What should a GP do in the first 5 minutes of a seizure?

The most important GP action in the first 5 minutes of a witnessed seizure is to **start the clock**. If the seizure has not stopped by 5 minutes, treatment should begin — not at 10 minutes, not "when the ambulance arrives if it hasn't stopped." Call 000 at any time, but do not wait for the ambulance to give first-line treatment if it is available in your setting. Remove hazards from around the person, place them in the recovery position (lateral), do not restrain limb movements, do not insert anything into the mouth. If intranasal midazolam (0.2 mg/kg, max 10 mg) or buccal midazolam (10 mg) is available (as it is in schools and some families with known epilepsy), administer it. If IM midazolam (Hypnovel) is available in your practice emergency kit, 10 mg IM into the outer thigh at 5 minutes is first-line. Check blood glucose immediately — hypoglycaemia is the most immediately reversible cause. Document the seizure type, duration, any known trigger, and current antiepileptic medication.

Why is midazolam IM better than IV lorazepam in the pre-hospital setting?

IV lorazepam is effective when IV access is already established (e.g., a patient in hospital), but in the community, IV access takes 3–7 minutes to establish during an active convulsion. This delay costs critical treatment time. The RAMPART trial (Silbergleit et al., NEJM 2012) specifically addressed this by randomising ambulance-treated SE patients to midazolam 10 mg IM versus lorazepam 4 mg IV. Key findings: midazolam IM was superior in seizure cessation (73.4% vs 63.4%, p < 0.001), had fewer adverse events (3.4% respiratory depression vs 6.5%), and — crucially — patients in the IM arm received their medication significantly faster because IV access setup was avoided. Midazolam IM is rapidly absorbed from the deltoid or anterolateral thigh muscle; peak plasma levels are achieved in 15–30 minutes. Buccal midazolam (10 mg, licensed in Australia) and intranasal midazolam are acceptable alternatives in the community when IM is not available. IV diazepam and IM haloperidol are inferior and should not be used as first-line SE treatment.

What is the second-line treatment if benzodiazepine fails?

If a standard first-line benzodiazepine (midazolam or lorazepam) has been given and the seizure continues at 10–20 minutes, second-line treatment should be administered. The ESETT trial (Kapur et al., NEJM 2019) randomised 400+ patients with benzodiazepine-resistant SE to levetiracetam 60 mg/kg IV (max 4,500 mg), phenytoin 20 mg/kg fosphenytoin equivalent IV, or valproate 40 mg/kg IV (max 3,000 mg). All three achieved seizure cessation in approximately 47–48% of patients; there was no significant difference. Levetiracetam is preferred in many Australian ICU and neurology guidelines because of its simple dosing, minimal drug interactions, and absence of cardiac conduction concerns (unlike phenytoin's arrhythmia risk). Sodium valproate is avoided in women of childbearing potential due to teratogenicity. This second-line decision is typically an emergency department or ICU decision, but GP knowledge informs handover quality. Document what has been given and when, and relay to the paramedics.

What are the AU driving rules after a seizure?

Australian driving regulations after a seizure are governed by the **Austroads Assessing Fitness to Drive (AFTD) 2022** guidelines, which set minimum seizure-free periods before driving may resume. These are: - **Unprovoked first seizure (private vehicle)**: 6 months seizure-free, neurology review, driving authority notified - **Epilepsy, any seizure (private vehicle)**: 6 months seizure-free after each seizure, on treatment - **Commercial vehicle (heavy vehicle, bus, truck, taxi, ride-share)**: 5–10 years seizure-free (specific requirements by state); many commercial authorities require permanent medical fitness certification by a neurologist GPs have a **mandatory notification obligation** in most Australian states and territories when a patient with epilepsy is medically unfit to drive and continues to drive. This creates a tension with therapeutic relationship and confidentiality; the RACGP and Austroads both provide guidance. The GP should document that the patient has been counselled about driving restrictions and that notification obligations have been fulfilled or the patient has agreed to self-notify. For specific state requirements, the relevant licensing authority (VicRoads, TMC NSW, DTMR QLD, etc.) should be consulted directly.

What is SUDEP and why does every GP managing epilepsy need to discuss it?

Sudden unexpected death in epilepsy (SUDEP) is the leading cause of epilepsy-related death, accounting for approximately 500–1,000 Australian deaths per year — higher than epilepsy-related deaths from status epilepticus, drowning, or accidents combined (AIHW). SUDEP typically occurs during or shortly after a nocturnal generalised tonic-clonic seizure and likely involves cardiorespiratory arrest during the postictal period. Risk factors: poorly controlled generalised tonic-clonic seizures (especially nocturnal), subtherapeutic antiepileptic medication levels, young adults with frequent seizures, seizures during sleep without supervision. **SUDEP counselling is now considered a quality-of-care requirement in Australian epilepsy management** — it should not be avoided out of concern it will frighten patients. Resources: Epilepsy Australia's 'SUDEP and Seizure Safety' discussion guide, ILAE SUDEP toolkit. Practical protective measures: not sleeping alone, co-sleeping safety monitor devices (EMFIT, SAMi), strict medication adherence, seizure freedom as the primary clinical goal.

Status epilepticus (generalised convulsive)

Status epilepticus: midazolam IM at 5 min, ESETT second-line

Q: What is the second-line treatment if benzodiazepine fails?

If a standard first-line benzodiazepine (midazolam or lorazepam) has been given and the seizure continues at 10–20 minutes, second-line treatment should be administered. The ESETT trial (Kapur et al., NEJM 2019) randomised 400+ patients with benzodiazepine-resistant SE to levetiracetam 60 mg/kg IV (max 4,500 mg), phenytoin 20 mg/kg fosphenytoin equivalent IV, or valproate 40 mg/kg IV (max 3,000 mg). All three achieved seizure cessation in approximately 47–48% of patients; there was no significant difference. Levetiracetam is preferred in many Australian ICU and neurology guidelines because of its simple dosing, minimal drug interactions, and absence of cardiac conduction concerns (unlike phenytoin's arrhythmia risk). Sodium valproate is avoided in women of childbearing potential due to teratogenicity. This second-line decision is typically an emergency department or ICU decision, but GP knowledge informs handover quality. Document what has been given and when, and relay to the paramedics.

Q: What are the AU driving rules after a seizure?

Australian driving regulations after a seizure are governed by the **Austroads Assessing Fitness to Drive (AFTD) 2022** guidelines, which set minimum seizure-free periods before driving may resume. These are: - **Unprovoked first seizure (private vehicle)**: 6 months seizure-free, neurology review, driving authority notified - **Epilepsy, any seizure (private vehicle)**: 6 months seizure-free after each seizure, on treatment - **Commercial vehicle (heavy vehicle, bus, truck, taxi, ride-share)**: 5–10 years seizure-free (specific requirements by state); many commercial authorities require permanent medical fitness certification by a neurologist GPs have a **mandatory notification obligation** in most Australian states and territories when a patient with epilepsy is medically unfit to drive and continues to drive. This creates a tension with therapeutic relationship and confidentiality; the RACGP and Austroads both provide guidance. The GP should document that the patient has been counselled about driving restrictions and that notification obligations have been fulfilled or the patient has agreed to self-notify. For specific state requirements, the relevant licensing authority (VicRoads, TMC NSW, DTMR QLD, etc.) should be consulted directly.

Q: What is SUDEP and why does every GP managing epilepsy need to discuss it?

Sudden unexpected death in epilepsy (SUDEP) is the leading cause of epilepsy-related death, accounting for approximately 500–1,000 Australian deaths per year — higher than epilepsy-related deaths from status epilepticus, drowning, or accidents combined (AIHW). SUDEP typically occurs during or shortly after a nocturnal generalised tonic-clonic seizure and likely involves cardiorespiratory arrest during the postictal period. Risk factors: poorly controlled generalised tonic-clonic seizures (especially nocturnal), subtherapeutic antiepileptic medication levels, young adults with frequent seizures, seizures during sleep without supervision. **SUDEP counselling is now considered a quality-of-care requirement in Australian epilepsy management** — it should not be avoided out of concern it will frighten patients. Resources: Epilepsy Australia's 'SUDEP and Seizure Safety' discussion guide, ILAE SUDEP toolkit. Practical protective measures: not sleeping alone, co-sleeping safety monitor devices (EMFIT, SAMi), strict medication adherence, seizure freedom as the primary clinical goal.

By Dr HB Lo, FACRRM Reviewed 16 September 2026 9 min read

Status epilepticus (SE) is a seizure ≥ 5 minutes or recurrent seizures without recovery — treat at t1 = 5 minutes without waiting. First-line: **midazolam 10 mg IM** into the outer thigh (RAMPART, NEJM 2012: 73% cessation vs 63% with IV lorazepam, faster delivery, fewer adverse events). Establish IV access while IM midazolam is working. If SE continues at 20 minutes, second-line options are equivalent (ESETT, NEJM 2019): levetiracetam 60 mg/kg, phenytoin 20 mg/kg, or valproate 40 mg/kg IV — levetiracetam preferred for simplest dosing. Neuronal injury begins at t2 = 30 minutes; refractory SE requires anaesthesia and ICU.

Status epilepticus is one of the most time-critical neurological emergencies in general practice. Delay in treatment beyond 5 minutes allows SE to become self-sustaining — benzodiazepine receptors internalise, GABA-mediated inhibition fails, and each additional minute without treatment doubles the risk of refractory SE. The GP who understands the t1/t2 framework and has midazolam available acts faster and more effectively than one who waits for the ambulance.

This guide covers the treatment algorithm, the evidence behind midazolam IM over IV lorazepam, second-line agent selection, and the mandatory post-seizure responsibilities that every GP must fulfil: driving notification and SUDEP counselling.

A. Core clinical — the time-based framework every GP must internalise

The t1/t2 model

Timepoint	Clinical significance	Action
t1 = 5 minutes	Seizure unlikely to self-terminate	Begin benzodiazepine treatment. Do not wait.
t2 = 30 minutes	Neuronal injury begins; “established SE”	Second-line agent given if first-line failed; ICU/anaesthesia if still ongoing
> 60 minutes	“Refractory SE”	General anaesthesia + ITU; RSE has > 30% mortality

The 5-minute rule is not intuitive — many clinicians wait 10–15 minutes before treating. The evidence base (RAMPART, ESETT, AES guidelines) is unambiguous: treat at 5 minutes.

Pre-hospital and practice first-line treatment

Algorithm:

t = 0: Witness or confirm seizure onset. Start clock. Call 000.
t = 0–5 min: Secure environment. Recovery position. Check blood glucose.
t = 5 min: Give midazolam 10 mg IM (anterolateral thigh or deltoid). If IM not available: buccal midazolam 10 mg (Epistatus, off-label) or intranasal midazolam 0.2 mg/kg (if mucosal atomiser device available). Attempt IV access while IM is working.
Document: time of seizure onset, time of drug administration, dose, route. Give to paramedics on handover.
t = 10 min: If seizure ongoing after first dose, and IV access now established: IV lorazepam 4 mg (0.1 mg/kg) OR repeat midazolam 10 mg IM if no IV access.

Why not IV diazepam? Diazepam IV is effective but not preferred in SE for three reasons: it is highly lipid-soluble and rapidly redistributes out of the CNS (shorter duration of action than lorazepam), it causes greater respiratory depression per effective dose, and it is less convenient to administer in the community. Rectal diazepam is now considered second-choice buccal/intranasal midazolam in adults.

Glucose — the always-exclude cause

Give IV glucose (50 mL of 50% dextrose) immediately if point-of-care blood glucose is < 4 mmol/L, or if glucose cannot be measured. Hypoglycaemia is the commonest immediately reversible cause of SE. Thiamine 100 mg IV (Pabrinex, if available) before dextrose in patients with alcohol use or nutritional deficiency risk (Wernicke prophylaxis).

B. Evidence for the recommended approach

RAMPART — midazolam IM versus lorazepam IV pre-hospital

Silbergleit et al. (NEJM 2012) enrolled 893 patients in a double-blind, double-dummy, non-inferiority trial comparing midazolam 10 mg IM versus lorazepam 4 mg IV for SE in the pre-hospital setting.

Key results:

Seizure cessation before hospital arrival: 73.4% midazolam IM vs 63.4% lorazepam IV (p < 0.001; midazolam superior, not merely non-inferior)
Median time to treatment: 1.2 min (IM) vs 4.8 min (IV) — IV access is the bottleneck
Respiratory depression: 3.4% (IM) vs 6.5% (IV) — midazolam had significantly fewer adverse events
Subsequent intubation: 13.8% vs 16.9% (not significant)

The trial decisively established IM midazolam as the community and pre-hospital first-line agent, irrespective of IV access.

ESETT — second-line agent equivalence

Kapur et al. (NEJM 2019) enrolled 384 patients with benzodiazepine-resistant SE in a double-blind, randomised trial comparing levetiracetam 60 mg/kg IV, fosphenytoin 20 mg/kg PE IV, and valproate 40 mg/kg IV.

Key results:

Seizure cessation at 60 minutes: levetiracetam 47%, fosphenytoin 45%, valproate 46% (no significant difference between any pair)
Adverse events: fosphenytoin had the most cardiac rhythm monitoring alerts; levetiracetam the fewest; valproate associated with the most hypotension in a subset
Mortality at 30 days: similar across arms (~3%)

Clinical implication: All three are acceptable. Levetiracetam is preferred in many Australian contexts because of:

Simpler weight-based dose (60 mg/kg, no need for cardiac monitoring during infusion)
No significant drug interactions (unlike phenytoin, a potent CYP inducer)
Safe in hepatic impairment (renal dose adjustment required)
PBS-listed; widely available

Sodium valproate is avoided in women of childbearing potential (teratogenicity risk — valproate embryopathy) and generally in young women regardless of reproductive status.

C. Post-seizure clinical responsibilities in general practice

1. Search for the cause

Every first seizure or changed seizure pattern demands an aetiology search. In general practice:

Category	Examples	Investigation
Structural	Stroke, tumour, abscess, cortical dysplasia	MRI brain ± contrast (CT if MRI unavailable/urgent)
Metabolic	Hypoglycaemia, hyponatraemia, hypocalcaemia, uraemia	EUC, glucose, Ca, Mg, LFTs
Toxic / drug-related	Alcohol withdrawal, cocaine, tramadol, ciprofloxacin	Drug screen, alcohol history
Infectious	Encephalitis, meningitis (see encephalitis article)	CSF if any fever or meningism
Epileptic — subtherapeutic	Missed antiepileptic doses, drug interactions	Antiepileptic drug levels (where relevant — phenytoin, valproate)
Epileptic — breakthrough	Intercurrent illness, sleep deprivation, menses	History

2. Driving notification

Austroads AFTD 2022 sets the national standard (states and territories adopt it). After any seizure:

Private vehicles: minimum 6 months seizure-free before driving resumes; neurology review recommended
Commercial vehicles (buses, trucks, taxis, forklifts, ride-share): considerably longer seizure-free requirements (often 5–10 years, state-specific); specialist certification required
GP must document that the patient has been advised not to drive and informed of their statutory obligation to notify the relevant licensing authority
In Victoria, NSW, QLD, SA, WA, TAS, NT, and ACT, there are provisions for mandatory GP reporting where the patient is medically unfit to drive and unwilling to self-notify — check state-specific requirements (RACGP position statement on fitness to drive 2021 provides state-by-state summary)

3. SUDEP counselling

SUDEP occurs in approximately 1 in 1,000 people with epilepsy per year — higher in uncontrolled epilepsy (1 in 150 per year in some high-risk groups). Key counselling points:

SUDEP is real and worth discussing openly — most patients prefer to know
The main modifiable risk is poorly controlled generalised tonic-clonic seizures, particularly nocturnal
Maximising seizure control (medication adherence, seizure triggers avoided, lifestyle factors) is the primary intervention
Safety strategies: not sleeping alone, supervision devices (EMFIT, SAMi), regular medication review
Discuss this at diagnosis, at first breakthrough seizure, and whenever AED is changed or discontinued
Resources to provide: Epilepsy Australia’s SUDEP discussion guide

D. Australian clinical operations

MBS items for epilepsy management

Service	Item
Comprehensive consultation for new seizure	36 or 44
Mental health care plan (anxiety/depression in epilepsy)	2700–2702
EEG (referral)	11500 (specialist-billed)
Neurologist consultation	Specialist rebate item (varies by state)

PBS antiepileptic drugs

Levetiracetam: PBS General Schedule (generic available, low cost; IV formulation for hospitals)
Sodium valproate: PBS-listed; Pregnancy Prevention Programme (PPP) mandatory documentation for women of reproductive age since February 2024 (TGA requirement)
Phenytoin / fosphenytoin: PBS-listed; monitoring of drug levels via MBS Item 66695
Midazolam (Hypnovel injection): Available on PBS for hospital use; buccal/nasal formulations available at private cost for community use; check with specialist for individual authority prescriptions

Buccal midazolam in community setting

Buccal midazolam (Epistatus 10 mg/mL) can be prescribed by GPs for patients with known epilepsy and carers managing breakthrough seizures. This is an authority prescription in Australia. The prescriber must document a clinical indication (known epilepsy, at-risk of prolonged seizures). Carers should be trained in administration. School nurse and childcare staff are legally permitted to administer midazolam following a Seizure Action Plan under state health legislation.

E. Special populations

Children and adolescents

Status epilepticus in children follows the same principles but weight-based dosing is critical. Midazolam IM or buccal is first-line in children too (0.1–0.2 mg/kg buccal, max 10 mg). Febrile SE (a prolonged febrile seizure ≥ 5 minutes, or ≥ 2 seizures in 24 hours with fever) is the most common type of SE in young children; LP is guided by clinical assessment and age. FIRES (febrile infection-related epilepsy syndrome) is rare but severe.

Pregnant women

SE in pregnancy is an obstetric emergency. Benzodiazepines are acceptable in an acute emergency (benefit > teratogenic risk during active convulsion). Sodium valproate is absolutely contraindicated in pregnancy for non-emergency management. Seizure threshold may change across trimesters. Obstetric and neurology co-management from first trimester is standard for women with epilepsy planning pregnancy. Folic acid 5 mg daily (not 400 mcg) is recommended pre-conception for women on antiepileptic drugs to reduce neural tube defect risk.

Elderly patients

New-onset seizures in patients over 65 are most commonly due to structural lesions (stroke, small vessel disease, tumour) or metabolic causes; the yield from brain imaging in first seizure in this age group is higher than in young adults. Drug interactions are a particular concern: phenytoin and carbamazepine induce hepatic enzymes and can destabilise warfarin, statins, and many other common geriatric medications. Levetiracetam is generally preferred for its simpler interaction profile.

Patients with intellectual disability

SE rates are significantly higher in people with intellectual disability, particularly those with genetic epilepsy syndromes (Dravet syndrome, Angelman syndrome, Lennox-Gastaut syndrome). These patients are often managed on complex antiepileptic regimens. GPs play a critical coordination role between specialist neurology, disability services, carers, and NDIS support plans. An individualised Seizure Action Plan should be in place, accessible to all carers and filed in the GP record.

When to escalate

Call 000 immediately:

Any seizure lasting ≥ 5 minutes (start treatment at 5 minutes; call 000 simultaneously at seizure onset)
New-onset seizure in an adult without a prior diagnosis of epilepsy
Seizure in a pregnant woman
Seizure with fever and neck stiffness (meningitis/encephalitis — see encephalitis article)
Second seizure within 24 hours without full recovery between

After the seizure (same day review / emergency department):

First unprovoked seizure in an adult — requires MRI, EEG, and specialist review before the GP can advise it is safe to drive
Seizure with head injury or focal neurological deficit (stroke workup)
Seizure in a known epileptic who has missed doses — check drug levels, review medication, assess for trigger

Neurology referral (non-urgent):

New diagnosis of epilepsy for specialist workup, EEG, medication initiation
Seizures not controlled on first agent — medication adjustment
Preconception counselling in a woman with epilepsy

What this article is and is not

This article is an evidence-based educational summary for Australian general practitioners, drawing on eTG, AMH, Austroads AFTD 2022, ANZAN guidelines, and international peer-reviewed literature including the RAMPART and ESETT trials. It is written to support GP recognition of status epilepticus and immediate treatment, and to guide mandatory post-seizure obligations (driving notification, SUDEP counselling).

This article does not replace a formal medical consultation, nor does it substitute for the judgment of a neurologist managing individual epilepsy cases. Dosing and drug interaction information is current at date of publication; always verify in current eTG, AMH, or product information before prescribing.

No individual is mentioned in this article, and no personal testimonials are cited.

Sources cited

eTG — Status epilepticus management. Therapeutic Guidelines Limited. tg.org.au
AMH — Antiepileptic drugs and status epilepticus chapter. Australian Medicines Handbook. amhonline.amh.net.au
Silbergleit R et al. (RAMPART). Intramuscular versus intravenous therapy for prehospital status epilepticus. NEJM 2012;366:591–600. nejm.org
Kapur J et al. (ESETT). Randomised trial of three anticonvulsant medications for status epilepticus. NEJM 2019;381:2103–2113. nejm.org
Austroads — Assessing Fitness to Drive (AFTD) 2022. austroads.com.au
ANZAN — Australian and New Zealand Association of Neurologists — status epilepticus guidelines. anzan.org.au
Epilepsy Australia — SUDEP and seizure safety. epilepsyaustralia.net
AIHW — Epilepsy and SUDEP in Australia. aihw.gov.au
Healthdirect — Status epilepticus. healthdirect.gov.au
Better Health Channel — Epilepsy. betterhealth.vic.gov.au
Epilepsy Foundation of Victoria — Patient support and information. epfv.org.au
PBS Online — Antiepileptic drug listings. pbs.gov.au
MBS Online — Neurology consultation and EEG items. mbsonline.gov.au

Frequently asked questions

What should a GP do in the first 5 minutes of a seizure?

The most important GP action in the first 5 minutes of a witnessed seizure is to **start the clock**. If the seizure has not stopped by 5 minutes, treatment should begin — not at 10 minutes, not "when the ambulance arrives if it hasn't stopped." Call 000 at any time, but do not wait for the ambulance to give first-line treatment if it is available in your setting. Remove hazards from around the person, place them in the recovery position (lateral), do not restrain limb movements, do not insert anything into the mouth. If intranasal midazolam (0.2 mg/kg, max 10 mg) or buccal midazolam (10 mg) is available (as it is in schools and some families with known epilepsy), administer it. If IM midazolam (Hypnovel) is available in your practice emergency kit, 10 mg IM into the outer thigh at 5 minutes is first-line. Check blood glucose immediately — hypoglycaemia is the most immediately reversible cause. Document the seizure type, duration, any known trigger, and current antiepileptic medication.
Why is midazolam IM better than IV lorazepam in the pre-hospital setting?

IV lorazepam is effective when IV access is already established (e.g., a patient in hospital), but in the community, IV access takes 3–7 minutes to establish during an active convulsion. This delay costs critical treatment time. The RAMPART trial (Silbergleit et al., NEJM 2012) specifically addressed this by randomising ambulance-treated SE patients to midazolam 10 mg IM versus lorazepam 4 mg IV. Key findings: midazolam IM was superior in seizure cessation (73.4% vs 63.4%, p < 0.001), had fewer adverse events (3.4% respiratory depression vs 6.5%), and — crucially — patients in the IM arm received their medication significantly faster because IV access setup was avoided. Midazolam IM is rapidly absorbed from the deltoid or anterolateral thigh muscle; peak plasma levels are achieved in 15–30 minutes. Buccal midazolam (10 mg, licensed in Australia) and intranasal midazolam are acceptable alternatives in the community when IM is not available. IV diazepam and IM haloperidol are inferior and should not be used as first-line SE treatment.
What is the second-line treatment if benzodiazepine fails?

If a standard first-line benzodiazepine (midazolam or lorazepam) has been given and the seizure continues at 10–20 minutes, second-line treatment should be administered. The ESETT trial (Kapur et al., NEJM 2019) randomised 400+ patients with benzodiazepine-resistant SE to levetiracetam 60 mg/kg IV (max 4,500 mg), phenytoin 20 mg/kg fosphenytoin equivalent IV, or valproate 40 mg/kg IV (max 3,000 mg). All three achieved seizure cessation in approximately 47–48% of patients; there was no significant difference. Levetiracetam is preferred in many Australian ICU and neurology guidelines because of its simple dosing, minimal drug interactions, and absence of cardiac conduction concerns (unlike phenytoin's arrhythmia risk). Sodium valproate is avoided in women of childbearing potential due to teratogenicity. This second-line decision is typically an emergency department or ICU decision, but GP knowledge informs handover quality. Document what has been given and when, and relay to the paramedics.
What are the AU driving rules after a seizure?

Australian driving regulations after a seizure are governed by the **Austroads Assessing Fitness to Drive (AFTD) 2022** guidelines, which set minimum seizure-free periods before driving may resume. These are: - **Unprovoked first seizure (private vehicle)**: 6 months seizure-free, neurology review, driving authority notified - **Epilepsy, any seizure (private vehicle)**: 6 months seizure-free after each seizure, on treatment - **Commercial vehicle (heavy vehicle, bus, truck, taxi, ride-share)**: 5–10 years seizure-free (specific requirements by state); many commercial authorities require permanent medical fitness certification by a neurologist GPs have a **mandatory notification obligation** in most Australian states and territories when a patient with epilepsy is medically unfit to drive and continues to drive. This creates a tension with therapeutic relationship and confidentiality; the RACGP and Austroads both provide guidance. The GP should document that the patient has been counselled about driving restrictions and that notification obligations have been fulfilled or the patient has agreed to self-notify. For specific state requirements, the relevant licensing authority (VicRoads, TMC NSW, DTMR QLD, etc.) should be consulted directly.
What is SUDEP and why does every GP managing epilepsy need to discuss it?

Sudden unexpected death in epilepsy (SUDEP) is the leading cause of epilepsy-related death, accounting for approximately 500–1,000 Australian deaths per year — higher than epilepsy-related deaths from status epilepticus, drowning, or accidents combined (AIHW). SUDEP typically occurs during or shortly after a nocturnal generalised tonic-clonic seizure and likely involves cardiorespiratory arrest during the postictal period. Risk factors: poorly controlled generalised tonic-clonic seizures (especially nocturnal), subtherapeutic antiepileptic medication levels, young adults with frequent seizures, seizures during sleep without supervision. **SUDEP counselling is now considered a quality-of-care requirement in Australian epilepsy management** — it should not be avoided out of concern it will frighten patients. Resources: Epilepsy Australia's 'SUDEP and Seizure Safety' discussion guide, ILAE SUDEP toolkit. Practical protective measures: not sleeping alone, co-sleeping safety monitor devices (EMFIT, SAMi), strict medication adherence, seizure freedom as the primary clinical goal.

Source quality

Sources grouped by evidence tier. AU primary tier first; international where AU is silent or lagging; named-author reconstruction where guidelines have not yet caught up. How tiers work.