Certain types of spells or events can be mistaken for seizures and epilepsy. Examples of these imitators of epilepsy are described below.

It is important to see a health care provider who can confirm what type of events you are having and what types of testing or treatment may be needed. It is very helpful to take a cell phone video of the events, if possible, to show your health care provider.

The conditions listed here can be mistaken for epilepsy. They are separated into types of health problem.

Movement Disorders

Jitteriness

  • Jitteriness refers to tremor-like movements that are seen in one or more limbs in babies.
  • While jitteriness is often seen in healthy babies, in the first day of life, it can also be due to other medical causes, such as low blood sugar, low calcium levels or neonatal abstinence syndrome (symptoms that are seen when a baby withdraws from certain drugs).
  • Jitteriness can be distinguished from epilepsy seizures as it happens more often when the baby is unwrapped, stimulated, startled or crying. It can be stopped when the baby is wrapped, or the affected limb is held gently.

Hyperekplexia (Startle Disease)

  • Hyperekplexia is seen when there is an exaggerated normal startle response. It is usually genetic, with several types of gene variants known to cause this condition.
  • Symptoms often start very early in infancy. Babies are commonly very stiff. The stiffness can go away in sleep. They can startle too much in response to normal touch, noise or any unexpected stimulus. This can rarely lead to problems with breathing and bluish color of their lips.
  • Clonazepam may help reduce the startle and in decrease stiffness.
  • Symptoms tend to go away after infancy, but adults may have increased startle-induced falls and muscle twitches at night.

Benign Myoclonus of Infancy and Shuddering Attacks

  • Benign myoclonus of infancy and shuddering attacks are both self-limited and not harmful to the infant. They involve a brief jerk or shiver-like movement, sometimes with a change in the child’s facial expression.
  • These attacks typically start around 4 months of age. They can last up to the age of 6-7 years, with a remitting and relapsing course. For example, periods of the attacks can go away for a while then return.
  • Attacks can be very frequent, but each one usually lasts just a few seconds.
  • Attacks can be triggered by certain activities, such as feeding, head movements or certain tasks.
  • The events do not cause the child any distress and they return to their previous activity right away. There is no loss of awareness with these events.

Benign Paroxysmal Tonic Upgaze

  • Benign paroxysmal tonic upgaze starts in early infancy. The baby’s eyes gaze up for hours or days. The child is aware during the events.
  • Attacks are more common when the baby is sick with another illness.
  • These attacks go away after a few years.
  • A large number of children with these events may also have learning disabilities.

Tics

  • Tics are involuntary, sudden movements or sounds that are most commonly seen in children. They can wax and wane (start and stop) in number and intensity over time.
  • Tics are generally very brief, lasting seconds at most. They involve movements (such as head shaking, shoulder shrugging, blinking, scrunching up the face) or noises (such as repetitive throat clearing or sniffing).
  • Typically, the person feels an urge or compulsion to perform the tic. They are also able to briefly suppress the tic. These features help distinguish tics from seizures.

Stereotypies

  • Stereotypies are repetitive movements, such as body rocking, head banging or finger movements.
  • They can occur in otherwise healthy children but are more common in children with autism or intellectual disability.
  • They often occur when the child is less engaged in activities.
  • Stereotypies can be interrupted by engaging the child in activities.

Alternating Hemiplegia

  • Alternating hemiplegia of childhood is a rare disorder that starts in the first year of life. Infants develop recurrent attacks of weakness that affect one or the other side of the body. Sometimes weakness can affect both sides at once.
  • Attacks may last minutes to more than half an hour.
  • At first, infants are usually well between spells. As time goes on, many may develop a movement disorder called choreoathetosis, abnormal motor development, and learning problems.
  • Events may be triggered by stress, water, certain foods and exercise. The symptoms may resolve during sleep but may return 10-20 minutes after waking.
  • Children with alternating hemiplegia may have a higher risk of focal seizures over time.
  • Most, but not all, infants with this condition have changes in the ATP1A3 gene.

Sleep Disorders

Benign Neonatal Sleep Myoclonus

  • Benign neonatal sleep myoclonus is a normal sleep phenomenon that can be very frequent in some babies. It begins in the newborn period and may last for months to years.
  • Movements consist of brief shaking of one or more arms or legs and occur only during sleep. If the baby is woken, the movement stops. This is a key point to confirm the diagnosis.
  • Babies are otherwise healthy with normal feeding and behavior.
  • No treatment is needed.
  • Babies will ultimately outgrow this condition and develop normally.

Sleep-related Rhythmic Movement Disorders

  • Sleep-related rhythmic movement disorders include body rocking, rolling and head banging. These are usually exaggerated movements or habits seen in babies that may appear to be comforting. They happen in the sleep-wake transition or as a baby falls asleep. Sometimes noises can be heard with these events, which disturbs the rest of the family.
  • If events occur in older children and are seen repeatedly through the night, frontal lobe seizures should be excluded. Capturing the movements on video to share with your health care provider can be very helpful.

Hypnic Jerks

  • Hypnic jerks are normal phenomena felt in varying degrees by the majority of children and adults when they fall asleep. The person will suddenly twitch and may wake up briefly.
  • They are more common in children with motor and developmental disorders.

Parasomnias (Night Terrors, Sleep Walking, Confusional Arousals)

  • Night terrors, sleep walking and confusional arousals (or waking up confused) are behaviors that happen when a person is in a deep sleep, typically in the first-third of the night’s sleep. These are very common and tend to occur in families where there are other individuals with parasomnias.
  • Arousals can vary a lot. A child may sit up in bed and try to speak (often making no sense) and then lie down again. Or it can be a night terror in which a child wakens, may walk, talk, appear agitated or frightened, shout, scream, and fail to recognize family members. The events typically last several minutes, and the person returns to sleep immediately afterwards. The child has no memory of the event the next morning.
  • They can be regarded as part of normal sleep unless the behavior disrupts the individual or their family.
  • If arousals happen more than once a night or every night, then frontal lobe seizures should be considered. Capturing the event on video to show to your health care provider can be very helpful.
  • Frontal lobe seizures are usually briefer (less than 2 minutes), look nearly identical from spell to spell, and often have preserved awareness. In contrast, parasomnias usually last longer (greater than 10 minutes), are much more variable from event to event, and are associated with confusion and no memory of the event afterwards.
  • Parasomnias typically occur in the first-third of the night only. Frontal lobe seizures usually occur any time during the night.

Narcolepsy-cataplexy

  • Narcolepsy-cataplexy is a sleep disorder in which the distinctions between sleep and wakening are blurred.
  • Onset is typically in the teenage years, though it can occur in younger children and begin later in life.
  • Affected persons are very sleepy during the day. They also may have cataplexy (loss of body tone in response to strong emotion such as laughter), hallucinations that occur when waking up or falling asleep, sleep paralysis (a feeling of being unable to move when you wake up), and disturbed night-time sleep.
  • This disorder is more common among certain families.
  • It is typically lifelong.

Migraine or Migraine-equivalent Disorders

Benign Paroxysmal Torticollis

  • Benign paroxysmal torticollis is considered a type of migraine that happens in babies and early childhood. The main symptom is forced turning of the head to one side that can last minutes to hours.
  • During these episodes, babies appear pale and distressed. They may also vomit. If the child is old enough to walk, they are often unsteady during the attack.
  • This disorder resolves by early childhood, but many persons will develop migraine headaches later.

Benign Paroxysmal Vertigo

  • Benign paroxysmal vertigo is considered another type of migraine in childhood. Children feel off-balance like the world is spinning. They appear anxious and clutch onto an adult or lie down. They may vomit or have unusual movements of their eyes with these attacks.
  • The episodes last minutes to, less commonly, hours.
  • They resolve by mid-childhood, but many persons will develop migraine headaches later in life.

Cyclical Vomiting

  • Cyclical vomiting is a type of migraine in children too.
  • Children have periods of recurrent vomiting that may last hours to days. The child may feel well between episodes for weeks at a time.
  • Usually no specific trigger can be found.
  • Episodes usually start in early childhood and may evolve to migraine headaches with age.

Migraine with Aura

  • Migraine with aura is very common.
  • The aura is a feeling that starts minutes before the actual headache. A visual aura is common and can take a variety of forms. It’s typically seen on one side and contains flashes, arcs of lights, specks, flames, or blanking out or greying of the visual field.
  • The headache is often one-sided, throbbing, and associated with nausea, vomiting, and light sensitivity.
  • Some people can have changes in perceptions before a migraine headache, such as a feeling that a body part or parts (such as the hands) have grown dramatically or shrunk or that everything in the environment is louder. This is termed “Alice in Wonderland syndrome” and is most likely a migraine variant.

Familial Hemiplegic Migraine

  • Familial hemiplegic migraine is a type of migraine where the aura involves weakness of one side of the body. There is often speech disturbance, visual symptoms, and tingling on one side.
  • Variants in the genes CACNA1A, ATP1A2, and SCN1A are associated with familial hemiplegic migraine.
  • Severe attacks may be triggered by trauma and illness.

Psychological Disorders

Psychogenic Nonepileptic Seizures (PNES) or Events

Daydreaming and Inattention

  • Daydreaming and inattention are common and can be misdiagnosed as absence seizures. In contrast to absence seizures, daydreaming is often situational and seen more frequently at times when the child is tired, relaxed or bored. Daydreaming also lasts longer than absence seizures.
  • During daydreaming spells, the child stares blankly and appears to not respond to those around them. The child may not respond to someone calling them but will respond immediately to a strong touch stimulus (such as a tickle or pinch). A child cannot be distracted out of an absence seizure.
  • Daydreaming is more common in children with attention and learning difficulties.

Tantrums and Rage Attacks

  • Tantrums are common in young children and are usually easy to distinguish from an epileptic seizure. Rage reactions are recurrent episodes of rage that seem out of proportion to relatively minor stimuli. There may be screaming, swearing, aggression, damage to property, and physical violence. Throughout the event, it may seem the individual is not normally responsive.
  • Rage reactions typically last many minutes and sometimes up to half an hour or longer.
  • Individuals often report no memory of the event and may express remorse for their actions.
  • Aggressive or violent behaviors in an epileptic seizure are very rare. If these behaviors happen in a seizure, they are typically confused and non-directed actions.

Panic Attacks

  • Panic attacks are brief episodes, each lasting between 5 and 20 minutes.
  • They are seen as a sudden feeling of apprehension, anxiety, impending doom, fear or terror. Symptoms of breathlessness, a choking sensation, fluttering of the heart, chest pain, tingling of the fingers and mouth, dizziness, sweating, trembling, feeling faint, or loss of consciousness may also happen during panic attacks.
  • It may not be easy to identify a precipitant or trigger.
  • A family history of panic disorder, generalized anxiety disorder or depression may be seen.
  • Panic attacks can be distinguished from epileptic auras that present with a panicky feeling by the following variables:
    1. An epileptic aura with panic (ictal panic) is very short - less than 30 seconds.
    2. The intensity of the feeling of fear is less intense in a seizure than in panic attacks.
    3. An ictal panic is often associated with other seizure symptoms that involve temporal lobe structures, such as too much saliva, an uncomfortable feeling in the stomach, or a feeling of deja-vu. Panic in a seizure is often followed by loss of awareness of the surroundings.

Other

Tet Spells

  • Tet spells are a rare condition associated with a heart abnormality called Tetralogy of Fallot, which leads to obstruction of blood flow from the right heart to the lungs.
  • Babies and young children with Tetralogy of Fallot may suddenly develop blueness of the skin, nails and lips, often after crying, feeding or if agitated. Often toddlers will squat down during these spells.
  • In contrast to children with breath-holding spells who are otherwise healthy, those with Tet Spells have other symptoms of heart disease, including persistent blue discoloration of their skin between the spells, shortness of breath with movement or feeding, and poor growth.
  • If you suspect your child may have Tet spells, they need to be assessed by your health care provider right away. A child with Tetralogy of Fallot will need surgery.

Sandifer Syndrome

  • This syndrome is seen in babies with a medical condition called gastro-esophageal reflux (regurgitation of the food from the stomach back into the esophagus). The events are often seen with or after feeding.
  • The infants arch their back and turn or tilt their head, often with stiffening of their arms and legs. They may cry or appear uncomfortable during the event.
  • The events may be frequent.
  • Treatment of the gastro-esophageal reflux can help these symptoms go away.

Breath-holding Spells

  • Breath-holding attacks are common and affect about 1 in 20 children. They are more common if another family member had them or if there is a family history of fainting.
  • They can be very frightening to see but are not serious.
  • Breath-holding attacks can be distinguished from seizures as they are provoked, typically by pain or the child becoming upset.
    • Typically, the child will begin crying and then stop breathing as they breathe out.
    • It may sound like a silent cry or a series of grunts.
    • The child's face becomes blue, and they lose responsiveness and may appear floppy.
    • Sometimes, the child may have stiffening of the whole body and arching of the neck.
    • Often, there may be some irregular, very brief shaking movements of the arms or legs.
    • The child usually recovers consciousness quickly. Some children may sleep after an event.
  • The attacks are more common if the child has iron deficiency anemia. Treatment of the anemia with an iron supplement may lessen the attacks.
  • Children with breath-holding attacks outgrow them by the preschool years and always by age 6.

Vasovagal Syncope

  • Vasovagal syncope affects all ages from infancy to old age.
  • These attacks are often triggered by prolonged standing, dehydration, change in posture and emotional upset.
  • The heart rate slows and blood pressure drops, causing reduced blood flow to the brain. Early symptoms include blurring and loss of vision, ringing in the ears, and dizziness. The person appears pale and may describe a sense of flushing, sweating, feeling warm, nausea and stomach discomfort. Usually they crumple to the ground, with loss of tone, but stiffening and shaking movements may be seen at least half of the time. Shaking is very brief, lasting only seconds.
  • After vasovagal syndrome, the person is confused for only a very brief time and can then return to their activities, although they may feel lightheaded.
  • Urinary incontinence can be seen.
  • A family history of vasovagal syncope is common.
  • These episodes can be distinguished from epileptic seizures by the shorter length, triggers, associated symptoms, and quick recovery.

Long QT and Cardiac Syncope

  • Long QT and cardiac syncope are important to recognize as they may be life threatening.
  • These conditions cause lightheadedness or loss of consciousness and are caused by lack of blood flow to the brain due to a heart problem.
  • People who have an episode of syncope triggered by fright, exercise, surprise, and immersion in water should be assessed for prolonged QT syndrome.
  • Syncope in sleep, a strong family history of syncope, and a history of sudden death or drowning should raise suspicions of a cardiac syncope.
Authored By: 
Elaine Wirrell MD
Authored Date: 
10/2019
Reviewed By: 
Patty Obsorne Shafer RN, MN
Elaine Kiriakopoulos MD, MSc
on: 
Sunday, October 13, 2019