necessary to try several medications, or a combination of medications, rather than just one. Even if medication does not help, there are other treatments that can help reduce the frequency of seizures and their severity.

How long will this situation last?

Whether or not `provoked` seizures will stop depends on whether the underlying disease or problem that caused them can be treated. For most people, once the underlying problem is gone, the seizures will not occur again, unless it comes back.

Epilepsy is a lifelong condition because it cannot be cured. However, in some cases, the underlying cause of the seizures can be treated. When that is done, and you are able to remain seizure-free, your condition is said to be "in remission."

What is the outlook for tonic-clonic seizures?

For provoked tonic-clonic seizures, the prognosis depends on the underlying condition. If the condition is treatable, and you get treatment early, the prognosis is usually good. Your doctor can best tell you what the prognosis is for your condition and what you can do.

Although provoked seizures that occur with permanent or serious medical conditions (e.g., cancer, permanent brain damage) can sometimes be treated, the prognosis is usually poor due to the underlying cause. Seizures caused by genetic and congenital conditions also have a poorer prognosis.

The outlook for unprovoked seizures depends on several factors, including the underlying condition, the severity of the seizures, how often they occur, and whether treatment is helping.

Sudden unexpected death in epilepsy (SUDEP)

SUDEP is a rare condition that can affect anyone with epilepsy, but is less likely to occur when treated. One in 150 people with untreated epilepsy are at risk of SUDEP, compared to one in 1,000 people with treated epilepsy.

Experts still don't know exactly why SUDEP happens. The best explanation currently is that it's caused by heart or breathing problems that can occur along with seizures.

How do I take care of myself?

If you've had a tonic-clonic seizure once, it's a good idea to know what to do if you have another one. If you have another seizure or if you have a medical condition that can cause seizures, see your doctor as soon as possible.

If your doctor determines that you have epilepsy, there are several things you can do to help manage the condition:

• Take your medication as prescribed. It's important to continue taking your medication, even if you feel better. You should only stop taking your medication after talking to your doctor and if he or she tells you to.
• Talk to your doctor about your options. If you want to reduce your medication or switch to a different medication, talk to your doctor. He or she can guide you on how to do this safely and what options are available.
• See your doctor regularly. These appointments are important to manage your condition, monitor your progress, and make sure your medications and treatments are working properly.
• Don't ignore the symptoms. Early recognition and treatment can make a big difference in the treatment of seizures and epilepsy.

When should I go to the emergency room?

If you have an incident where you lose consciousness and you don't know why, you should go to the emergency room. Many people have people around them when they have their first seizure, but not everyone does. If you are alone and think you are having your first seizure, you should see a doctor right away.

If the person having a seizure knows that they have epilepsy, it is often not necessary to call an ambulance. However, if the seizure has caused injury, they may need medical attention.

When should I ask for help?

If someone has a seizure while you are present, remember these things:

• If this is his first seizure, seek help. Anyone who has a first seizure, whether suspected or confirmed, should be evaluated by a doctor. Seizures are often a symptom of a serious health problem.
• If you have status epilepticus, seek help. If the seizure lasts more than five minutes, or if another one occurs before the first one ends, call 1990 (Sri Lanka's emergency ambulance service) immediately. This is life-threatening! If you do not regain consciousness or respond properly for more than 10-15 minutes after the seizure has stopped, you should seek emergency help. This may be a sign that the seizure is still ongoing in the brain, even though you may not be moving.

If I have epilepsy, is it safe to get pregnant while taking medication?

Women with epilepsy can often have children. However, many medications used to treat epilepsy are not safe to take during pregnancy, as they can interfere with the development of the baby in the womb.

Fortunately, there are other medications that can be used temporarily during pregnancy, or at some point during it. The best person to talk to about this is your doctor. He or she can either give you direct guidance or refer you to a specialist.

Finally, things to remember (Take-Home Message)

Tonic-clonic seizures are a type of seizure that is easy to recognize and often frightening. It is normal to feel scared when you see them or when you have them. However, most of the time, they stop on their own within a few minutes. Although they can occur for many reasons, these seizures usually go away, especially when the underlying condition is treated. When these seizures occur with epilepsy, there are many ways to treat them. With effective treatment, many people with these seizures – even those with epilepsy – can live happy, successful, and fulfilling lives.

So, if you or someone you know has a problem with something like this, don't be afraid to seek medical advice. Quick treatment can turn many things around for the better.

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