I had withdrawal seizures. Does that mean that I now need to take an anticonvulsant?

Alcohol withdrawal seizures may or may not occur with DTs but are certainly more common, affecting up to one third of patients with chronic heavy alcohol use. Of those patients who have alcohol withdrawal seizures, between 30% to 50% will end up developing DTs. The seizures are generalized, meaning that they affect the entire body and occur within the first 24 to 48 hours after the last alcoholic drink. They tend to be brief and occur in a cluster of one to three seizures in fairly rapid succession. Generally, there are no auras or warning symptoms. An electroencephalogram and CT scan are usually normal, and the seizures usually do not recur. Electrolyte deficiencies can play a role in the intensity and duration of the seizures, particularly low sodium and magnesium. The seizures generally cease spontaneously and do not recur, although in about 3% of individuals the seizures will be prolonged. This condition is known as status epilepticus. When this occurs, further investigation is necessary to exclude other underlying medical conditions such as a head injury, an infection, or the development of epilepsy. Seizures are generally well controlled with benzodiazepines.

Aura a subjective sensation of voices or colors prior to a seizure.

Status epilepticus a state in a person whereby seizures occur in rapid succession without recovery of consciousness.

Dilantin is often also initiated in the emergency room but remains a controversial subject. The ASAM provides the following clinical practice guidelines for the use of Dilantin in alcohol withdrawal, as outlined in Table 15. (The grading of each recommendation is based on the amount and quality of the available research to support each recommendation. Grade A is obviously the best.) Thus, the general consensus is that short of having recurrent seizures from an underlying seizure disorder, the need for long-term Dilantin administration is not recommended. The maintenance of sobriety is the best anticonvulsant one can recommend.

Prophylaxis preventing the occurrence of something.

Epileptogenic causing epileptic attacks or seizures.

Table 15 Clinical Practice Guidelines for the Use of Dilantin in Alcohol Withdrawal


For patients with alcohol withdrawal syndrome and no history of seizures, phenytoin is not recommended as routine prophylaxis against alcohol withdrawal seizures. (Grade A recommendation.)


For patients with alcohol withdrawal syndrome and a history of seizures that are not alcohol related, phenytoin or other anticonvulsant therapy appropriate for the seizure type, in addition to adequate sedative-hypnotic medication, is recommended.

(Grade C recommendation.)


For patients with alcohol withdrawal syndrome and a history of alcohol withdrawal seizure, evidence is limited and conflicting, and expert opinion is mixed as to the benefit of adding phenytoin to adequate sedative—hypnotic medication. Therefore, sedative- hypnotics alone or with phenytoin are both options. (Grade C recommendation.)


Long-term phenytoin prophylaxis, except when indicated for seizure disorder unrelated to alcohol, is not recommended. (Grade C recommendation.)


For patients with alcohol withdrawal syndrome and other possible epileptogenic factors, factors that may increase the risk of alcohol withdrawal seizures, in addition to previous history of withdrawal seizure, include head injury, focal brain lesion, meningitis or encephalitis, and a family history of seizure disorder; however, no available research evidence clarifies the significance of these factors or provides guidance for appropriate management, and there is no clear consensus among experts. Therefore, sedative-hypnotics alone or with phenytoin are both options. (Grade C recommendation.)


For patients with acute alcohol withdrawal seizures, intravenous phenytoin is not recommended for patients with isolated, acute alcohol withdrawal seizure. (Grade A recommendation.)


For patients with alcohol-related status epilepticus, anticonvulsant therapy, which may include intravenous phenytoin, is appropriate for patients who develop alcohol-related status epilepticus. (Grade C recommendation.)

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