Protocol · WHO mhGAP
Epilepsy and seizures (mhGAP)
A convulsion is an emergency until it stops. Then ask whether something caused it, such as fever, infection, head injury, low glucose, alcohol or eclampsia. Epilepsy means repeated seizures with no acute cause. Most people can be well controlled with one regularly available medicine.
- Based on WHO mhGAP
- For doctors, clinical officers and nurses
- Reviewed October 2026
1Who / 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.
2Red 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.
3Assess
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.
4Classify
| 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 |
5Treat
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).
Status epilepticus is managed in a facility with oxygen and monitoring: IV phenytoin, phenobarbital, valproate or levetiracetam per national 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.
6Follow-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.
7Counsel
- 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.
8When 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.
9Sources
- World Health Organization. mhGAP Intervention Guide for mental, neurological and substance use disorders in non-specialized health settings, version 2.0. 2016 (ISBN 9789241549790). Epilepsy module (EPI emergency, EPI 1 to 3) and Table 1.
- World Health Organization. Mental Health Gap Action Programme (mhGAP) guideline for mental, neurological and substance use disorders. 2023 (ISBN 9789240084278). Recommendations EPI1 to EPI5 (first-line lamotrigine or levetiracetam; no valproate in women and girls of childbearing potential; nocturnal supervision).
- 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.
Adapted from WHO guidance; not endorsed by WHO. This page paraphrases and adapts the WHO publications listed under Sources, which are licensed CC BY-NC-SA 3.0 IGO; the adapted text is shared under the same licence for non-commercial education. Reasoning GP is not affiliated with WHO or any other organisation named here. Use it alongside your national guidelines, essential medicines list and formulary, and your clinical judgement. Doses are given only where they come from a WHO source; otherwise follow your national guideline or formulary.