Who / when
- Anyone convulsing now, or unresponsive and stiff.
- People with episodes of loss of consciousness with stiffness or jerking, tongue biting, incontinence, and drowsiness or confusion afterwards.
- This protocol covers convulsive seizures.
Red flags: refer now
- Convulsion lasting more than 5 minutes, or not waking up between convulsions (status epilepticus).
- Fever, stiff neck, headache or confusion: possible brain infection.
- Head injury, new weakness on one side, or other focal signs.
- Second half of pregnancy or up to 1 week after birth, with no past epilepsy: suspect eclampsia.
- Child aged 6 months to 6 years with fever and a seizure that is focal, lasts more than 15 minutes, or repeats in the same illness.
Refer urgentlyPossible head injury, brain infection (fever) or focal deficit: refer urgently to hospital.
Assess
During the convulsion
- Airway, breathing, circulation. Keep head and neck still if injury is possible. Time the convulsion.
- Lay the person on their side in a safe place; loosen tight clothing; something soft under the head. Nothing in the mouth. Do not leave them alone.
- Check glucose, BP, temperature and breathing rate.
Afterwards: is it epilepsy?
- Convulsive seizure likely: movements lasting more than 1 to 2 minutes plus at least two of: loss of consciousness, stiffness, bitten tongue or injury, incontinence, drowsiness, confusion, headache or one-sided weakness afterwards.
- Think of fainting (sweating, pallor, vision going dark first) and stress-related non-epileptic attacks.
- Look for an acute cause: fever, infection, head injury, low glucose or sodium, alcohol or drug intoxication or withdrawal.
- Epilepsy: at least two seizures on two different days in the past year, with no acute cause.
- Ask about birth injury, head injury, brain infection, family history; check for depression and substance use.
Classify
| Picture | Classify as | Action |
|---|
| Convulsing after 2 doses, or no recovery between convulsions | Status epilepticus | Treat in a health facility; refer |
| Fever, stiff neck, head injury or focal signs | Acute cause | Treat the cause; refer urgently |
| Child 6 months to 6 years, fever; focal, over 15 minutes, or repeated | Complex febrile seizure | Refer for admission |
| Child 6 months to 6 years, fever, none of the above | Simple febrile seizure | Find the cause (IMCI); observe 24 hours; no epilepsy medicine |
| Two or more unprovoked seizures on different days in a year | Epilepsy | Start one medicine |
| One seizure, no cause found | Not epilepsy yet | No maintenance medicine; review in 3 months |
Treat
Stop the convulsion
- No IV line: rectal diazepam (adult 10 mg; child 1 mg per year of age) or buccal or intranasal midazolam (adult 5 to 10 mg; child 0.2 mg/kg).
- IV line: diazepam 10 mg IV (child 1 mg per year of age) or lorazepam 4 mg IV (child 0.1 mg/kg). Give glucose (adult 5 mL of 50%; child 2 to 5 mL/kg of 10%).
- Still convulsing 10 minutes after the first dose: give a second dose. Never more than 2 doses; then refer urgently. Watch breathing.
- Eclampsia: magnesium sulphate 10 g IM and refer (follow your obstetric protocol).
Epilepsy: maintenance (one medicine, lowest dose, increase slowly)
- First line (WHO 2023): lamotrigine or levetiracetam; valproate is also first line for generalised seizures in men and in women who cannot become pregnant; carbamazepine for focal seizures if neither is available; phenobarbital or phenytoin if nothing else is. Choose a medicine that will always be available. Doses per national formulary.
- mhGAP-IG adult starting doses: carbamazepine 100 to 200 mg daily in 2 to 3 doses; phenobarbital 60 mg daily in 1 to 2 doses; sodium valproate 400 mg daily in 2 doses.
- Women and girls who could become pregnant: lamotrigine or levetiracetam; not valproate. Folic acid 5 mg daily for all women of childbearing age. In pregnancy avoid combinations and never stop medicine suddenly.
- People living with HIV: check interactions; mhGAP-IG prefers valproate (but not in women who could become pregnant); avoid phenytoin and carbamazepine where possible.
Follow-up
- Every 3 to 6 months: seizure diary, adherence, side effects, mood, new medicines, pregnancy plans.
- Seizures not halved: check adherence, raise the dose if tolerated; then switch (start the new one before tapering the old); still poor: refer.
- Drowsiness, unsteadiness or double vision usually mean the dose is too high.
- Seizure-free for at least 2 years: discuss stopping, reducing over about 2 months.
Counsel
- Epilepsy is a brain condition, not caused by witchcraft or spirits, and not contagious. Most people can live normal lives, marry, work and go to school.
- Take medicine every day; never stop suddenly.
- Avoid swimming alone, cooking on open fires, and jobs with a high risk of injury such as heavy machinery; follow local driving rules.
- Avoid heavy alcohol and too little sleep.
- Family: lay the person on their side, nothing in the mouth, do not hold them down, stay until they wake. Seek help for a convulsion over 5 minutes, breathing difficulty, or not waking up.
- Night-time supervision can be considered to reduce the risk of sudden death in epilepsy.
Fits come from the brain and can be controlled with medicine taken every day. During a fit, turn the person on their side, put nothing in their mouth, and stay with them.
When to refer
- Urgently: status epilepticus; suspected brain infection, head injury, eclampsia or focal signs; complex febrile seizure.
- Possible underlying cause (birth injury, head injury, brain infection, family history) for further evaluation.
- Not controlled after two single medicines at adequate doses.
- Women planning pregnancy or pregnant; children with developmental or behavioural problems.
Sources
World Health Organization. mhGAP Intervention Guide for mental, neurological and substance use disorders in non-specialized health settings, version 2.0. 2016. World Health Organization. Mental Health Gap Action Programme (mhGAP) guideline for mental, neurological and substance use disorders. 2023. World Health Organization. Basic emergency care: approach to the acutely ill and injured (WHO and ICRC). 2018. World Health Organization. WHO Model List of Essential Medicines. 2025.