Seizure Clusters and Rescue Medication
When several seizures happen close together — and why individually short seizures can still become an emergency
Most discussions about seizure emergencies focus on one seizure that lasts too long.
But there is another important emergency pattern:
several seizures happening close together.
These are often called:
seizure clusters
repeated seizures
serial seizures
or acute repetitive seizures.
The individual seizures may stop by themselves.
But the pattern of repeated seizures can still be dangerous.
Current NICE guidance says repeated or cluster seizures — typically 3 or more self-terminating seizures within 24 hours — should be managed as a medical emergency.
Some people who are known to experience prolonged seizures or clusters are prescribed rescue medication and have an individual emergency management plan explaining:
which seizures require treatment
when the medicine should be given
who can give it
whether another dose is permitted
and when emergency services should be called.
The aim is to stop the abnormal run of seizures before it progresses into a more serious emergency such as status epilepticus.
What is a seizure cluster?
There is no single definition used identically in every research study or healthcare system.
For practical UK clinical guidance, NICE describes repeated or cluster seizures as:
typically 3 or more self-terminating seizures within 24 hours.
The words self-terminating are important.
Each individual seizure stops.
But another seizure occurs unusually soon afterwards.
For example:
10:15 — focal seizure
11:05 — another focal seizure
13:40 — another similar seizure
This may represent a seizure cluster even though none of the individual events lasted long enough to be status epilepticus.
Three seizures is not a magical biological boundary
The NICE definition says typically three or more seizures.
That does not mean:
two seizures can never be clinically important.
Some people have a well-established individual cluster pattern.
For example, their epilepsy team may know that:
two particular seizures within one hour almost always lead to several more.
An individual emergency plan may therefore specify earlier intervention.
The person's usual seizure pattern matters.
A cluster is a change from the person's ordinary pattern
Frequency needs context.
Someone who normally has:
one seizure every few months
and suddenly has:
three in one afternoon
has experienced a major change.
Another person may ordinarily experience several brief seizures every day as part of their established epilepsy.
Their emergency threshold may therefore be different.
This is why a personalised plan is more useful than applying one simple number to everybody.
What is the difference between a cluster and status epilepticus?
With a seizure cluster, the individual seizures usually stop by themselves.
There may be some recovery between them.
With convulsive status epilepticus:
a convulsive seizure continues for 5 minutes or longer;
or convulsive seizures follow one another without adequate recovery.
NICE treats both status epilepticus and seizure clusters as medical emergencies, but they describe different patterns.
Related Information Hub page:
Status Epilepticus: When a Seizure Becomes a Medical Emergency
Recovery between seizures is important
Suppose someone has:
Seizure 1 — two minutes
then becomes responsive and begins recovering.
Forty minutes later:
Seizure 2 — one minute
then recovers again.
Later:
Seizure 3 — 90 seconds.
That can represent a cluster.
Now consider:
Seizure 1 — two minutes
the person never regains consciousness;
then another convulsion begins;
then another.
That raises much greater concern for status epilepticus because meaningful recovery is not occurring between seizures.
When recording repeated seizures, always note:
Did the person recover between them?
Clusters can include different seizure types
A cluster does not necessarily mean repeated tonic-clonic seizures.
Depending on the person's epilepsy, clusters might involve:
focal preserved-consciousness seizures
focal impaired-consciousness seizures
tonic seizures
absence seizures
myoclonic seizures
tonic-clonic seizures
or another established seizure type.
The clinical significance depends on:
seizure type
frequency
duration
recovery
injury risk
and the person's normal epilepsy pattern.
A seizure cluster can evolve
Sometimes several smaller seizures occur before a larger one.
For example:
focal aura
then:
focal impaired-consciousness seizure
then later:
focal to bilateral tonic-clonic seizure.
A person's emergency plan may recognise this pattern.
That can allow earlier intervention before the seizures escalate.
Why are seizure clusters taken seriously?
Repeated seizures can increase the risk of:
injury
aspiration
prolonged impaired consciousness
dehydration
exhaustion
additional seizures
and progression to status epilepticus.
NICE's evidence review specifically notes the importance of controlling repeated seizures before they progress into status epilepticus.
A cluster may therefore require treatment even though every individual seizure stops by itself.
Not everyone who has two seizures close together is automatically in status
This distinction prevents unnecessary confusion.
Imagine somebody experiences:
one 30-second focal seizure
recovers completely;
then six hours later:
another 30-second focal seizure.
That is not automatically status epilepticus.
But if the pattern is unusual for that person, it may still require urgent review.
The concern increases when:
seizures become progressively closer together
recovery becomes incomplete
seizure type changes
convulsive seizures occur
or the person's emergency threshold is reached.
What is rescue medication?
Rescue medication is medicine prescribed for use during a seizure emergency.
It is sometimes also called:
emergency medication
emergency seizure medicine
rescue medicine.
It is not intended to replace someone's regular daily antiseizure medication.
Instead, it is designed to interrupt an acute dangerous seizure pattern.
Epilepsy Action says people at risk of prolonged or cluster seizures may be prescribed rescue medication as part of an individual emergency plan.
Who might be prescribed rescue medication?
It may be considered when someone has a history of:
status epilepticus
prolonged seizures
seizure clusters
predictable escalation from smaller seizures to more dangerous seizures
or another pattern where rapid treatment is considered clinically important.
Not everybody with epilepsy needs rescue medication.
Many people's seizures are brief and consistently stop without emergency treatment.
Rescue medication is individual
The prescription should specify:
which seizure type it is intended to treat
how long or how many seizures should occur before it is given
the exact medication
the exact dose
administration route
whether another dose may be given
the maximum permitted amount
when 999 should be called
and what should happen afterwards.
Epilepsy Action advises that a person's care plan should specify which seizure types the medicine is prescribed for and exactly when it should be administered.
The emergency plan matters more than a generic internet instruction
Two people may both have epilepsy and both possess buccal midazolam.
Their instructions may still be different.
One plan might say:
give after a tonic-clonic seizure reaches 5 minutes.
Another might specify treatment:
after the second seizure in a recognised cluster.
Another person may have rescue medicine prescribed only for a particular focal seizure pattern.
The prescribed plan should therefore be followed rather than applying somebody else's instructions.
Buccal midazolam
One of the main rescue medicines used in the UK is buccal midazolam.
Buccal means the space between:
the cheek and gum.
The medicine is administered into this space and absorbed through the lining of the mouth.
It does not need to be swallowed.
Epilepsy Action describes buccal midazolam as a commonly used emergency medicine for prolonged seizures and seizure clusters.
Buccal midazolam is a benzodiazepine
Midazolam belongs to a group of medicines called benzodiazepines.
These medicines enhance inhibitory signalling in the brain and can suppress ongoing epileptic seizure activity.
Benzodiazepines are used because they can act relatively quickly.
But they can also cause:
drowsiness
reduced coordination
and, rarely, clinically important breathing suppression.
The person therefore needs observation after treatment.
Buccal medicine is not forced down the throat
This distinction matters.
Buccal midazolam is placed between the:
gum and cheek.
It should not be poured into the back of an unconscious person's mouth in an attempt to make them swallow.
During a seizure, nothing should be forced down the person's throat.
The technique should be taught during rescue-medication training.
Different brands and formulations exist
UK midazolam products can differ in:
concentration
syringe volume
presentation
and licensed age range.
For example, products such as Buccolam and Epistatus are encountered in UK practice.
This means carers should not assume that:
one syringe always equals the same dose.
Follow the specific prescription and care plan.
Product substitutions should be checked with the pharmacist or prescribing team rather than guessed.
Rectal diazepam
Another established rescue treatment is rectal diazepam.
Diazepam is also a benzodiazepine.
The medicine is administered into the rectum using the prescribed formulation.
Epilepsy Action lists rectal diazepam alongside buccal midazolam as one of the main UK rescue medicines used in seizure emergencies.
Why is buccal midazolam often preferred?
NICE notes that rectal diazepam is not generally preferred for repeated or cluster seizures because of the route of administration.
Buccal midazolam may be:
easier
quicker
and more acceptable
in many community situations.
But rectal diazepam remains appropriate for some people who already have it prescribed and have an established care plan.
The correct medicine is the one selected for that individual by their clinical team.
What about clobazam?
NICE says that when someone has repeated or cluster seizures and there is no immediately available individual management plan, clinicians should consider a benzodiazepine such as:
clobazam
or midazolam.
Clobazam is an oral benzodiazepine used in epilepsy treatment and can sometimes form part of an individually agreed cluster strategy.
This is a clinical prescribing decision.
A bystander should not improvise by giving extra clobazam unless this is explicitly included in the person's prescribed plan.
What about rectal paraldehyde?
Some children with particular severe epilepsy patterns may have rectal paraldehyde prescribed as emergency medicine.
Epilepsy Action notes that this remains an option for some children.
It is much less commonly encountered than buccal midazolam.
It should only be used according to the child's specialist prescription and emergency protocol.
Can a second dose of rescue medication be given?
Sometimes.
But only when the person's plan specifically allows it or healthcare professionals instruct it.
For convulsive status epilepticus, NICE says that if the first benzodiazepine dose fails, emergency services should be called in the community; if seizure activity continues, a second benzodiazepine dose may be given after 5 to 10 minutes according to the emergency plan or clinical protocol.
This does not mean every family member should automatically repeat a dose after ten minutes.
The written plan must be followed.
Why can repeated benzodiazepines be risky?
Benzodiazepines can cause:
sedation
reduced consciousness
reduced muscle tone
and respiratory depression.
The risk can increase with:
repeated doses
other sedating medicines
alcohol
respiratory illness
or significant underlying medical problems.
That is one reason maximum doses and emergency thresholds should be written clearly into the care plan.
Rescue medication does not always mean an ambulance is automatically required
This depends on the individual emergency plan and circumstances.
Epilepsy Action notes that some people may not require hospital attendance if:
prescribed rescue medicine stops the emergency
and they recover normally according to their care plan.
However, emergency help may still be needed if:
the treatment fails
another seizure occurs
recovery is abnormal
breathing is impaired
injury occurred
or the plan instructs carers to call 999.
Seizure clusters are still considered a medical emergency
This is important even if an ambulance is not required every time under an established home plan.
Current NICE guidance explicitly states:
manage repeated or cluster seizures as a medical emergency.
For someone with a recognised recurrent cluster pattern, that emergency may sometimes be managed initially through a specialist-written home plan.
For someone without such a plan, urgent clinical help is needed rather than simply watching repeated seizures continue indefinitely.
What if there is no emergency plan?
If somebody suddenly develops repeated seizures and has no established plan, do not invent a rescue protocol.
NICE advises clinicians to consider immediate benzodiazepine treatment for repeated or cluster seizures and to obtain expert guidance if further episodes occur.
For family or members of the public, repeated unexpected seizures warrant urgent medical assessment.
Call 999 when:
seizures become prolonged
the person does not recover normally
another convulsive seizure begins without recovery
significant breathing problems occur
serious injury occurs
or the situation otherwise appears life-threatening.
What if the person's normal pattern is frequent seizures?
An emergency plan becomes especially important.
Some people with severe epilepsy may have several seizures on an ordinary day.
Calling every sequence a new cluster may not accurately describe their individual baseline.
The specialist team can define:
what is normal
what constitutes an abnormal increase
what pattern requires rescue medicine
and what pattern requires hospital care.
The plan needs to reflect the person's own epilepsy, not an average patient.
Changes from the normal cluster pattern matter
Even someone with established clusters should seek specialist advice when the pattern changes.
Examples include:
more seizures than usual
shorter gaps between seizures
new tonic-clonic seizures
seizures becoming longer
incomplete recovery
rescue medicine working less effectively
a new seizure type
or increasingly frequent cluster days.
A changing pattern may indicate that treatment needs reviewing.
What might trigger a seizure cluster?
Clusters can occur without an identifiable trigger.
Possible contributing factors in some people include:
missed antiseizure medication
illness
fever
sleep deprivation
vomiting affecting medication absorption
medication changes
hormonal changes
alcohol or drug exposure
or other individual triggers.
A trigger is not the same as the underlying cause of epilepsy.
Related Information Hub page:
Seizure Triggers vs Seizure Causes — What's the Difference?
Missed medication can be especially important
A missed dose does not guarantee a seizure.
But for some people, a reduction in antiseizure medicine levels can lead to:
breakthrough seizures
clusters
or status epilepticus.
Epilepsy Action specifically identifies low antiseizure medication levels as an important cause of severe seizure emergencies in people with epilepsy.
Do not compensate for a missed dose by taking an improvised extra amount.
Follow the medicine's missed-dose instructions or ask a pharmacist, epilepsy nurse or prescribing clinician.
Vomiting can interfere with regular medication
If someone vomits shortly after taking antiseizure medicine, it may not have been fully absorbed.
Repeated vomiting can also:
cause dehydration
disturb electrolytes
and make normal medication schedules difficult.
People prone to clusters may need individual advice about what to do when illness interferes with their regular treatment.
Do not automatically repeat a dose unless the medicine-specific advice or clinical team says to do so.
Rescue medication does not prevent every future seizure
A rescue medicine is intended to interrupt the current emergency pattern.
Someone may still have:
another seizure later that day
further clusters in the future
or ordinary seizures despite successful rescue treatment.
Long-term prevention requires review of the person's ongoing epilepsy treatment.
Frequent use of rescue medicine is important information
If rescue medicine is being required more often, the epilepsy team needs to know.
Increasing rescue use may indicate:
worsening seizure control
a changing epilepsy pattern
medication problems
illness
or treatment that needs reassessment.
Rescue medication should not simply become a repeatedly used substitute for reviewing uncontrolled epilepsy.
Keep a record whenever rescue medicine is used
Useful information includes:
date
time
seizure type
number of seizures before treatment
duration of seizures
medicine given
dose
time given
response
whether another dose was used
breathing and recovery
whether 999 was called
and whether hospital treatment was needed.
This information can help the epilepsy team judge whether the current plan is effective.
Record the seizures individually where possible
Instead of:
“Had a cluster all afternoon.”
write:
13:05 — focal impaired-consciousness seizure, 55 seconds
13:42 — similar seizure, 70 seconds
14:10 — third event, 60 seconds
Rescue medicine given at 14:15 according to plan
No further seizures
Fully responsive by 14:40
That provides far more useful clinical information.
Related Information Hub page:
Seizure Diaries and Videos: How to Record Useful Evidence
Do not delay treatment to create a perfect record
Timing and recording are helpful.
But if the person's emergency threshold has been reached:
follow the plan.
Do not delay rescue medication because someone wants to:
finish filming
complete diary details
or obtain a better recording.
Safety comes first.
What should an emergency management plan contain?
A useful plan should identify the person and clearly describe their epilepsy.
It should state:
What their ordinary seizures look like
This helps carers distinguish the relevant seizure type.
Their usual seizure duration
This makes abnormal prolongation easier to recognise.
Their usual recovery
This helps carers recognise when recovery is abnormal.
What constitutes a cluster for that person
This may be number, timing or a particular sequence.
When rescue medicine should be given
This should be precise.
Which medicine and dose
Including exact formulation where necessary.
Who may administer it
According to training and local arrangements.
Whether another dose can be given
Including the minimum interval and maximum permitted amount.
When 999 should be called
There should be no ambiguity.
What should happen after successful treatment
Including observation and recovery advice.
The care plan needs reviewing
A plan written years ago may no longer match:
current seizure type
body weight
medication
rescue medicine
frequency
or clinical risk.
Epilepsy Action recommends maintaining an up-to-date emergency care plan when rescue medicine is prescribed.
Plans should also be reviewed after significant changes in seizure pattern or treatment.
Rescue medicine at school
Children who may require emergency seizure medicine at school need an individual healthcare plan.
The plan should explain:
what the child's seizures look like
what constitutes an emergency
which medicine is prescribed
exact dose
when it should be administered
who is trained
and when emergency services should be contacted.
Epilepsy Action emphasises that anyone giving rescue medication in an emergency needs appropriate training.
Rescue medicine in supported living and care settings
The same principle applies in:
residential care
supported living
respite care
day services
and other settings.
Staff expected to administer emergency medication need:
access to the correct medicine
the current plan
appropriate training
and clear documentation.
A medication stored in a cupboard but inaccessible to trained staff during a seizure is not an effective emergency plan.
Family and carers should know where the medicine is
A practical emergency plan should include:
where the medicine is normally kept
whether it must accompany the person outside the home
expiry checks
storage requirements
and who is responsible for replacements.
Rescue medicine that expired months ago or was left at home cannot help during an emergency elsewhere.
Check expiry dates
Emergency medication may be used infrequently.
That makes expiry particularly easy to overlook.
It is sensible to have a routine system for checking:
expiry dates
packaging
dose
and whether the plan still matches the medicine supplied.
A pharmacist or epilepsy team can advise if replacement is needed.
Do not use someone else's rescue medicine
Even if two people are both prescribed midazolam, their:
doses
formulations
indications
and medical circumstances
may differ.
Emergency medicine should be used only for the person to whom it was prescribed and according to their plan.
Do not give extra regular antiseizure medication unless instructed
During a cluster, it can be tempting to think:
“Another dose of their normal tablets might stop it.”
Do not improvise.
Some plans may include a prescribed short-term additional medication strategy.
But this must be specifically agreed by the treating team.
Giving unplanned extra medication can create:
overdose
excessive sedation
drug interactions
or confusion about subsequent doses.
What should happen after the rescue medicine works?
Continue observing the person.
They may be:
sleepy
confused
unsteady
or recovering from both the seizures and benzodiazepine.
Check that:
breathing appears normal
no serious injury occurred
recovery follows the expected pattern
and no further seizure begins.
Follow the person's plan regarding:
rest
observation
contacting healthcare professionals
and whether hospital assessment is required.
Sleepiness after midazolam or diazepam can be expected
Both:
seizures
and benzodiazepines
can cause substantial drowsiness.
This can make it difficult to determine exactly how much sleepiness is due to:
the seizure
the postictal state
or the rescue medicine.
The important issue is whether the person is:
breathing adequately
recovering as expected
and showing no concerning deterioration.
When is breathing a concern?
Seek emergency help if the person has:
significant difficulty breathing
abnormal prolonged pauses
concerning colour change
or another serious deterioration.
Benzodiazepines can rarely suppress breathing, particularly after repeated doses or in vulnerable people. Epilepsy Action therefore advises close observation during recovery.
When should 999 definitely be considered?
Follow the individual plan first.
Emergency ambulance assessment is particularly important when:
a convulsive seizure reaches 5 minutes
another convulsive seizure begins without recovery
the person's rescue medicine fails
the plan says to call 999
significant breathing difficulty occurs
the person remains unusually unresponsive
serious injury occurs
seizures occur in water
the seizure pattern is substantially different from normal
or there is another life-threatening concern.
A first unexpected cluster also warrants urgent medical assessment.
What if rescue medicine stops one seizure but another begins?
Follow the written plan.
The correct action depends on:
seizure type
time since treatment
prescribed maximum dose
whether a second dose is allowed
and the person's previous emergency history.
Do not repeatedly administer benzodiazepines beyond the prescribed limit.
If the plan has been exhausted and seizures continue, seek emergency help.
What if the person has three brief auras?
If those auras are known epileptic focal seizures, they may count as repeated seizures.
But whether they meet that person's emergency treatment threshold depends on the individual plan.
Someone whose ordinary epilepsy includes several very brief focal seizures every day may not receive emergency benzodiazepine every time three occur.
This demonstrates why:
“three seizures in 24 hours”
is a useful NICE clinical definition of a cluster but not a substitute for individual planning.
What if the person has three tonic-clonic seizures?
This deserves particular concern.
Repeated tonic-clonic seizures can produce:
injury
aspiration risk
respiratory stress
profound exhaustion
and progression into status.
Even if each seizure stops, this represents a significant emergency pattern.
Follow the individual's rescue plan and seek emergency medical help according to that plan and the person's condition.
What if the person does not remember the cluster?
Impaired-consciousness seizures can interfere with memory.
The person may therefore believe they had:
one seizure
while witnesses or monitoring recorded several.
This can affect:
treatment decisions
assessment of seizure burden
and whether rescue medication should be prescribed.
Witness records and video telemetry can sometimes reveal clusters the person was unaware of.
Night-time clusters can also be missed
A person may:
sleep through smaller seizures
wake briefly and forget them
or have no witness.
This means seizure diaries may underestimate nocturnal clustering.
A specialist may consider:
video
ambulatory EEG
or inpatient monitoring
when true seizure burden is uncertain.
Can seizure detection devices identify clusters?
Some devices may detect repeated:
convulsive movement
falls
heart-rate changes
or other physiological signals.
But detection depends heavily on the seizure type.
Devices are generally much less capable of detecting:
focal sensory seizures
brief staring
subtle impaired-consciousness events
or aura-only seizures.
A device therefore should not automatically be treated as a complete seizure counter.
This will be covered separately in:
Seizure Detection Devices, Alarms and Wearables
Can clusters happen without any obvious trigger?
Yes.
It is often impossible to identify a reason.
This does not mean someone:
forgot something
caused the cluster
or failed to avoid the correct trigger.
Epilepsy can fluctuate spontaneously.
A diary may help reveal recurring patterns, but not every cluster has a preventable explanation.
Does having seizure clusters mean epilepsy is drug resistant?
Not automatically.
A single cluster can occur in somebody whose epilepsy is otherwise well controlled.
However, recurrent clusters despite appropriately selected treatment may contribute to evidence that seizure control remains inadequate.
Drug-resistant epilepsy has a specific definition based on failure of appropriately selected and used antiseizure medication schedules to achieve sustained seizure freedom.
Related Information Hub page:
Drug-Resistant Epilepsy: What It Actually Means
Frequent clusters should prompt treatment review
The clinical question should not only be:
“Does rescue medicine stop them?”
It should also be:
“Why are these clusters continuing to happen?”
The epilepsy team may review:
diagnosis
seizure classification
regular medication
adherence
medicine levels where appropriate
interactions
triggers
sleep
hormones
underlying illness
and whether specialist treatment is required.
A successful rescue plan should still be reviewed periodically
Imagine someone previously had:
one cluster every six months
but is now using rescue medicine:
twice every week.
Even if the medicine continues to stop each cluster, the epilepsy itself has changed.
That warrants specialist review rather than simply repeatedly using emergency medication.
Clusters can affect quality of life even when they do not become status
A person may lose:
an entire day
several days
work
school
independence
sleep
or confidence
because repeated seizures and recovery periods accumulate.
The impact of clusters should therefore not be assessed only by asking:
“Did they go to hospital?”
The total seizure and recovery burden matters.
Questions to ask the epilepsy team
Useful questions include:
What counts as a cluster for me?
Which of my seizure types should be counted?
At what point should rescue medicine be given?
Which medicine have you prescribed?
What exact dose should be used?
Who can give it?
Does that person need formal training?
Can a second dose ever be given?
How long must we wait before a second dose?
What is the maximum amount in 24 hours?
When should 999 be called?
When can I remain at home after treatment?
What recovery should my family expect?
Questions if clusters are becoming more frequent
Useful questions include:
Why might my pattern be changing?
Does my regular treatment need reviewing?
Could medication absorption or missed doses be contributing?
Could these represent a different seizure type?
Do I need video EEG or another investigation?
Do I meet criteria for tertiary referral?
Should my rescue threshold change?
Do I need a different emergency plan?
Questions for family, carers or school staff
They should know:
Which seizure requires treatment?
How many seizures constitute the person's cluster?
How is the medicine administered?
Where is it stored?
When does it expire?
What time was it given?
Can it be repeated?
When must an ambulance be called?
What should normal recovery look like?
Who should be informed afterwards?
If those answers are unclear, the plan needs improving.
The most important message
A seizure does not need to last five minutes to become part of a serious seizure emergency.
Several self-terminating seizures close together can form a seizure cluster.
Current NICE guidance defines repeated or cluster seizures as typically three or more self-terminating seizures within 24 hours and says they should be managed as a medical emergency.
But the number three is not an individual prescription.
Some people have distinctive cluster patterns that require treatment earlier.
Others ordinarily experience frequent brief seizures and require a different threshold.
That is why people at risk of clusters should have an individual emergency management plan.
Rescue medicines can include:
buccal midazolam
rectal diazepam
and, in particular plans, other benzodiazepine strategies such as clobazam.
Buccal midazolam is placed between the cheek and gum.
It should never be forced down an unconscious person's throat.
Because benzodiazepines can cause sedation and occasionally affect breathing, anyone administering prescribed rescue medicine should understand:
the correct dose
technique
repeat-dose instructions
observation requirements
and emergency thresholds.
A cluster and status epilepticus are not identical.
In a cluster, individual seizures usually stop.
In status, seizure activity becomes abnormally prolonged or seizures recur without adequate recovery.
But a cluster can progress into status.
That is why early recognition matters.
A good emergency plan should answer, before the emergency happens:
What does this person's cluster look like?
When do we treat it?
What medicine do we use?
What happens if it does not work?
and:
When do we call 999?
Sources and further reading
NICE — Epilepsies in children, young people and adults (NG217): Treating status epilepticus, repeated or cluster seizures, and prolonged seizures.
Current NICE guidance defines repeated or cluster seizures as typically three or more self-terminating seizures in 24 hours, recommends managing them as a medical emergency, following the person's individual management plan where available, and considering a benzodiazepine such as clobazam or midazolam when no plan is immediately available. NG217 was last updated in January 2025.
NICE — Rationale and impact for repeated or cluster seizures.
NICE notes that evidence for acute treatment of seizure clusters remains limited. Benzodiazepines are recommended based on available evidence and clinical experience, with clobazam and midazolam given as examples. NICE notes that rectal diazepam is generally not preferred for clusters because of the route of administration.
NICE Evidence Review 10 — Antiseizure medications for repetitive/cluster seizures.
Explains the clinical importance of controlling repeated seizures before they progress to status epilepticus and identifies continuing uncertainty about the most effective acute medication strategies.
Epilepsy Action — Status epilepticus and rescue medicine.
Current UK information covering seizure clusters, individual emergency plans, buccal midazolam, rectal diazepam, training, observation after benzodiazepines and emergency management. Last modified April 2026.
Epilepsy Action — Buccal midazolam.
Current professional information explaining how buccal midazolam is administered, the circumstances in which it may be prescribed and the importance of an individual care plan and trained administration.
NHS Specialist Pharmacy Service — Buccal midazolam for seizure management.
Current professional NHS medicines information. The national ambulance-service PGD for buccal midazolam was republished in April 2026.
Information reviewed: September 2026.
This page provides general educational information. Rescue seizure medication should be administered only according to the individual's prescription and emergency management plan by somebody appropriately instructed or trained. If seizures become prolonged, recovery is incomplete, breathing is significantly affected or the prescribed emergency plan is unsuccessful, seek emergency medical help.
