Preictal warning phenomena in focal epilepsy

Objective: To summarize current evidence on the prevalence, phenomenology, and temporal characteristics of prodromal symptoms and early ictal manifestations (auras) in focal epilepsy, and to clarify their clinical relevance for patient counseling and management.

Material and methods. A narrative review of the literature on prodromal symptoms and auras in focal epilepsy was conducted. Publications were identified through searches in PubMed/MEDLINE and by screening reference lists of key articles. Given the heterogeneity in definitions and time frames across studies, findings were analyzed qualitatively without meta-analysis, particularly emphasizing on practical aspects of clinical interviewing and safety recommendations.

Results. Prodromal symptoms are reported in a substantial proportion of patients with focal epilepsy; reported prevalence varies depending on assessment methods and diagnostic criteria. Prodromes typically occur minutes to hours (less commonly a day or more) before seizure onset and may include affective, cognitive, and autonomic manifestations. According to the current classification by the International League Against Epilepsy, an aura is defined as a focal aware seizure and represents the ictal phase of the epileptic event. Clinically, auras are characterized by brief, stereotyped subjective experiences occurring seconds to minutes before potential seizure propagation. Patients’ responses to warning symptoms often include cessation of ongoing activities, seeking a safe environment, and alerting others, which may reduce the risk of injury. However, in some individuals, anticipatory anxiety and avoidance behaviors develop, negatively affecting quality of life.

Conclusion. In patients with focal epilepsy, routine and systematic inquiry about prodromal symptoms and auras during clinical evaluation is advisable. Clinicians should carefully distinguish between prodromal and early ictal manifestations and help patients adopt proportionate safety measures without reinforcing hypervigilance or unnecessary restrictions in daily activities.

1. Fisher R.S., Cross J.H., French J.A., et al. Operational classification of seizure types by the International League Against Epilepsy: Position Paper of the ILAE Commission for Classification and Terminology. Epilepsia. 2017; 58 (4): 522–30. https://doi.org/10.1111/epi.13670.

2. Blume W.T., Lüders H.O., Mizrahi E., et al. Glossary of descriptive terminology for ictal semiology: Report of the ILAE Task Force on Classification and Terminology. Epilepsia. 2001; 42 (9): 1212–8. https://doi.org/10.1046/j.1528-1157.2001.22001.x.

3. Kanner A.M., Carrazana E.E., Munger Clary H.M., et al. Anticipatory anxiety of seizures in epilepsy: a common, complex, and underrecognized phenomenon? Epileptic Disord. 2024; 26 (3): 273–81. https://doi.org/10.1002/epd2.20224.

4. Weiss A., Canetti L., Ben David S., et al. Seizure phobia: a distinct psychiatric disorder among people with epilepsy. Seizure. 2022; 95: 26–32. https://doi.org/10.1016/j.seizure.2021.12.009.

5. Fazekas B., Megaw B., Eade D., Kronfeld N. Insights into the real-life experiences of people living with epilepsy: a qualitative netnographic study. Epilepsy Behav. 2021; 116: 107729. https://doi.org/10.1016/j.yebeh.2020.107729.

6. Jacoby A., Gorry J., Gamble C., Baker G.A. Public knowledge, private grief: a study of public attitudes to epilepsy in the United Kingdom and implications for stigma. Epilepsia. 2004; 45 (11): 1405–15. https://doi.org/10.1111/j.0013-9580.2004.02904.x.

7. de Boer H.M., Mula M., Sander J.W. The global burden and stigma of epilepsy. Epilepsy Behav. 2008; 12 (4): 540–6. https://doi.org/10.1016/j.yebeh.2007.12.019.

8. Besag F.M.C., Vasey M.J. Prodrome in epilepsy. Epilepsy Behav. 2018; 83: 219–33. https://doi.org/10.1016/j.yebeh.2018.03.019.

9. Scaramelli A., Braga P., Avellanal A., et al. Prodromal symptoms in epileptic patients: clinical characterization of the pre-ictal phase. Seizure. 2009; 18 (4): 246–50. https://doi.org/10.1016/j.seizure.2008.10.007.

10. Vasconcelos Calheiros de Oliveira Costa G., Fornari Caprara A.L., Pitton Rissardo J., et al. Evaluating prodromal symptoms and health locus of control as predictors of seizure reactivity and neuropsychiatric outcomes in drug-resistant epilepsy: a cross-sectional study. Epilepsy Behav. 2026; 175: 110854. https://doi.org/10.1016/j.yebeh.2025.110854.

11. Ottman R., Hauser W.A., Stallone L. Semistructured interview for seizure classification: agreement with physicians’ diagnoses. Epilepsia. 1990; 31 (1): 110–5. https://doi.org/10.1111/j.1528-1157.1990.tb05368.x.

12. Spencer D.C.Auras are frequent in patients with generalized epilepsy. Epilepsy Curr. 2015; 15 (2): 75–7. https://doi.org/10.5698/1535-759715.2.75.

13. Manford M., Fish D.R., Shorvon S.D. An analysis of clinical seizure patterns and their localizing value in frontal and temporal lobe epilepsies. Brain. 1996; 119 (Pt 1): 17–40. https://doi.org/10.1093/brain/119.1.17.

14. Haut S.R. Seizure clustering. Epilepsy Behav. 2006; 8 (1): 50–5. https://doi.org/10.1016/j.yebeh.2005.08.018.

15. Blum D., Eskola J., Bortz J.J., Fisher R.S. Patient awareness of seizures. Neurology. 1996; 47 (1): 260–4. https://doi.org/10.1212/wnl.47.1.260.

16. Bellon M., Walker C., Peterson C. Seizure-related injuries and hospitalizations: self-report data from the 2010 Australian Epilepsy Longitudinal Survey. Epilepsy Behav. 2013; 26 (1): 7–10. https://doi.org/10.1016/j.yebeh.2012.10.019.

17. Lawn N.D., Bamlet W.R., Radhakrishnan K., et al. Injuries due to seizures in persons with epilepsy: a population-based study. Neurology. 2004; 63 (9): 1565–70. https://doi.org/10.1212/01.wnl.0000142991.14507.b5.

18. Narodova E.A. Digital tools for seizure monitoring and selfmanagement in epilepsy: a narrative review. J Clin Med. 2025; 14 (24): 8701. https://doi.org/10.3390/jcm14248701.

19. Bandura A. Self-efficacy: toward a unifying theory of behavioral change. Psychol Rev. 1977; 84 (2): 191–215. https://doi.org/10.1037/0033295X.84.2.191.

20. Mormann F., Andrzejak R.G., Elger C.E., Lehnertz K. Seizure prediction: the long and winding road. Brain. 2007; 130 (Pt 2): 314–33. https://doi.org/10.1093/brain/awl241.

21. Federico P., Abbott D.F., Briellmann R.S., et al. Functional MRI of the pre-ictal state. Brain. 2005; 128 (Pt 8): 1811–7. https://doi.org/10.1093/brain/awh533.

22. Sumsky S., Greenfield L.J. Jr. Network analysis of preictal iEEG reveals changes in network structure preceding seizure onset. Sci Rep. 2022; 12 (1): 12526. https://doi.org/10.1038/s41598-022-16877-x.

23. Johansson D., Ohlsson F., Krýsl D., et al. Tonic-clonic seizure detection using accelerometry-based wearable sensors: a prospective, video-EEG controlled study. Seizure. 2019; 65: 48–54. https://doi.org/10.1016/j.seizure.2018.12.024.

24. NICE. Epilepsies in children, young people and adults (NG217). Available at: https://www.nice.org.uk/guidance/ng217 (accessed 15.12.2025).

25. Kanner A.M. Psychiatric comorbidities in epilepsy: should they be considered in the classification of epileptic disorders? Epilepsy Behav. 2016; 64 (Pt B): 306–8. https://doi.org/10.1016/j.yebeh.2016.06.040.

26. Andualem F., Melkam M., Tadesse G., et al. Quality of life and associated factors among people with epilepsy in Ethiopia: a systematic review and meta-analysis. BMC Public Health. 2024; 24 (1): 1529. https://doi.org/10.1186/s12889-024-19018-3.

27. Nixon A., Kerr C., Breheny K., Wild D. Patient Reported Outcome (PRO) assessment in epilepsy: a review of epilepsy-specific PROs according to the Food and Drug Administration (FDA) regulatory requirements. Health Qual Life Outcomes. 2013; 11: 38. https://doi.org/10.1186/14777525-11-38.