Prodrome Most generalized tonic–clonic seizures begin without warning and abruptly, but some epileptic patients describe a prodrome. The prodrome of a generalized tonic–clonic seizure is a sort of premonitory feeling hours before a seizure. This type of prodrome is distinct from stereotypic aura of focal seizures that become generalized seizures. Phases A tonic–clonic seizure comprises three phases: the tonic phase, clonic phase and postictal phase. * Tonic phase :The tonic phase is usually the first phase and consciousness will quickly be lost (though not all generalized tonic–clonic seizures involve a full loss of consciousness), and the skeletal muscles will suddenly tense, often causing the extremities to be pulled towards the body or rigidly pushed away from it, which will cause the patient to fall if standing or sitting. There may also be upward deviation of the eyes with the mouth open. The tonic phase is usually the shortest part of the seizure, normally lasting only 10–20 seconds. The patient may also express brief vocalizations like a loud moan upon entering the tonic stage, due to air being forcefully expelled from the lungs. This vocalization is commonly referred to as an "ictal cry." Starting in the tonic phase, there may also be bluing of the skin from respiration impairment as well as pooling of saliva in the back of the throat. Increased blood pressure, pupillary size and heart rate (sympathetic response) may also be noted with clenching of the jaw possibly resulting in biting the tongue. * Clonic phase :The clonic phase is an evolution of the tonic phase and is caused by muscle relaxations superimposed on the tonic phase muscle contractions. This phase is longer than the tonic phase with the total ictal period usually lasting no longer than 1 min. Skeletal muscles will start to contract and relax rapidly, causing convulsions. These may range from exaggerated twitches of the limbs to violent shaking or vibrating of the stiffened extremities. The patient may roll and stretch as the seizure spreads. Initially, these contractions may be high frequency and low amplitude, which will progress to decreased frequency and high amplitude. An eventual decrease in contraction amplitude just before seizure cessation is also typical. *Postictal phase :The postictal phase causes are multifactorial to include alteration of cerebral blood flow and effects on multiple neurotransmitters. These changes after a generalized tonic–clonic seizure cause a period of postictal sleep with stertorous breathing. Confusion and total amnesia upon regaining consciousness are also usually experienced and slowly wear off as the patient becomes gradually aware that a seizure occurred and remembers their identity and location. Impaired consciousness duration can last several hours after a seizure, especially with a compounding central nervous system condition or a prolonged seizure. Occasionally the patient may vomit or burst into tears from the experienced mental trauma. An additional smaller seizure can also occur several minutes after the main seizure, particularly if the patient's seizure threshold has been brought unusually low by known factors or combinations of such. Examples include: severe hangovers, sleep deprivation, elevated estrogen at ovulation, prolonged physical tiredness, and drug use or abuse (including, but not limited to, stimulants, alcohol and caffeine).
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