Status Epilepticus
When a seizure becomes a medical emergency
Most epileptic seizures stop by themselves.
A tonic-clonic seizure often lasts only a minute or two.
But sometimes a seizure continues for much longer than expected, or another seizure begins before the person has recovered from the first.
This can become status epilepticus.
Status epilepticus — often shortened to status or SE — is one of the most important neurological emergencies associated with epilepsy.
It can happen:
in someone already diagnosed with epilepsy
during someone's first recognised seizure
because of an acute brain or medical illness
or in someone who has never previously had epilepsy.
Status epilepticus is not one single type of seizure.
It can be:
convulsive
focal
non-convulsive
absence-related
tonic
or another form.
The urgency and possible consequences vary according to:
seizure type
duration
underlying cause
age
other medical conditions
and how quickly effective treatment begins.
For convulsive status epilepticus, current NICE guidance says that a seizure lasting 5 minutes or more requires resuscitation and immediate emergency treatment.
The old “30-minute rule” is outdated for emergency treatment
People may still encounter older information saying a seizure needs to last:
30 minutes
before it counts as status epilepticus.
That is no longer the appropriate threshold for treating convulsive status.
Waiting 30 minutes would delay treatment far too long.
The International League Against Epilepsy — ILAE — introduced a modern operational definition based on two important time points.
For convulsive tonic-clonic status:
t1 = 5 minutes
This is the point at which seizure activity is sufficiently prolonged that treatment should begin rather than continuing to wait for spontaneous termination.
t2 = approximately 30 minutes
This represents the point beyond which continuing convulsive seizure activity carries increasing concern about long-term consequences such as neuronal injury and alteration of brain networks.
These are operational time points rather than a stopwatch predicting exactly when damage will occur in an individual person.
Why is the five-minute point so important?
Most ordinary tonic-clonic seizures stop spontaneously before five minutes.
As a convulsive seizure continues, the chance that it will simply stop by itself decreases.
Treatment can also become more difficult as status progresses.
The ILAE therefore treats five minutes as the practical point at which clinicians should regard continuing tonic-clonic activity as status epilepticus and begin emergency treatment.
This does not mean:
“Nothing matters until exactly 5 minutes and 1 second.”
Seizure first aid begins immediately.
The five-minute threshold tells us when an ongoing convulsive seizure requires emergency medical treatment.
NICE's current UK definition for convulsive status
NICE says to provide immediate emergency treatment when a child, young person or adult has a convulsive seizure lasting 5 minutes or more.
Status can also occur when tonic-clonic seizures happen one after another without the person recovering between them.
So there are two important patterns:
One seizure that does not stop
or
repeated seizures without recovery in between.
Both can constitute a medical emergency.
Recovery between seizures matters
Imagine somebody has:
a two-minute tonic-clonic seizure
begins to regain consciousness
later has another separate seizure.
That is different from:
one tonic-clonic seizure
another immediately follows
and the person never regains consciousness between them.
The second situation is particularly concerning for status epilepticus.
This is why witnesses should record not only:
how many seizures occurred
but also:
whether the person recovered between them.
Status epilepticus is not the same as a seizure cluster
These terms overlap clinically, but they are not identical.
NICE describes repeated or cluster seizures as typically:
3 or more self-terminating seizures within 24 hours.
NICE says these should also be managed as a medical emergency.
The important difference is that cluster seizures may stop individually, with some recovery between episodes.
Status involves seizure activity that is continuing abnormally or recurring without adequate recovery.
We will cover seizure clusters separately in the next planned Information Hub page.
Status is not restricted to tonic-clonic seizures
The dramatic image most people associate with status is prolonged convulsion.
But prolonged seizure activity can occur without major shaking.
This is called non-convulsive status epilepticus — NCSE.
It may involve much subtler changes such as:
prolonged confusion
reduced responsiveness
unusual behaviour
staring
altered cognition
subtle repetitive movements
or a change in mental state.
Epilepsy Action notes that non-convulsive status can occur with seizure types including focal impaired-consciousness and absence seizures.
Convulsive status epilepticus
Convulsive status typically involves ongoing or repeatedly recurring tonic-clonic seizure activity.
Possible features include:
loss of consciousness
stiffening
rhythmic jerking
abnormal breathing
saliva or frothing
colour change
and failure to recover normally.
This is a life-threatening medical emergency.
Treatment should not wait for 30 minutes.
NICE uses the five-minute threshold for emergency intervention.
Why can prolonged convulsive seizures become dangerous?
A prolonged convulsive seizure places substantial physiological stress on the body.
Problems can include:
impaired breathing
reduced oxygenation
aspiration
changes in blood pressure
abnormal heart rhythm
overheating
metabolic disturbance
muscle breakdown
injury
and, as seizure activity persists, risk of neurological injury.
The underlying illness that caused status can itself also be dangerous.
For example, status caused by:
stroke
encephalitis
severe metabolic disturbance
or acute brain injury
may carry risks beyond the seizure itself.
Outcome therefore depends on both:
the status
and:
why the status happened.
Status epilepticus is not synonymous with brain damage
It would be inaccurate to tell everyone who experiences status:
“You definitely have brain damage.”
The ILAE definition recognises the potential for long-term consequences after sufficiently prolonged seizure activity, including:
neuronal injury
neuronal death
and alterations in neuronal networks.
But the actual outcome depends on:
seizure type
how long it lasts
underlying cause
age
other health conditions
complications
and treatment.
Some people recover well.
Others may experience significant complications.
What are t1 and t2?
The ILAE introduced these concepts because different seizure types do not all behave in exactly the same way.
t1 is the point after which seizure activity should be considered abnormally prolonged and treatment should be started.
t2 is the approximate point beyond which ongoing seizure activity is increasingly associated with potential long-term consequences.
For tonic-clonic status, the ILAE's best-supported estimates are:
t1: 5 minutes
t2: 30 minutes.
The ILAE emphasises that these are operational estimates based on available evidence rather than precise biological cut-offs applying identically to every person.
What about focal status epilepticus?
Focal status can occur with or without major impairment of consciousness.
Depending on the network involved, symptoms might include prolonged or repetitive:
focal jerking
sensory symptoms
language disturbance
visual symptoms
automatisms
altered awareness
or unusual behaviour.
The ILAE framework has used an operational t1 of around 10 minutes for focal status, although the evidence for non-convulsive forms is less robust than for convulsive tonic-clonic status.
In practical care, however, an event lasting substantially longer than a person's usual seizure should be treated seriously even before any abstract classification threshold is reached.
NICE also recognises a person's normal seizure duration
This is especially useful because some people's ordinary seizures are extremely short.
NICE defines a prolonged convulsive seizure as a convulsive seizure lasting more than 2 minutes longer than that person's usual seizure and says it should be managed as a medical emergency.
If a convulsive seizure reaches five minutes, the status epilepticus pathway applies.
This means the person's own usual pattern matters.
An example
Suppose somebody's typical convulsive seizure lasts:
45 seconds.
One day it reaches:
3 minutes.
Although it has not yet reached the formal five-minute convulsive-status threshold, it is already more than two minutes longer than that person's usual seizure.
Under NICE guidance, that qualifies as a prolonged convulsive seizure requiring emergency management.
This is one reason an individual emergency plan can be more useful than a generic rule.
Non-convulsive status epilepticus
Non-convulsive status can be harder to recognise because there may be no dramatic convulsion.
Someone might instead have:
prolonged confusion
unusually reduced responsiveness
persistent staring
subtle repetitive movements
disorientation
altered language
unusual behaviour
or an unexplained prolonged change in mental state.
Epilepsy Action notes that NCSE can include changes in:
movement
confusion
personality
and sometimes psychiatric-like symptoms.
Why is non-convulsive status difficult to diagnose?
Many other conditions can cause prolonged confusion or reduced responsiveness.
These include:
postictal confusion
medication effects
infection
metabolic disturbance
stroke
intoxication
delirium
encephalopathy
and functional neurological events.
The diagnosis of NCSE therefore frequently depends heavily on EEG.
Published diagnostic frameworks for non-convulsive status rely substantially on EEG criteria interpreted together with the clinical picture.
Postictal confusion is not automatically non-convulsive status
After a significant seizure, somebody may remain:
confused
sleepy
slow to respond
or unable to remember events.
That may simply be the postictal state.
However, if recovery is unexpectedly delayed or the person remains markedly different from their normal post-seizure pattern, clinicians may consider whether seizure activity is still continuing without obvious convulsions.
EEG can be crucial in distinguishing:
ongoing electrical seizure activity
from:
recovery after a seizure has already stopped.
Non-convulsive status can follow convulsive status
Sometimes the obvious tonic-clonic movements stop but the brain remains in ongoing epileptic seizure activity.
The person may fail to wake or recover as expected.
This is one reason persistent unexplained unconsciousness or profound confusion after convulsive status may require urgent EEG assessment.
Epilepsy Action specifically notes that NCSE can occur following convulsive status epilepticus.
Absence status epilepticus
Absence seizures are usually brief.
But prolonged or repeatedly continuous absence-type seizure activity can occur.
The person may appear:
confused
slowed
vacant
partially responsive
or cognitively altered
rather than convulsing.
The ILAE framework has proposed an approximate t1 of around 10 to 15 minutes for absence status, although evidence for exact timing is less certain than for tonic-clonic status.
EEG is central to confirming this diagnosis.
Tonic status epilepticus
Status can also involve repeated tonic seizures.
These involve periods of sustained stiffening.
Epilepsy Action notes that tonic status occurs particularly in some severe epilepsies, including Lennox-Gastaut syndrome, and can occasionally persist for very prolonged periods.
This is a specialist form of status and should not be confused with one ordinary brief tonic seizure.
What causes status epilepticus?
There are many possible causes.
In somebody already diagnosed with epilepsy, possible contributors include:
missed medication
medication levels becoming too low
vomiting affecting medication absorption
changes to treatment
acute illness
sleep deprivation
metabolic disturbance
alcohol withdrawal
or worsening of the underlying epilepsy.
But status can also be the first sign of a new neurological or medical illness.
Causes can include:
stroke
brain injury
central nervous system infection
encephalitis
metabolic disturbance
severe glucose abnormalities
toxic exposure
recreational drugs
alcohol withdrawal
brain tumour
autoimmune encephalitis
and other acute neurological disease.
Status epilepticus does not automatically mean the person has epilepsy
This distinction matters.
Epilepsy is a condition involving an enduring predisposition to recurrent epileptic seizures.
Someone can experience status as an acute symptomatic seizure emergency because of something such as:
stroke
meningitis
severe metabolic disturbance
or poisoning.
Whether that person subsequently has epilepsy depends on the underlying cause and future seizure risk.
Status is therefore a seizure emergency.
It is not itself synonymous with an epilepsy diagnosis.
Missing antiseizure medication can matter
In people with established epilepsy, inadequate antiseizure medication exposure is a recognised precipitant of status.
This can happen because of:
missed doses
difficulty obtaining medication
vomiting
interactions
or inappropriate abrupt withdrawal.
Epilepsy Action lists low epilepsy-medication levels among important causes of status in people with epilepsy.
This is one reason antiseizure medication should generally not be abruptly stopped without medical advice.
Status after deliberately stopping medication
During specialist inpatient epilepsy monitoring, antiseizure medication is sometimes carefully reduced to increase the chance of recording seizures.
This occurs with:
continuous observation
emergency treatment available
trained staff
and a planned protocol.
It should not be copied at home.
Abruptly withdrawing antiseizure medication independently can increase the risk of:
breakthrough seizures
clusters
and status epilepticus.
What should a witness do during a prolonged convulsive seizure?
First aid begins immediately.
Important actions include:
protect the person from nearby hazards
cushion their head where possible
loosen restrictive clothing around the neck
remove dangerous objects from the immediate area
start timing the seizure
do not restrain them
do not put anything in their mouth
and follow their individual emergency plan if one exists.
If the seizure reaches emergency criteria, call 999.
Epilepsy Action's current first-aid advice says to call an ambulance if a seizure lasts more than five minutes, if another follows without recovery, if the person does not regain consciousness, or if there is significant breathing difficulty afterwards.
Do not put anything in the mouth
A person cannot swallow their tongue.
Putting:
fingers
spoons
medication tablets
cloth
or another object
into the mouth during a convulsive seizure can cause serious injury.
It can injure:
teeth
gums
jaw
or the person trying to help.
Rescue medicine is administered only by the prescribed route described in the person's emergency plan.
Do not restrain the convulsions
Holding someone's arms or legs down will not stop seizure activity occurring in the brain.
Restraint can instead cause:
injury
fractures
dislocations
distress
and difficulty providing appropriate first aid.
Protect the person from hazards rather than trying to physically stop the movements.
Why timing the seizure matters
People experiencing an emergency often understandably lose track of time.
A seizure that feels like ten minutes may actually have lasted two.
Or a seizure may genuinely have crossed the five-minute emergency threshold without anyone realising.
Starting a timer as soon as possible gives responders important information.
If the beginning was not witnessed, say:
“Start time unknown.”
Do not invent a duration.
What is rescue medicine?
Some people at increased risk of prolonged seizures or status are prescribed rescue medication.
In the UK, commonly used rescue medicines include:
buccal midazolam
and rectal diazepam.
Epilepsy Action identifies both as licensed emergency treatments used in the UK for prolonged seizures/status, with some children also prescribed rectal paraldehyde in specific circumstances.
The exact medicine, dose and timing must come from the person's individual prescription and emergency plan.
What does “buccal” mean?
Buccal midazolam is given into the space between the:
cheek and gum.
It is absorbed through the lining of the mouth.
It is not the same as forcing tablets or liquid down the throat of an unconscious person.
Epilepsy Action describes buccal midazolam as a commonly prescribed emergency medicine for prolonged tonic-clonic seizures.
Who can give rescue medicine?
This should follow:
the person's prescription
emergency management plan
and appropriate training.
Epilepsy Action advises that people expected to administer buccal midazolam should be trained to do so.
The plan should specify:
which medicine to give
dose
when to give it
whether a second dose is permitted
when to call 999
and what observations are required afterwards.
Why does the emergency plan matter?
Not everybody's seizure pattern is identical.
One person may be instructed to receive rescue treatment after:
5 minutes.
Another may have an earlier threshold because their ordinary seizures usually last only seconds and they have a history of rapid progression.
A plan can also include instructions for:
seizure clusters
repeat dosing
ambulance attendance
oxygen or other care where relevant
and when hospital admission is required.
NICE says that if an individual emergency management plan is immediately available during convulsive status, it should be followed.
What if there is no emergency plan?
Current NICE guidance says that when convulsive status occurs and no immediately available individual plan exists, first-line treatment in the community is a benzodiazepine, usually:
buccal midazolam
or rectal diazepam.
Intravenous lorazepam can be used where IV access and resuscitation facilities are immediately available.
For members of the public, the practical action is to:
call 999 and follow the emergency operator's instructions.
Do not administer somebody else's prescription or improvise doses.
What happens if the first rescue treatment does not work?
NICE says that if convulsive status does not respond to the first benzodiazepine dose:
emergency services should be called if the person is in the community;
and expert guidance should be sought in hospital.
If the seizure continues, NICE recommends following the person's plan or giving a second benzodiazepine dose after 5 to 10 minutes according to the clinical protocol.
This is medical/rescue-medication guidance, not an instruction for an untrained bystander to independently repeat doses.
What happens in hospital?
Emergency care does more than simply give another epilepsy medicine.
The team may need to assess and support:
airway
breathing
oxygenation
circulation
blood glucose
blood pressure
temperature
heart rhythm
intravenous access
and injuries.
They also investigate the cause.
Possible tests may include:
blood tests
ECG
brain imaging
toxicology
infection investigations
antiseizure medication levels where relevant
lumbar puncture in selected cases
and EEG.
The investigations depend on the clinical circumstances.
What happens after benzodiazepines?
If convulsive status continues after two doses of a benzodiazepine, NICE recommends intravenous second-line antiseizure treatment.
Current NICE options include:
levetiracetam
phenytoin
or sodium valproate, subject to current MHRA valproate safety requirements.
NICE notes that levetiracetam may be quicker to administer and may have fewer adverse effects than alternatives in some circumstances.
The choice is made by healthcare professionals according to the individual situation.
Why are valproate restrictions relevant?
Sodium valproate has important reproductive safety restrictions because exposure during pregnancy carries substantial risks to an unborn child.
Current NICE guidance therefore directs clinicians to follow MHRA safety measures whenever valproate is being considered.
In a life-threatening emergency, medication decisions require specialist risk-benefit assessment.
This is not something a bystander needs to decide.
What if second-line treatment also fails?
If status continues after initial benzodiazepines and appropriate second-line medication, the situation becomes increasingly serious.
NICE recommends expert consideration of:
an alternative second-line agent
and, if second-line approaches fail, third-line treatment such as phenobarbital or general anaesthesia.
This may require:
intensive-care treatment
airway support
mechanical ventilation
continuous EEG
and anaesthetic medication.
What is refractory status epilepticus?
The term refractory status epilepticus is generally used when status continues despite appropriately administered initial treatment, typically including:
a benzodiazepine
and a suitable second-line antiseizure medicine.
At this stage, intensive specialist treatment may be required.
Refractory status is not the same as ordinary drug-resistant epilepsy.
Drug-resistant epilepsy describes failure of long-term antiseizure treatment to achieve sustained seizure freedom.
Refractory status describes an acute seizure emergency that is failing to stop with emergency treatment.
What is super-refractory status epilepticus?
A further term sometimes encountered in specialist medicine is:
super-refractory status epilepticus.
This refers to status that continues or recurs despite prolonged anaesthetic treatment, including recurrence after anaesthesia is reduced or stopped.
This is an intensive-care neurological emergency and can require highly specialised investigation and treatment.
It should not be confused with an unusually long ordinary seizure at home.
Why might doctors use general anaesthesia?
In severe refractory convulsive status, the aim may become to suppress ongoing seizure activity while:
protecting the airway
supporting breathing
and allowing continuous treatment and EEG monitoring.
Anaesthetic medicines can strongly suppress brain electrical activity and seizures.
Because they can also suppress:
breathing
blood pressure
and consciousness,
this treatment requires intensive-care monitoring.
The movements can stop while electrical status continues
This is another important reason EEG may be required.
After:
benzodiazepines
anaesthetic treatment
muscle-relaxing medication
or progression of the condition,
visible convulsive movements may disappear.
That does not always prove that electrical seizure activity has ended.
Continuous EEG can help determine whether seizures are still occurring in the brain.
What is continuous EEG?
Continuous EEG records brain electrical activity over an extended period.
It can be particularly important when somebody:
remains unconscious
fails to recover after status
is sedated
or is suspected of having non-convulsive seizures.
The purpose is to establish whether ongoing abnormal mental state reflects:
continuing seizures
postictal recovery
sedation
encephalopathy
or another process.
Status in intensive care may look very different from the original seizure
A person may initially arrive with dramatic tonic-clonic activity.
After emergency medication, they may appear:
deeply sleepy
unresponsive
ventilated
or sedated.
At that stage, doctors may rely much more heavily on:
EEG
vital signs
blood tests
imaging
and the clinical cause
than on visible seizure movement.
What about functional seizures that last a long time?
Functional seizures can sometimes last considerably longer than ordinary epileptic seizures.
Because they can involve:
shaking
reduced responsiveness
and dramatic movement,
they can occasionally be mistaken for convulsive status epilepticus.
NICE's evidence review specifically notes the importance of distinguishing psychogenic non-epileptic seizures — now commonly called functional seizures — from apparent convulsive status.
This distinction matters because inappropriate escalation of intensive antiseizure treatment can itself cause harm.
But do not try to make that distinction during an emergency yourself
A bystander should not decide:
“This has lasted too long, so it must be functional.”
Prolonged convulsive-looking activity needs appropriate medical assessment.
The distinction may require:
trained observation
previous history
video
EEG
and specialist evaluation.
If an emergency seizure plan exists, follow it.
Otherwise, seek emergency help.
What is status epilepticus in someone with no previous epilepsy?
This requires urgent investigation because there may be a new underlying cause.
Doctors may consider:
stroke
infection
autoimmune encephalitis
tumour
traumatic injury
metabolic disturbance
toxic exposure
substance withdrawal
or another acute neurological illness.
Stopping the seizure is only part of treatment.
The cause also needs to be identified and treated.
Status and autoimmune encephalitis
New-onset seizures or status can occasionally be part of autoimmune encephalitis.
Suspicion may increase when seizures occur alongside rapidly developing:
memory problems
confusion
psychiatric or behavioural changes
abnormal movements
autonomic disturbance
or altered consciousness.
This may prompt specialist:
MRI
EEG
blood testing
cerebrospinal-fluid analysis
and antibody testing.
Related Information Hub page:
Blood Tests, Lumbar Puncture and Antibody Testing in Epilepsy
What is NORSE?
NORSE — New-Onset Refractory Status Epilepticus — describes a clinical presentation in which somebody without active epilepsy or another obvious relevant neurological disorder develops new refractory status without a clear acute cause being identified at the beginning.
NORSE is not one particular disease.
Possible underlying causes include:
autoimmune disease
infection
inflammatory disorders
genetic or metabolic conditions
and causes that remain unexplained.
We have a separate specialist page planned:
New-Onset Refractory Status Epilepticus — NORSE
so it will not be expanded further here.
What about FIRES?
FIRES — Febrile Infection-Related Epilepsy Syndrome — is a rare subtype of NORSE in which a febrile illness precedes the onset of refractory status.
It occurs most famously in children but can also occur in adults.
This also warrants its own specialist syndrome page and should not be confused with an ordinary fever-triggered seizure.
Does fever always mean status?
No.
Many childhood febrile seizures stop spontaneously.
Likewise, fever in someone with epilepsy may simply act as an illness-related seizure precipitant.
Status refers to the prolonged or inadequately terminating seizure activity, not merely the presence of fever.
Can status happen during sleep?
Yes.
A seizure beginning during sleep can become prolonged just like a seizure beginning while awake.
The danger is that a prolonged nocturnal seizure may not be witnessed immediately.
This is one reason people with known prolonged night-time seizures may require an individual safety and emergency plan.
Related Information Hub page:
Sleep Studies, Parasomnias and Nocturnal Events
How is status different from a long postictal state?
A seizure may stop but leave somebody:
deeply asleep
confused
agitated
disorientated
or unable to remember what happened.
That can persist much longer than the active seizure.
The person is not automatically still in status.
But unusually prolonged failure to recover can also be a sign of:
non-convulsive status
injury
hypoxia
medication effect
infection
stroke
metabolic disturbance
or another complication.
This is why unexpectedly prolonged altered consciousness needs medical assessment.
Timing the seizure and timing recovery separately
A useful record would say:
Convulsive activity: approximately 6 minutes
No further visible seizures
Remained unresponsive/confused for 35 minutes afterwards
rather than:
“The seizure lasted 41 minutes.”
This distinction can be extremely important to clinicians.
Can status cause memory problems afterwards?
Recovery varies enormously.
Some people may experience temporary:
memory difficulty
confusion
fatigue
speech problems
or cognitive slowing.
More severe status may be followed by prolonged neurological or cognitive effects.
Epilepsy Action notes that recovery depends partly on:
cause
seizure duration
age
other medical conditions
and treatment.
Not everybody has the same recovery trajectory.
Why might somebody be exhausted afterwards?
Status can place considerable stress on:
brain
muscles
cardiovascular system
breathing
and metabolism.
Treatment itself can also produce profound drowsiness.
Benzodiazepines and other emergency medicines may contribute to:
sleepiness
reduced coordination
slowed responses
and breathing suppression.
Recovery therefore reflects both the seizure emergency and its treatment.
Rescue medicine can affect breathing
Benzodiazepines are effective emergency antiseizure medicines but can also cause:
marked sedation
and, less commonly, respiratory depression.
Epilepsy Action advises close observation after emergency medicines such as midazolam or diazepam because breathing difficulties can occur.
This is another reason rescue treatment should follow a prescribed plan and appropriate training.
Can status happen again?
Yes.
Previous status may mean the epilepsy team wants to establish or update an emergency plan.
NICE specifically recommends agreeing an emergency management plan when there is concern that prolonged seizures or clusters may recur.
The plan should make future emergency action clearer.
Reducing risk
Not every episode of status can be prevented.
But potentially modifiable risks can include:
taking antiseizure medication as prescribed
avoiding abrupt medication withdrawal
having a plan for vomiting or missed doses
obtaining repeat prescriptions in time
managing known triggers where possible
treating significant medical illness
and using prescribed rescue medication according to the care plan.
Epilepsy Action specifically highlights regular antiseizure medication use and appropriate emergency medication as important parts of risk management.
A rescue plan should be specific
A useful emergency plan can include:
The person's ordinary seizure pattern
What normally happens?
Usual duration
How long does the ordinary seizure last?
When to start timing
Usually immediately.
When rescue medication should be given
The exact prescribed threshold.
Which medication
Including formulation and prescribed dose.
Whether another dose is allowed
And under what circumstances.
When 999 should be called
This should be unambiguous.
What to do after the seizure stops
Including recovery monitoring.
Who is trained to administer treatment
Particularly in:
home
school
respite care
or supported settings.
Schools and rescue medication
Children who may require rescue medication at school should have an appropriate healthcare plan.
The plan should clearly explain:
seizure type
emergency threshold
medication
dose
administration
and when emergency services should be called.
Epilepsy Action notes that staff expected to administer emergency seizure medication require appropriate training.
What should family and carers know?
People regularly supporting someone at risk of prolonged seizures should ideally know:
what the person's ordinary seizures look like
their normal duration
when a seizure becomes abnormal for them
where the emergency plan is kept
where rescue medication is stored
who is trained to administer it
when to call 999
and what recovery normally looks like.
This information is considerably more useful during an emergency than trying to search the internet while a seizure is already happening.
What information should be given to paramedics?
Useful information includes:
when the seizure started
whether it ever stopped
whether several seizures occurred
whether the person recovered between them
seizure type
rescue medication given
exact dose
time it was given
current antiseizure medication
known allergies
injury
possible trigger or illness
and whether this has happened before.
If the person's emergency plan is available, give it to the ambulance crew.
When should emergency services be called?
For someone with a known epilepsy plan, follow their individual emergency instructions.
In general, emergency help is appropriate when:
a convulsive seizure reaches 5 minutes
seizures repeat without recovery
the person is not recovering as expected
there is significant breathing difficulty
serious injury has occurred
the seizure happened in water
or it is the person's first recognised seizure.
Epilepsy Action's current UK first-aid advice specifically includes the five-minute threshold, repeated seizures without recovery, lack of regained consciousness and breathing difficulty.
When uncertain in a serious emergency, call 999.
What if someone's normal seizure already lasts close to five minutes?
They need an individualised plan.
Waiting for a generic threshold may not always be appropriate.
NICE specifically recognises prolonged seizures relative to the person's usual duration and recommends an individual emergency plan where recurrent prolonged seizures are a concern.
The treating epilepsy team can determine the safest rescue threshold.
What if the seizure stops at 4 minutes 50 seconds?
The number five is not a magical biological boundary.
If:
the seizure is substantially longer than usual
serious breathing problems occur
the person is badly injured
another seizure follows
or their care plan says treatment should begin sooner,
emergency action may be appropriate before five minutes.
NICE specifically regards a convulsive seizure more than two minutes longer than a person's usual seizure as a prolonged seizure requiring emergency management.
What if the seizure stops shortly after 5 minutes?
It still matters that it crossed the status threshold.
The person may require assessment depending on:
their emergency plan
whether rescue medicine was used
recovery
injuries
breathing
whether this is unusual for them
and whether another seizure occurs.
Follow the person's plan and emergency-service advice.
Does every person with epilepsy need rescue medication?
No.
Most seizures stop spontaneously and many people will never require emergency rescue medicine.
Rescue medication is usually prescribed when clinicians believe there is a meaningful risk of:
prolonged seizures
status
or clinically significant clusters.
The decision is individual.
Status epilepticus and seizure freedom
A prolonged seizure is still a seizure.
If somebody is being assessed for seizure control or drug-resistant epilepsy, status episodes form part of that history.
However, the treatment strategy may need to consider both:
preventing ordinary seizures
and specifically preventing prolonged seizures or clusters.
An emergency medicine can stop prolonged seizures without necessarily preventing the person's epilepsy from producing future seizures.
Questions to ask after an episode of status
Useful questions include:
Do you know why this episode became prolonged?
Was this definitely convulsive status epilepticus?
Could seizure activity have continued after the movements stopped?
Was EEG needed?
Did my antiseizure medication level contribute?
Does my regular medication need changing?
Do I now need rescue medication?
What exact duration should trigger rescue treatment for me?
When should my family call 999?
Can they be trained to administer the medicine?
What should happen if the first rescue dose does not work?
Should I have a written emergency management plan?
Questions about recovery
Useful questions include:
What recovery symptoms are expected after my episode?
How long might medication-related sedation last?
Were there any complications such as aspiration, low oxygen or injury?
Do I need follow-up blood tests or imaging?
Do I need cognitive or neurological follow-up?
Should I contact the team if particular symptoms persist?
Recovery advice should be individual because status has many different causes and severities.
The most important message
Status epilepticus is not simply:
“a particularly bad seizure.”
It is a state in which seizure activity has become abnormally prolonged or repeatedly continues without sufficient recovery.
For convulsive tonic-clonic status epilepticus, the key emergency threshold is:
5 minutes.
Do not wait 30 minutes.
The ILAE's modern framework identifies approximately:
5 minutes — t1: treatment should begin because the seizure is abnormally prolonged.
30 minutes — t2: continuing convulsive seizure activity carries increasing concern about long-term neurological consequences.
These are clinical operational thresholds, not exact predictions of what will happen to an individual person's brain.
Status can also occur without obvious convulsions.
Non-convulsive status may appear as prolonged:
confusion
altered consciousness
unusual behaviour
or subtle seizure activity
and often requires EEG for diagnosis.
Current NICE guidance treats convulsive status as an immediate medical emergency.
Initial treatment usually involves a benzodiazepine.
If seizures continue, hospital treatment escalates through additional antiseizure medicines and, in refractory cases, may require:
intensive care
general anaesthesia
respiratory support
and continuous EEG.
The safest preparation for someone known to be at risk is a clear individual emergency management plan explaining:
what their ordinary seizure looks like
when an event becomes an emergency
when rescue medicine should be given
and when 999 should be called.
The aim is simple:
recognise prolonged seizure activity early and treat it before it becomes harder and more dangerous to stop.
Sources and further reading
NICE — Epilepsies in children, young people and adults (NG217): Treating status epilepticus, repeated or cluster seizures, and prolonged seizures.
Current UK guidance defines convulsive status epilepticus as convulsive seizure activity lasting 5 minutes or more and sets out emergency benzodiazepine treatment, escalation after unsuccessful first-line treatment, cluster-seizure management and individual emergency plans.
NICE NG217 — Management when initial treatment is unsuccessful.
Current recommendations include a second benzodiazepine where appropriate, followed by intravenous levetiracetam, phenytoin or sodium valproate if two benzodiazepine doses fail, with phenobarbital or general anaesthesia considered under expert guidance when second-line treatment fails.
International League Against Epilepsy — Definition and classification of status epilepticus.
The ILAE Task Force introduced the two-time-point concept of t1 and t2. For convulsive tonic-clonic status, t1 is approximately 5 minutes and t2 approximately 30 minutes.
ILAE — Time Is Brain: Treating Status Epilepticus.
Explains the operational treatment thresholds used for tonic-clonic, focal and absence forms of status and why modern treatment should begin much earlier than the historic 30-minute definition.
ILAE — What's New in Status Epilepticus, 2025.
Current specialist discussion reiterates that tonic-clonic seizure activity continuing beyond five minutes represents the treatment threshold at which spontaneous termination becomes less likely and intervention is required.
Epilepsy Action — Status epilepticus and rescue medicine.
Current UK patient information covering convulsive and non-convulsive status, emergency action, rescue medication, causes, recovery and emergency management plans. Last modified April 2026.
Epilepsy Action — Seizure First Aid.
Current first-aid guidance includes calling 999 for seizures continuing beyond five minutes, repeated seizures without recovery, failure to regain consciousness and significant breathing difficulty.
Information reviewed: September 2026.
This page provides general educational information. Convulsive status epilepticus is a medical emergency. Follow the person's individual emergency plan where available and call 999 when emergency criteria are met. Rescue medication should be used only as prescribed and by somebody appropriately instructed or trained.
