RCGP SCA Algorithm — UK Primary Care
A first suspected seizure requires urgent referral for specialist assessment within 2 weeks. Send the patient to the emergency department or call 999 if there is persistent altered consciousness, ongoing/recurrent seizure activity, injury requiring treatment, new focal neurological deficit, meningism/fever, severe persistent headache, suspected intracranial pathology, significant metabolic disturbance, pregnancy/eclampsia, or a high-risk cardiac presentation. A patient who has fully recovered from a single suspected seizure, with no red flags and a normal initial assessment, may be referred urgently through the first-seizure pathway rather than automatically sent by ambulance.
The clinical challenge is that many patients presenting with "fits" do not have epilepsy — syncope and functional/dissociative seizures (PNES) can be misdiagnosed as epilepsy, leading to unnecessary antiseizure treatment. Conversely, cardiac syncope from arrhythmia is life-threatening if missed. A witness account is a key discriminator — always obtain collateral history and video footage where available; the diagnosis remains clinical and specialist.
The history is central to the diagnosis. Always obtain a witness account — phone the witness if necessary — and ask for video footage where available (NICE NG217).
Lateral tongue biting is strongly supportive of epileptic seizure, and prolonged post-ictal confusion is also supportive — but no single feature is diagnostic in isolation. Syncope risk scores (such as the Canadian Syncope Risk Score) were developed for emergency departments; in primary care, use the red-flag features (NICE CG109). DVLA notification is a legal requirement — failure to advise patients about driving restrictions after first seizure is a significant medico-legal risk.
Functional/dissociative seizures (PNES) are an important differential — misdiagnosis in either direction causes harm. Diagnosis is specialist-led, usually with video-EEG capturing a typical event where appropriate. Cardiac syncope is lethal if missed: Brugada syndrome, long QT, and HOCM cause sudden cardiac death in young, apparently healthy people — the ECG is the key screening test.
Lying-to-standing BP is essential in any unexplained LOC — orthostatic hypotension is common in older people and is frequently missed. An innocent-sounding ejection systolic murmur in a young patient with exertional syncope may indicate HOCM — the murmur increases on Valsalva (unlike aortic stenosis). Papilloedema in a patient with seizures mandates emergency CT before LP — lumbar puncture with raised ICP causes tonsillar herniation.
ECG is the most important immediate investigation — inherited arrhythmia syndromes such as long QT cause sudden death in young people, many without prior symptoms. QTc measurement requires a calibrated measurement (automated ECG machines often miscalculate). NICE NG217 recommends MRI (epilepsy protocol) as the preferred imaging after epilepsy is diagnosed, unless idiopathic generalised epilepsy or another specified syndrome; CT is less sensitive for epileptogenic lesions. A normal EEG does NOT exclude epilepsy.
NICE NG217 is explicit: all patients with a first seizure must be seen by an epilepsy specialist within 2 weeks. Starting AEDs in primary care before specialist review is inappropriate — the diagnosis must be confirmed because many "first seizures" are not epilepsy. DVLA rules for seizures are strict and legally binding — there is significant clinical and medico-legal risk in failing to advise patients. For syncope, the DVLA publishes specific criteria by category — direct patients to the current DVLA guidance on gov.uk.
Next steps: see Epilepsy · Vasovagal syncope · Driving and the DVLA · Stroke and TIA
Sodium valproate is contraindicated in women of childbearing potential unless the Pregnancy Prevention Programme is in place; MHRA measures require review by two specialists when initiating in patients under 55 (not required for men already taking valproate) — it causes major congenital malformations and neurodevelopmental disorders after in-utero exposure. Alternatives are a specialist choice based on seizure type and individual factors. Physical counterpressure manoeuvres for vasovagal syncope are backed by RCT evidence (PC Trial). Emergency benzodiazepines should be given according to the individual emergency plan/local protocol by trained staff.
SUDEP is the leading cause of death in young people with epilepsy — epilepsy-related deaths number around 1,000 a year in the UK, many of them SUDEP. Good seizure control reduces SUDEP risk. Enzyme-inducing AEDs (carbamazepine, phenytoin, phenobarbital, topiramate, oxcarbazepine) reduce contraceptive pill efficacy — unintended pregnancy with ongoing teratogenic AED exposure is a significant preventable harm. Vasovagal syncope patient education about physical counterpressure techniques can reduce further episodes.
Carbamazepine can cause hyponatraemia (SIADH) — elderly patients are at particular risk of falls from dilutional hyponatraemia. Valproate can cause hyperammonaemia presenting as encephalopathy — check ammonia if unexplained reduced consciousness, vomiting or ataxia. A structured review at least annually is standard practice for established epilepsy (NICE IND227 measures a structured review in the preceding 12 months) — seizure diaries should be reviewed, seizure frequency tracked, and medication step-up considered if breakthrough seizures occurring. Folic acid 5 mg (not the standard 400 mcg) is required in women with epilepsy on AEDs — enzyme-inducing AEDs deplete folate, and higher supplementation is needed to reduce neural tube defect risk.