Tonic-clonic movements do represent a seizure, whether from a true neurological event or convulsive syncope. These authors said the history may be a cornerstone for the diagnosis.

Syncope:Findings without Diagnostic Value These authors rightly stated the ECG can be helpful but is not always, and prolonged cardiac monitoring, which was not available when this was written, may be required. The authors noted that the major befuddlement is whether the patient had a seizure and needs to be treated with anticonvulsants or if he had a decrease in cerebral blood flow that caused syncope, followed by brief seizure activity. It appears that the task of distinguishing seizure from syncope was a challenging assignment even 25 years ago. Transient Loss of Consciousness: The Value of the History for Distinguishing Seizure from Syncope It's important to take a good history to distinguish seizure from syncope with the hope of getting the patient directed to the right consultant. This may be one reason we see patients on anticonvulsants who continue to seize. As it turns out, a significant number of patients who are told they have a seizure disorder actually do not. We usually add another drug or attribute seizures to noncompliance. He would then check the anticonvulsant level, adjust any necessary derangements in the drug levels, and send the patient on his way. Most clinicians would simply believe the diagnosis if a patient comes to the ED with loss of consciousness and gives a history of prior seizures. The commonly used short-term Holter cardiac monitor is a popular intervention but of minimal actual value. Long-term ECG monitoring, as well as tilt table testing, are some tools that can further reveal the origin of the transient loss of consciousness. Basic ED labs and an ECG, even an outpatient EEG, are not always sensitive enough to differentiate seizures from syncope. Seizures can result from an occult cardiac etiology, and some causes, such as an episodic arrhythmia, can escape elucidation in the ED. A seizure resulting from syncope is termed convulsive syncope, and seizure activity occurs in up to 20 percent of episodes of syncope. That would seem to straightforward, but 10-20 percent of patients diagnosed as having a seizure do not have a seizure disorder but rather a cardiovascular event that caused transient loss of consciousness. If one believes that the episode was caused by a seizure, neurological testing and consultation is required. If one concludes that the event was syncope, it's usually from a cardiovascular event, and some can be serious or even fatal. Transient loss of consciousness can occur from seizure or syncope, and the emergency clinician must distinguish between the two general conditions, especially if it's the patient's first episode, and direct the appropriate initial evaluation and follow-up. FigureДifferentiating between syncope and seizures, a relatively easy task, is not quite so simple in the ED. Differentiating a seizure from syncope in an event that occurred outside the hospital that was witnessed only by nonmedical personnel makes the task more formidable. It was observed by physicians, there was a tonic phase of muscular activity, clonic movements lasted 60 seconds, the patient remembered nothing of the event, and he was disoriented for 15 minutes. There was no problem calling this patient's event a seizure, and there was no confusing it with syncope.

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Syncopal episode