Non-epileptic paroxysmal events (seizure mimics)

What they are and why distinguishing them matters

A paroxysmal event is any sudden, recurring episode with a clear start and stop. Many such events are not epileptic seizures at all — they arise from normal developmental phenomena, the heart and circulation, sleep, movement disorders, behaviour or strong emotion. Because they can look alarmingly like seizures, they are commonly mistaken for epilepsy. Getting the distinction right avoids years of unnecessary antiseizure medication and points to the correct treatment, which is often simple reassurance.

In newborns and young infants

• Jitteriness — fine trembling that stops when the limb is gently held (unlike a seizure)
• Benign neonatal sleep myoclonus — jerks only during sleep, stopping on waking
• Benign myoclonus of early infancy — clusters of jerks or spasms with a normal EEG (mimics infantile spasms)
• Sandifer syndrome — arching and head-turning linked to gastro-oesophageal reflux
• Hyperekplexia — an exaggerated startle with stiffening
• Self-soothing/self-gratification behaviour and tonic upward gaze

In toddlers and preschoolers ('play age')

• Breath-holding spells — triggered by upset, pain or frustration; the child cries, holds their breath and may go blue or pale, briefly lose consciousness and stiffen or jerk (frightening but benign)
• Benign paroxysmal vertigo — sudden brief unsteadiness or fear, the child clinging or pale, then back to normal
• Shuddering attacks and stereotypies (repetitive movements)
• Staring/inattention that can be mistaken for absence seizures
• Night terrors and other parasomnias (see the sleep page)

In school-age children

• Fainting (vasovagal syncope) — often with stiffening or a few jerks ('convulsive syncope'), easily mistaken for a seizure
• Tics and stereotypies
• Daydreaming and inattention
• Migraine and its variants (including visual or sensory auras)
• Parasomnias

In adolescents

• Fainting (vasovagal or on standing); important to exclude any heart cause
• Functional (dissociative) seizures, sometimes called psychogenic non-epileptic seizures — real, involuntary events linked to how the brain processes stress, needing a supportive, specific approach rather than antiseizure drugs
• Panic attacks and hyperventilation
• Migraine aura and paroxysmal movement disorders (paroxysmal dyskinesias)

How they are diagnosed (and why home videos help)

The single most useful tool is a detailed description of the events — what triggers them, how they start, what exactly happens, how long they last and how the child is afterwards. Because these episodes are rarely seen by a doctor, a smartphone video of an event is enormously valuable and can change the diagnosis. Depending on the picture, an ECG is done to check the heart when fainting is possible, and an EEG (sometimes prolonged video-EEG to capture an event) is used when epilepsy remains a genuine question. A normal EEG does not rule epilepsy in or out by itself — the clinical picture leads.

Treatment

Treatment depends entirely on the specific event. Most benign developmental phenomena need only reassurance and time. Breath-holding spells linked to iron deficiency can improve with iron; fainting is managed with hydration, salt and avoiding triggers (and a cardiology opinion if there are warning signs); reflux-related events are treated as reflux; and functional seizures respond best to a clear, non-blaming explanation and psychological support rather than antiseizure medicines. The key, in every case, is making the right diagnosis first.

How an educational review can help

If there is uncertainty about whether your child's spells are epileptic, an educational review can help organise the history, suggest what to capture on video, explain the features that point toward or away from epilepsy, and clarify which assessments are worth pursuing — so you can prepare questions for your treating team. It is educational and does not replace your clinician's care.