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A generalized tonic–clonic seizure (also known as a grand mal seizure ) is a type of generalized seizure that affects the entire brain. Tonic–clonic seizures are the seizure type most commonly associated with epilepsy and seizures in general and the most common seizure associated with metabolic imbalances. However, it is a misconception that they are the only type of seizure as they only account for the main seizure type in ~10% of those with epilepsy.

These seizures typically initiate abruptly with either a focal or generalized onset. A prodrome (vague sense of impending seizure) may also be present before the seizure begins. The seizure itself includes both tonic and clonic contractions with tonic contractions usually preceding myoclonic contractions. After these series of contractions, there is an extended postical state where the person is unresponsive, is sleeping with loud snoring and has eventual confusion upon awakening.

Of note, tonic–clonic seizures can be induced deliberately in electroconvulsive therapy.

Prodrome, Phases, and Recovery
Prodrome

Most generalized tonic-clonic seizures begin without warning and abruptly, but some epileptic patients describe a prodrome. The prodrome of a generalized tonic-clonic seizure is a sort of premonitory feeling hours before a seizure. This type of prodrome is distinct from stereotypic auras of focal seizures that become generalized seizures.

Phases

A tonic–clonic seizure comprises two phases, the tonic phase and the clonic phase.


 * Tonic phase
 * The tonic phase is usually the first phase and the patient will quickly lose consciousness (though not all generalized tonic-clonic seizures involve a full loss of consciousness), and the skeletal muscles will suddenly tense, often causing the extremities to be pulled towards the body or rigidly pushed away from it, which will cause the patient to fall if standing or sitting. There may also be upward deviation of the eyes with the mouth open. The tonic phase is usually the shortest part of the seizure, lasting only 10-20 seconds. The patient may also express brief vocalizations like a loud moan upon entering the beginning seizure with the tonic stage, due to air forcefully expelled from the lungs. This vocalization is commonly referred to as a "ictal cry." There may also be bluing of the skin from respiration impairment as well as pooling of saliva in the back of the throat. Increased blood pressure, pupillary size and heart rate (sympathetic response) will also be noted with clenching of the jaw possibly resulting in biting the tongue.
 * Clonic phase
 * The patient's muscles will start to contract and relax rapidly, causing convulsions. These may range from exaggerated twitches of the limbs to violent shaking or vibrating of the stiffened extremities. The patient may roll and stretch as the seizure spreads. The eyes typically roll back or close and the tongue often suffers bruising or crushing injuries sustained by strong jaw contractions. The lips or extremities may turn slightly bluish (cyanosis) and incontinence is seen in some cases.

Due to physical, mental and nervous exhaustion, postictal sleep with stertorous breathing invariably follows a tonic–clonic seizure. Confusion and total amnesia upon regaining consciousness are usually experienced and slowly wear off as the patient becomes gradually aware that a seizure occurred and remembers their identity and location. Occasionally the patient may vomit or burst into tears from the experienced mental trauma. An additional smaller seizure can occur several minutes after the main seizure, particularly if the patient's seizure threshold has been brought unusually low by known factors or combinations of such - for example severe hangovers, sleep deprivation, elevated estrogen at ovulation, prolonged physical tiredness and/or drug use including some pharmaceuticals, alcohol and caffeine.


 * Greetings Clark.MedicalEdits (talk) 18:55, 19 November 2018 (UTC)