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Alcohol Withdrawal Seizures: Causes, Signs & Symptoms

Medically Reviewed By: Benjamin Caleb Williams RN, BA, CEN

Written By: Phillippe Greenough

Article Updated: 09/25/2020

Number of References: 11 Sources

Alcohol withdrawal is one of the most dangerous types of withdrawal from any drug known to man. There is not only a risk of death but also brain damage which is due in large part to alcohol withdrawal seizures. These seizures are indicative of an extreme neurotransmitter balance due to withdrawal and can be a warning of further complications later in the detox process.

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What Are Alcohol Withdrawal Seizures?

These seizures are quite common, being experienced by between 23-33% of people who undergo withdrawal. They are different from epileptic seizures in that they may manifest without warning. These types of seizures are not only dangerous in and of themselves, but they also warn of greater challenges ahead for anyone who experiences them. In severe cases of withdrawal, these seizures may also escalate to a potentially fatal condition known as status epilepticus.

Alcohol withdrawal may produce different seizure types, the most serious of which are known as tonic-clonic (previously known as grand-mal), which is derived from the two common phases:

  • Tonic Phase: Someone loses consciousness and their muscles stiffen.
  • Clonic Phase: Repetitive and rhythmic contracting and relaxing of the muscles.

The tonic phase is fairly short, typically lasting less than 30 seconds, while the clonic phase may last around 2 minutes on average. These seizures typically end on their own after a brief period of seizing. The period of greatest seizure risk is between 6-48 hours after someone has taken their last drink of alcohol.

Signs

People who suffer seizures may exhibit a series of symptoms which are common during tonic-clonic (T-C) seizures. It should be mentioned that even though the symptoms resemble those of generalized T-C seizures, the underlying causes are very different. Some of the obvious outward signs of the tonic phase of an alcohol withdrawal seizure include:

  • Sudden spasm or stiffening of muscles
  • A cry or yell (produced by chest muscle contractions squeezing air out of the lungs)
  • Biting of the lip or tongue
  • Drooling (sometimes bloody if they bit the inside of their mouth)
  • Loss of consciousness

Symptoms

The above signs are just the tonic phase of the seizure. The clonic phase is next, and is what most people think of when they imagine seizures. The clonic phase of a withdrawal seizure exhibits symptoms such as:

  • Rhythmic but sometimes violent contractions of the arms and/or legs
  • Flexing at the waist or hips
  • Their face or skin may appear pale or even blue if they are having breathing difficulties
  • Involuntary urination or defecation

The clonic phase can last between 1 and 3 minutes, but the average time is around 2 minutes. After the convulsions in the clonic phase, someone will usually return to consciousness slowly, appearing very confused and disoriented. They may feel very sleepy, depressed, or irritable. These seizures should be expected during withdrawal and medical help should be summoned immediately.

Alcohol withdrawal seizures also introduce complications indirectly arising from the seizure. This can include injury while seizing, such as suffering a concussion, biting through the tongue, choking, and a variety of other injuries. These issues, while not directly due to alcohol withdrawal, are very serious and great care should be taken when someone is experiencing a seizure.

There is a condition known as status epilepticus that may result in the seizure lasting longer than 5 minutes, or someone suffering several seizures in a row without a return to consciousness. This is a very dangerous and potentially fatal condition. To reiterate; if medical help has not already been called, this should be done immediately.

What Causes Alcohol Withdrawal Seizures?

There are several factors that contribute to the emergence of alcohol withdrawal seizures. The primary contributors are the neurotransmitters GABA and glutamate. These neurotransmitters are critical in dampening or amplifying, respectively, signals sent between neurons in the brain and body.

The particulars of how the body develops a dependence upon alcohol through chronic abuse will set the stage for these seizures. Once dependence has been developed, in the absence of alcohol the reduced levels of GABA and the increased levels of glutamate act synergistically to greatly lower the seizure threshold. Every living thing that has a brain could experience a seizure; it is the limit of the seizure threshold which determines how likely it is that a seizure will occur.

There is a possibility that blood glucose fluctuations as well as increased levels of the neurotransmitter norepinephrine are also contributors. These may play minor roles in these seizures, but the main perpetrators are certainly GABA and glutamate. Let’s take a look at the exact role that these 2 neurotransmitters play in seizure threshold reduction:

GABA

GABA is an inhibitory neurotransmitter that is responsible for dampening or slowing down signals in the brain. When drinking alcohol, GABA levels are greatly increased, leading to an increased depressant effect. When alcohol is used for long periods, the brain adapts to this increase in GABA by reducing its responses to GABA. When alcohol use is suddenly ceased, GABA stimulation becomes reduced. Coupled with the brain’s decreased sensitivity to GABA this severely reduces the ability of the brain to moderate signals and slow itself down.

Glutamate

Glutamate is an excitatory neurotransmitter that acts to intensify nerve signals in the brain. Alcohol use reduces the levels of glutamate in the brain which produces depressant effects. After prolonged exposure to alcohol, the brain will increase sensitivity to glutamate to compensate for the reduced levels. Once alcohol is removed, the levels of glutamate rise dramatically. Along with the increased sensitivity to glutamate, this produces a dangerous state of hyperarousal in the brain.

Combined GABA and Glutamate Interactions

The main interaction between these neurotransmitters regarding seizures is GABAs direct effect on glutamate activity. GABA acts as a braking system to slow down nerve signals as well as lower the levels of glutamate released postsynaptically. These 2 chemicals tend to keep each other in check and balanced in a healthy brain. Due to the reduced ability of GABA to slow the brain down as well as the increase in excitatory glutamate, there is a perfect storm of hyperactive signaling in the brain which results in an alcohol withdrawal seizure.

Risks of Alcohol Withdrawal Seizures

One of the greatest dangers posed by alcohol withdrawal is not necessarily from the seizures themselves, but by falls or accidents caused by a sudden and unexpected loss of consciousness. People who suffer seizures regularly such as generalized T-C seizures or epilepsy often report a strange feeling, which is known as an aura, prior to the seizure which gives them time to prepare. In alcohol withdrawal seizures there is no such warning, so these seizures happen suddenly, often catching their victim completely unaware. Falls, car accidents, or a variety of other injuries are often experienced in this way.

Additionally, there is a shocking 4.8x increase in the mortality rate of those who experience seizures compared to those who do not experience seizures during withdrawal. This does not seem to be due to the seizures themselves, but rather due to complications which arise from severe alcohol withdrawal. This suggests that alcohol withdrawal seizures may indicate deeper underlying issues that may warrant a further diagnosis, treatment, and care.

Delirium Tremens

Somewhere between 30-50% of people who suffer an alcohol withdrawal seizure will develop delirium tremens (DTs), which is an extremely dangerous condition. When medical care or appropriate medication is not available, DTs have a 37% mortality rate. The typical onset of delirium tremens is between 48 and 72 hours from the last time someone had a drink of alcohol. The symptoms of DTs include all of the symptoms of alcohol withdrawal in general, with the addition of several very intense symptoms that are unique to DTs.

Delirium Tremens: Causes, Symptoms, and Treatments

Status Epilepticus

About 3% of people who experience withdrawal seizures will have a severe form of seizure known as status epilepticus. Status epilepticus (SE) is currently defined as any seizure which lasts more than 5 minutes, or if a person has multiple seizures without regaining consciousness in between events. SE is potentially fatal and is often a sign of permanent brain damage. Studies vary slightly, but adults who develop SE have an average mortality rate of 26% and this risk rises along with the patient’s age at the time of onset (patients 80 years and older had a mortality rate of greater than 50%).

Most T-C seizures last between 1-2 minutes, and the longer a seizure persists beyond this point, the less likely it is to stop on its own. Furthermore, the longer a seizure lasts into SE the lower the chances are that it will respond to treatments and medications. When SE does not respond to the normal seizure treatments it is referred to as “Refractory Status Epilepticus” and this occurs in about 30% of all status epilepticus cases.

Finally, somewhere between 9-25% of new cases of status epilepticus are a direct result of alcohol withdrawal seizures. Preventative steps may be taken if a seizure is anticipated, as preventing a seizure from occurring will eliminate the possibility of a status epilepticus event.

Kindling Process

There is a documented tendency for people who have experienced alcohol withdrawal seizures in the past to suffer them more easily or frequently than those who have never had one. The exact mechanisms for this are not known, but this is referred to as the “kindling process” by researchers. One study found that someone is 4x more likely to have a seizure if they have undergone alcohol withdrawal 5 or more times in the past.

Finally, the severity and duration of withdrawal symptoms grow with each subsequent episode of alcohol withdrawal in general, and this intensifies the seizures in particular. This is independent of the amount and duration of alcohol consumed but seems to have more to do with the number of alcohol withdrawal episodes that someone has experienced. This is thought to be through a sensitization process, although the exact mechanisms are currently unknown.

Medication For Seizure Risk Reduction

There is a wide range of medications that can be used to prevent or terminate a withdrawal seizure. Several of these medications are commonly used as part of alcohol detox treatment, but some are used solely to treat alcohol withdrawal seizures.

Some of the more commonly used alcohol withdrawal medications for treating these seizures include:

Sedatives

  • Benzodiazepines (Benzos): This class of medication is the first-line treatment for alcohol withdrawal seizures as well as alcohol withdrawal in general. The use of benzos can reduce the incidence of alcohol withdrawal seizure by roughly 84% and are generally well tolerated. The main choices for this purpose include diazepam, lorazepam, midazolam, and oxazepam. Benzos enhance GABA-α receptor function and can greatly reduce the risks or even prevent seizures from occurring.
  • Barbiturates: This is a very old class of medications that has fallen out of widespread use as safer, better-tolerated medications have become available. They act similarly to benzos by enhancing GABA function. The medication phenobarbital is the most commonly used for the treatment of withdrawal seizures but is usually only used if the seizures are unresponsive (refractory) to benzos. Barbiturates also depress breathing more than benzos, and there is no way to reverse a barbiturate overdose or toxicity, so they are not regularly used today.
Benzodiazepines For Alcohol Withdrawal

Anticonvulsants

This class of medications were specifically developed to treat epileptic seizures, but have been found effective in preventing alcohol withdrawal seizures as well. While they have not proven to be more effective than benzos for treating these seizures, there is promise for some of the newer medications in this class such as levetiracetam.

Anesthetics

Particularly propofol, this medication is used for human and veterinary anesthesia prior to surgery. Propofol works in direct opposition to alcohol withdrawal by increasing sensitivity at GABA-α receptors while simultaneously reducing sensitivity at NMDA glutamate receptors. This counteracts the neurotransmitter imbalances produced by alcohol withdrawal, possibly reducing the likelihood of a seizure occurring.

Professional Detox

The absolute best way to prevent or reduce the risk of alcohol withdrawal seizures is to enter an alcohol detox center. Individuals will differ in their tolerances to certain medications, and medical professionals will be able to determine the unique needs of each person. The dangers posed by these seizures should not be taken lightly, and there are safe and effective treatments available. All that is required to safely stop using alcohol is the willingness to ask for help.

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