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

Clinical answer with reasoning, red flags and references. Clinically reviewed by Dr Kola Tytler MBBS CertHE MBA MRCGP.

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 .
Use a 12-lead ECG to help identify cardiac conditions that could mimic seizures .
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 .
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 .

Management in primary care:

Undertake a routine review at least once a year, assessing seizure control, medication adherence, and impact on daily life .
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 .
Assess for mental health issues such as anxiety and depression, and cognitive problems, and manage appropriately .
Ensure the person is aware of driving regulations and has contacted the DVLA if they wish to drive .
Check adherence to antiepileptic drugs, monitor for adverse effects, and consider blood level testing if toxicity or non-compliance is suspected .

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 .
Children under 3 years, or those with specific features such as deterioration in behaviour, speech, or learning, should be referred urgently within 2 weeks .
Ensure access to epilepsy specialist nurses for information, education, and support, with regular reviews, especially for those with ongoing seizures .

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