Norton Children’s

Published: July 21, 2026

When a child presents with a first seizure, the temptation is to order tests immediately. But the most powerful diagnostic tool is a carefully obtained history and witness description, according to Siddharth V. Jain, M.D., pediatric epileptologist with Norton Children’s Neuroscience Institute and assistant professor of pediatrics at the University of Louisville School of Medicine.

Testing, Dr. Jain emphasized, should be considered in conjunction with what clinical reasoning has already suggested.

In a recent continuing medical education opportunity, Dr. Jain presented a five-step clinical framework for evaluating new-onset seizures in pediatric patients. The structured approach is designed to guide front-line clinicians from initial presentation through diagnosis, workup and risk stratification.

Step 1: Is this actually a seizure?

Before any other consideration, clinicians need to determine whether the event was a seizure at all. Does it meet the description of a transient, stereotyped, network-driven event resulting from abnormal electrical activity in the brain? Three features characterize it:

• Transient – It comes and goes without lasting effect; think of it as a brief electrical storm.
• Stereotyped – It follows a predictable, repeatable pattern each time it occurs in that patient. This is the single most powerful discriminating feature between epileptic seizures and parasomnias, behavioral events and psychogenic nonepileptic seizures (PNES).

Network-driven – the sequence of symptoms mirrors well-defined brain networks, which is why seizures can present so differently depending on where they originate

These three features are not just academic distinctions — they are the practical lens through which witness descriptions become diagnostic data.

Seizure vs. epilepsy: An early and essential distinction

This distinction must be made early and clearly communicated to families, according to Dr. Jain. A seizure is a single event — an isolated episode of abnormal electrical activity. Epilepsy is the underlying disease: a brain disorder characterized by an enduring predisposition to generate epileptic seizures.

Clinically, epilepsy is diagnosed when any of the following criteria are met:

• Two or more unprovoked seizures occurring more than 24 hours apart
• One unprovoked seizure plus electroencephalogram (EEG) or clinical features that put the recurrence risk above 60% — equivalent to the risk seen after two unprovoked seizures
• A single seizure with features that match a specific epilepsy syndrome, such as childhood absence epilepsy (CAE), juvenile myoclonic epilepsy (JME), or West syndrome (infantile spasms)

This shapes the urgency of workup, the conversation with families and the decision about whether to initiate treatment.

Step 2: Localize using semiology

Careful observation of what happens during a seizure — its semiology — provides critical localizing information before any test has been ordered. Video EEG is the gold standard, but in the clinic, a well-obtained witness description is the first diagnostic tool.

When taking the history, Dr. Jain recommends starting with open-ended questions (“Tell me what you saw.”), then becoming specific: What was the first thing that happened? Which body part moved first? Was the patient aware and responsive? How long did it last? What happened after it ended?

Seizure semiology maps to cortical anatomy. Here is a practical summary of what each region of onset looks like:

Frontal lobe

• Often nocturnal, brief (10 to 60 seconds), occurring in clusters
• Hypermotor features: thrashing, bicycling legs, pelvic thrusting — can appear bizarre or behavioral
• Asymmetric tonic posturing; head and eye deviation away from seizure focus
• Rapid return to baseline with minimal or no postictal confusion
• Common mimics: parasomnias, behavioral events; key differentiator is stereotypy

Temporal lobe (most common lobe of focal onset)

• Aura as cardinal clue: epigastric rising sensation, déjà vu, fear or dread
• Behavioral arrest with oral and manual automatisms (lip smacking, hand fumbling)
• Prolonged postictal confusion — a key distinguishing feature from absence seizures and PNES
• The Metzer sign: postictal nose wiping with the ipsilateral hand (contralateral hand relatively weak)
• Common mimics: panic attacks, daydreaming

Parietal lobe

• Positive sensory symptoms: tingling, numbness, paresthesias marching across the body (Jacksonian sensory march)
• Distorted body perception; spatial disorientation
• Often spreads to adjacent lobes, so semiology may reflect spread rather than onset
• Common mimic: migraine with aura — key difference is that epileptic sensory symptoms build fast and resolve quickly; migraine aura evolves over five to 20 minutes

Occipital lobe

• Elementary visual hallucinations: colored lights, flashing spots, zigzag patterns — brief and stereotyped
• Rapid spread anteriorly to temporal (automatisms) or parietal cortex
• Seizure appearing temporal or parietal in origin (if visual aura goes unrecognized)
• Common mimic: migraine with visual aura

Insula

• Visceral and autonomic auras: throat tightness, chest pressure, laryngeal sensation, flushing, tachycardia
• Ictal pain possible — often described as burning or electrical
• EEG may not clearly localize due to the insula’s depth
• Common mimics: panic disorder, cardiac disease, gastrointestinal reflux disease (GERD)

Step 3: Determine need for EEG, MRI and admission

History first — it is the workup

When a patient presents after a first unprovoked seizure, the detailed history is not preliminary to the workup — it is the workup. The history guides every subsequent decision: what tests to order, whether to admit and how to stratify recurrence risk.

Key elements to document: event description (stereotypy, duration, progression), level of awareness, postictal phase, relevant history (prior febrile seizures, family history of epilepsy, neurodevelopmental conditions) and any precipitating factors.

When to order an EEG

A routine EEG is appropriate in most children with a reasonable clinical concern for seizures or epilepsy. Beyond simply confirming or ruling out a seizure, EEG can:

• Classify seizures as focal versus generalized, which directly guides medication selection.
• Assess recurrence risk based on the frequency and character of discharges.
• Detect subclinical epileptic activity during sleep that may affect cognitive development without causing overt seizures.
• Reveal a syndrome diagnosis after a single seizure — for example, classic 3-hertz spike-wave in a child with staring spells points to CAE.

A few important caveats for primary care:

• A normal, routine, awake EEG does not rule out epilepsy — sleep capture and sleep-deprived or prolonged EEGs significantly improve yield.
• EEG abnormalities can appear in children with attention-deficit/hyperactivity disorder or autism who do not have epilepsy, which reduces specificity.
• If clinical suspicion remains high after a normal EEG, repeat with sleep capture or consider a prolonged video EEG.

When to order an MRI

MRI is not needed for every first seizure. It is indicated when there is concern for a structural or focal cause, including:

• Focal onset semiology (any of the lobar patterns above)
• Focal neurological deficits on exam
• Abnormal or focal EEG findings
• Unusual features such as gelastic seizures (raises concern for hypothalamic hamartoma) or ictal vomiting (suggests right temporal or insular involvement)
• Failure to respond to appropriate first-line therapy

Red flags requiring urgent evaluation

The following warrant urgent or emergency evaluation — they may signal an acute neurological condition such as infection, stroke or injury rather than primary epilepsy:

• Status epilepticus: seizure lasting more than five minutes
• Recurrent seizures without return to baseline between episodes
• Focal neurological deficits persisting after the event
• Severe headache with altered mental status following the seizure
• Fever with altered mental status beyond the expected postictal period

Admission decisions

Not every first seizure requires admission. A child who has returned to baseline, has no focal deficits, no red flags and a clear first unprovoked seizure in the context of normal development often can be managed as an outpatient with close follow-up and expedited EEG. Admission is appropriate when the diagnosis is unclear, red flags are present, or PNES is suspected and inpatient video EEG monitoring is needed to capture an event.

Step 4: Interpret EEG in context

EEG must never be interpreted in isolation. A positive finding alone is not sufficient for diagnosis, and a normal EEG does not rule out epilepsy. The EEG has to be read alongside the clinical picture.

Key considerations:

• Pretest probability matters — stronger clinical suspicion increases the value of an abnormal result.
• Normal pediatric EEG variants can be mistaken for pathological discharges; specialist interpretation is important.
• Syndrome-specific patterns carry weight: 3-hertz spike-wave provoked by hyperventilation in a school-age child with staring spells strongly suggests CAE; generalized polyspike-wave in an adolescent with morning myoclonus points to JME.
• The timing of EEG abnormalities relative to sleep and wakefulness adds diagnostic and prognostic information — certain epilepsies activate at specific sleep-wake transitions.
• In developmental and epileptic encephalopathy (DEE), the burden of epileptic activity on EEG may independently contribute to cognitive slowing, which can influence treatment decisions beyond seizure control.

Step 5: Assess recurrence risk and diagnose epilepsy

The final step pulls together everything from the preceding four to answer the question families ask most: How likely is this to happen again?

Recurrence risk is shaped by:

• EEG findings – Epileptiform discharges increase estimated risk.
• Etiology – Structural causes (prior stroke, cortical dysplasia on MRI) carry higher risk than an idiopathic first event.
• Syndrome classification– Age of onset, developmental trajectory and seizure type can point to a specific syndrome, each with its own prognosis.

A single seizure with clear syndrome features (e.g., 3-hertz spike-wave on EEG after a staring spell) can establish an epilepsy diagnosis right away.

Syndrome identification, when possible, is the most actionable step. According to Dr. Jain, a patient with childhood absence epilepsy has a fundamentally different trajectory than a child with Dravet syndrome — even though both may present with generalized seizures.

Getting to a syndrome diagnosis:

• Drives medication selection – Some medications are syndrome-specific; some are contraindicated in certain syndromes.
• Sets expectations for treatment duration – CAE typically resolves by adolescence; JME generally requires lifelong treatment.
• Guides genetic counseling and anticipatory guidance about comorbidities.
• Informs surgical candidacy discussions for refractory focal epilepsy.

When a syndrome diagnosis cannot be made, treatment follows general principles based on seizure type (focal versus generalized). Further clinical evaluation and repeat testing may clarify the picture over time.