Case-Based Review

Febrile Seizures: Evaluation and Treatment



From the Nationwide Children’s Hospital, Columbus, OH (Dr. Patel) and Cook Children’s Medical Center, Fort Worth, TX (Dr. Perry).


  • Objective: To review the current understanding and management of febrile seizures.
  • Methods: Review of the literature.
  • Results: Febrile seizures are a common manifestation in early childhood and very often a benign occurrence. For simple febrile seizures, minimal evaluation is necessary and treatment typically not warranted beyond reassurance and education of caregivers. For complex febrile seizures, additional evaluation in rare cases may suggest an underlying seizure tendency, though most follow a typical benign course of febrile seizures. In some cases, as-needed benzodiazepines used for prolonged or recurrent febrile seizures may be of value. There are well described epilepsy syndromes for which febrile seizures may be the initial manifestation and it is paramount that providers recognize the signs and symptoms of these syndromes in order to appropriately counsel families and initiate treatment or referral when warranted.
  • Conclusion: Providers caring for pediatric patients should be aware of the clinical considerations in managing patients with febrile seizures.

Key words: febrile seizure; Dravat syndrome; GEFS+; PCDH19; FIRES; complex febrile seizure.

A febrile seizure is defined as a seizure in association with a febrile illness in the absence of a central nervous system infection or acute electrolyte imbalance in children older than 1 month of age without prior afebrile seizures [1]. The mechanism by which fever provokes a febrile seizure is unclear [2]. Febrile seizures are the most common type of childhood seizures, affecting 2% to 5% of children [1]. The age of onset is between 6 months and 5 years [3]; peak incidence occurs at about 18 months of age. Simple febrile seizures are the most common type of febrile seizure. By definition, they are generalized, last less than 10 minutes and only occur once in a 24-hour time-period. A complex febrile seizure is one with focal onset or one that occurs more than once during a febrile illness, or lasts more than 10 minutes. Febrile status epilepticus, a subtype of complex febrile seizures, represents about 25% of all episodes of childhood status epilepticus. They account for more than two-thirds of cases during the first 2 years of life.

The risk of reoccurrence after presenting with one febrile seizure is approximately 30%, with the risk being 60% after 2 febrile seizures and 90% after 3 [4–6]. Some families have an autosomal dominant inheritance pattern with polygenic inheritance suspected for the majority of patients presenting with febrile seizures.

Multiple chromosomes have been postulated to be associated with genetic susceptibility for febrile seizures, with siblings having a 25% increased risk and high concordance noted in monozygotic twins [7]. The pathophysiology for febrile seizures has been associated with a genetic risk associated with the rate of temperature rise with animal studies suggesting temperature regulation of c-aminobutyric acid (GABA) a receptors [2]. Other studies propose a link between genetic and environmental factors resulting in an inflammatory process which influences neuronal excitement predisposing one to a febrile seizure [8].

Debate exists between the relation of febrile seizures and childhood vaccinations. Seizures are rare following administration of childhood vaccines. Most seizures following administration of vaccines are simple febrile seizures [9]. Febrile seizures associated with vaccines are more associated with underlying epilepsy. In a study of patients with vaccine-related encephalopathy and febrile status epilepticus, the majority of patients were found to have Dravet syndrome; it was determined that the vaccine may have triggered an earlier onset of the presentation for Dravet in those predestined to develop this disease but did not adversely impact ultimate outcome [10].

In this article, we review simple and complex febrile seizures with a focus on clinical management. Epilepsy syndromes associated with febrile seizures are also discussed. Cases are provided to highlight important clinical considerations.

Case 1: Simple Febrile Seizure

A 9-month-old infant and his mother present to the pediatrician. The mother notes that the infant had an event of concern. She notes the infant had stiffness in all 4 extremities followed by jerking that lasted 30 to 60 seconds. The infant was not responsive during the event. He was sleepy afterward, but returned to normal soon after the event ended. After, she noted that the infant felt warm and she checked his temperature. He had a fever of 101°F. The infant has normal development and no other medical problems.

  • What are management considerations for simple febrile seizure?

A simple febrile seizure is the most common type of febrile seizure. They are generalized, lasting less than 10 minutes and only occur once in a 24-hour period. There is no increased risk of developing epilepsy or developmental delay for patients after the first simple febrile seizures when compared to other children [5,6]. The diagnosis is based on history provided and a physical examination including evaluation of body temperature [11,12].

No routine laboratory tests are needed as a result of a simple febrile seizure unless obtained to assist in identifying the fever source [3,11]. Routine EEG testing is not recommended for these patients [3,11]. Routine imaging of the brain is also not needed [3,11]. Only if a patient has signs of meningitis should a lumbar puncture be performed [11]. The American Academy of Pediatrics states that a lumbar puncture is strongly considered for those younger than 12 months if they present with their first complex febrile seizure as signs of meningitis may be absent in young children. For infants 6 to 12 months of age, a lumbar puncture can be considered when immunization status is deficient or unknown [13,14]. Also, a lumbar puncture is an option for children who are pretreated with antibiotics [11]. For patients younger than 6 months, data is lacking on the percentage of patients with bacterial meningitis following a simple febrile seizure.

Daily preventative therapy with an anti-epilepsy medication is not necessary [3,11]. A review of several treatment studies shows that some anti-epileptic medications are effective in preventing recurrent simple febrile seizures. Studies have demonstrated the effectiveness of phenobarbital, primidone, and valproic acid in preventing the recurrence of simple febrile seizures; however, the side effects of each medication outweighed the benefit [3]. Carbamazepine and phenytoin have not been shown to be effective in preventing recurrent febrile seizures [3].

For anxious caregivers with children having recurrent febrile seizures, a daily medication or treating with an abortive seizure medication at the time of a febrile illness can be considered [3,5,6,15]. Treating with an abortive medication may mask signs and symptoms of meningitis making evaluation more challenging [16]. Evidence does not support that using antipyretic medications such as acetaminophen or ibuprofen will reduce the recurrence of febrile seizures. The seizure usually is the first noticed symptom due to the rise of temperature being the cause of the febrile seizure in an otherwise well child prior to the seizure [11,17]. Damage to the brain and associated structures is not found with patients presenting with simple febrile seizures [5,6]. Education on all of these principles is strongly recommended for caregiver reassurance.


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