Alcohol Withdrawal Seizure Treatment

Key Takeaways

• When chronic, heavy drinkers suddenly stop drinking, they may experience alcohol withdrawal symptoms. 
• Withdrawal symptoms may vary from mild to severe. Among the severe symptoms are seizures and delirium tremens.
• Alcohol disrupts the balance of two neurotransmitters: GABA and glutamate.
• Alcohol withdrawal has four stages: minor withdrawal symptoms, hallucinations, withdrawal seizure, and delirium tremens.
• There are many risk factors for alcohol withdrawal. But having a previous history of withdrawal is the most reliable predictor of who is at risk.
• The Clinical Institute Withdrawal Assessment for Alcohol, Revised (CIWA-Ar) is a tool for assessing withdrawal symptoms. Patients are scored on ten items.
• Benzodiazepines are used to treat seizures and other alcohol withdrawal symptoms. 
• Avoiding regular and heavy drinking is the best way to prevent withdrawal seizures.

What is Alcohol Withdrawal?

Heavy drinking is bad for health. However, suddenly stopping alcohol consumption can also be dangerous for heavy drinkers. 

Alcohol withdrawal syndrome is a collection of physical and mental symptoms experienced by regular, heavy drinkers who suddenly stop drinking. 

These withdrawal symptoms can range from mild to severe. Among the severe symptoms are seizures and delirium tremens (DTs).

What Triggers Alcohol Withdrawal?

Alcohol is a depressant. The substance has a calming effect on the central nervous system. It does this by influencing certain brain chemicals called neurotransmitters. 

Alcohol affects two neurotransmitters:¹

1. Glutamate: A powerful excitatory neurotransmitter. “Excitatory” means it excites nerve cells to send signals to one another. Glutamate plays a crucial part in learning and memory.
2. Gamma-aminobutyric acid (GABA): The primary inhibitory neurotransmitter. “Inhibitory” means it blocks signals between nerves and puts a brake on brain activity. GABA’s action produces a calming effect.

In everyday situations, glutamate and GABA are in balance. This is necessary to keep the brain functioning optimally. 

When a person drinks, alcohol triggers GABA activity. This action reduces nerve excitation, causing relaxation. 

If people drink regularly, they eventually become dependent on alcohol. They drink more to get the same relaxing effect they felt when they first started drinking alcohol.

Over time, the body becomes used to alcohol. It works hard to counter alcohol’s suppressive effect to keep the brain and nerves awake. 

When a person suddenly stops drinking, GABA drops to below normal levels. 

The excitation of nerves caused by glutamate will be left unopposed. This causes the brain to go into hyperactive mode, leading to alcohol withdrawal (symptoms like tremors, seizures, and delirium).^{1, 2}

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What to Expect During Alcohol Withdrawal (Symptoms) 

Alcohol withdrawal syndrome is made up of four stages based on severity:^{3, 4}

Stage 1: Minor Withdrawal Symptoms

The following mild symptoms may develop within 6 to 12 hours after the last drink: 

• Anxiety
• Tremors (like shaky hands)
• Headache
• Gastrointestinal upset (like vomiting and nausea)
• Insomnia
• Sweating
• Increased heart rate
• Increased body temperature

Stage 2: Alcoholic Hallucinosis

Hallucinations may happen 12 to 24 hours after the last drink. 

The minor symptoms from stage 1 can also become severe and life-threatening if not treated.

Stage 3: Alcohol Withdrawal Seizures

The onset of seizures or “rum fits” happens during this stage.  

Seizures happen in about 10% of patients undergoing alcohol withdrawal. They typically start 24 to 48 hours after a person’s last drink.⁴

Alcohol itself rarely causes seizures. But during withdrawal, alcohol’s relaxing effect is removed. As a result, the brain becomes hyperactive and more prone to seizures.

Alcohol withdrawal seizures are of the tonic-clonic type. They involve muscle stiffening (tonic phase) and twitching or jerking (clonic phase). 

Stage 4: Delirium Tremens

Delirium tremens (DTs) usually happen 48 to 72 hours after the last drink. Symptoms include:^{1, 5}

• Fever 
• Sweating
• Nightmares
• Agitation
• Confusion
• Disorientation
• Visual and auditory hallucinations
• Seizures
• Cardiovascular and metabolic complications (like high blood pressure and increased heart rate)

Reports say that patients with delirium tremens have a mortality rate of 1 to 15%.^{6, 7}

How to Diagnose Alcohol Withdrawal

The Clinical Institute Withdrawal Assessment for Alcohol, Revised (CIWA-Ar) is a tool used to identify withdrawal symptoms. 

According to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), an alcohol withdrawal syndrome diagnosis is made by observing the person. There must be at least two symptoms present:⁸

1. Nausea and vomiting 
2. Tremors 
3. Sweating 
4. Anxiety 
5. Agitation
6. Tactile disturbances (itching, pins and needles sensation, numbness) 
7. Auditory disturbances
8. Visual disturbances
9. Headache and fullness of head 
10. Orientation and clouding of the sensorium (the brain’s "seat of sensation”)

Each item is scored depending on the severity of symptoms. Items 1 to 9 are assigned 0 to 7 points. Item 10 is assigned 0 to 4 points. The highest score a patient can get is 67 points.⁹

The total score is computed and used to classify the patient’s alcohol withdrawal condition:^{2, 4}

• Less than 8: Mild. The patient may not need medications. 
• 8 to 15: Moderate. The patient may need medications to prevent the progression of symptoms.
• Greater than 15: Severe. There’s a high chance that the patient will have seizures and delirium.

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Who is at Risk for Seizures From Withdrawal?

Here are some risk factors for severe alcohol withdrawal:⁴

• Previous history of alcohol withdrawal
• Moderate or severe withdrawal at diagnosis (CIWA-Ar score of 10 or more)
• Alcohol dependence
• Recent alcohol intoxication
• Use of other illicit substances
• High alcohol level in the blood
• Abnormal liver function
• Older age
• Being male
• Presence of medical conditions like liver disease, central nervous infection, electrolyte disturbances, hypoglycemia (low blood glucose)

While alcohol withdrawal can lead to seizures, not everyone experiencing withdrawal will have them. The above risk factors do not automatically apply to seizures.  

Here are the risk factors that studies have linked to withdrawal seizures:^{2, 10, 11}

• Previous history of seizure and other withdrawal symptoms: 

• Thrombocytopenia (low platelet count)
• Hypokalemia (low potassium level)
• Structural brain lesions

Previous withdrawal episodes appear to be the most reliable predictor of who is at risk for future withdrawal, with or without seizures.

What to Do if Alcohol Withdrawal Causes Seizures

Treatment of alcohol withdrawal is usually based on the severity of withdrawal.

For mild and moderate symptoms, a person may go to an outpatient setting. This option is safe, effective, and relatively cheap. It also doesn’t disrupt their personal life. 

Hospital treatment is needed for more serious withdrawal cases. Intravenous fluids (to prevent dehydration) and medications (to ease symptoms) are often used. Doctors can also monitor and manage any complications.  

Those with these conditions are top candidates for inpatient treatment:^{3, 5, 12}

• Severe withdrawal symptoms
• History of withdrawal seizures
• High risk of delirium tremens
• Acute illnesses
• Poorly controlled chronic medical conditions
• Suicide thoughts and other serious psychiatric conditions
• Abnormal laboratory results
• Lack of a support network
• Use of other substances

Alcohol Withdrawal Seizure Treatment 

Those with severe withdrawal symptoms may need interventions that involve medications. However, not all drugs for alcohol withdrawal will be effective for seizures. 

Benzodiazepine

Benzodiazepines are the top choice for treating and preventing alcohol withdrawal in the U.S. 

They are sedatives that help reduce seizures and prevent symptoms from becoming severe.^{3, 5, 12, 13, 14}

The commonly prescribed benzodiazepines are chlordiazepoxide, lorazepam, and alprazolam.

Benzodiazepine can be combined with haloperidol, beta-blockers, clonidine, and phenytoin to treat withdrawal complications.¹⁵

Benzodiazepines carry an FDA warning because of their addictive properties. You should discuss this risk with your doctor and follow instructions carefully.

Carbamazepine

Carbamazepine is an anticonvulsant. It’s an alternative to benzodiazepines in the outpatient treatment of mild-to-moderate symptoms.¹⁵ It’s commonly prescribed in Europe.¹³

Chlormethiazole

Chlormethiazole (also called clomethiazole or heminevrin) enhances GABA activity. It can protect against withdrawal seizures. Like carbamazepine, it’s commonly prescribed in Europe.¹³

Valproate

Valproate (also known as valproic acid) reduces the incidence of seizures. It also prevents the progression of withdrawal symptoms.⁴ Like chlormethiazole and carbamazepine, it is commonly prescribed in Europe.¹³

Neuroleptics

Neuroleptic agents (like haloperidol and phenothiazines) may reduce the severity of withdrawal symptoms. They may work with patients with uncontrolled agitation. However, they are not as effective as benzodiazepines in treating seizures and delirium.³

Barbiturates

The combination of benzodiazepines and certain barbiturates can increase the efficacy of benzodiazepines’ action.⁴

Propofol

One of propofol’s effects is to stimulate GABA. This makes the drug useful for patients with severe delirium tremens who respond poorly to benzodiazepines.⁴

Sodium Oxybate

Sodium oxybate is structurally similar to GABA. It is approved in some European countries for alcohol withdrawal treatment. However, it’s not approved in other countries because of its addictive properties.⁴

Gabapentin

Gabapentin is another drug that’s structurally similar to GABA. It can be combined with other medications to treat partial seizures.^{3, 4}

Baclofen 

Baclofen can reduce alcohol withdrawal symptoms by activating GABA receptors.^{3, 4}

Supplements

Vitamins and minerals are given to replace essential nutrients that alcohol use has depleted. In particular, thiamine and folic acid are given to prevent a neurological disease called Wernicke’s encephalopathy.⁴

Additional supplements may be given to address nutritional deficiencies once the withdrawal is gone.⁵

How to Prevent Seizures When Quitting Drinking

Treatment is not the best way to fix alcohol withdrawal. The best way to prevent seizures and other withdrawal symptoms is to avoid regular and heavy alcohol use. 

Detoxification is another approach. It can minimize withdrawal symptoms, prevent complications, and speed up the process of abstinence.² It can be done by: 

• Gradually reducing the person’s dependence on alcohol
• Substituting alcohol with approved medications

If you or someone you know has alcohol use disorder, know that help is available. Speak with an addiction specialist today.