The prevalence of various seizure precipitants in relation to different epilepsy syndromes and patient age and gender was determined by a questionnaire survey of 400 patients attending (Dec 1998-May 1999) the Comprehensive Epilepsy Program, University of Virginia, Charlottesville. The mean age of the pediatric and adult patients was 25 +/- 16 years; 200 were male and 200 female. Specific ILAE epilepsy syndromes were defined in 309 (77%). At least one specific seizure precipitant was identified by 247 (62%) patients, the most frequent being stress, in 30%. Sleep deprivation was invoked by 18%, sleep in 14%, fever or illness (excluding simple febrile convulsions) in 14%, and fatigue in 13%. Other less frequent precipitants included heat and humidity (9%), flashing lights (4%), caffeine (2%), fasting (2%), and alcohol in only 0.5%. Rare precipitants were physical discomfort or pain in 3 patients, exertion in 2, awakening (2), light (2), odors (1), laughing (1), noise (1), and dietary triggers (1). No precipitant was recognized by 38% of patients.
Stress, fatigue, and sleep deprivation were positively correlated, and these precipitants were reported especially in patients with symptomatic localization-related epilepsies; 46% of patients with temporal lobe epilepsy (TLE) identified stress compared to 15% of those with cryptogenic generalized epilepsy (CGE). Sleep was negatively correlated with other precipitants, and was invoked in 66% of patients with idiopathic partial, extratemporal epilepsy compared to 4% of those with TLE. Extralimbic seizures (autosomal dominant frontal lobe epilepsy) are nocturnal and occur especially during sleep whereas limbic seizures (TLE) are diurnal and occur in wakefulness. Menstrual effects were particularly prominent in women with TLE (28%), more than twice the percentage in women with other epilepsy syndromes. 
COMMENT. The recognition and avoidance of specific seizure precipitants is an important aspect of the management of epilepsy. Stress, sleep deprivation, and fatigue are endogenous seizure precipitants that appear to act through common mechanisms. Sleep deprivation, usually associated with stress and fatigue, is a frequent trigger in patients with temporal lobe epilepsy whereas sleep predisposes to extratemporal and especially frontal lobe nocturnal epilepsy. Cryptogenic generalized epilepsies are less susceptible to the effects of sleep deprivation.
Numerous reflex epilepsy syndromes are described in children. These include epilepsy induced by “Soroban,” a Japanese calculator; reading epilepsy, graphogenic, arithmetic, cards and game playing, piano, Nintendo and Rubik’s cube epilepsy. Both mental activity under psychological tension and movements of fingers are involved in the induction of seizures in susceptible patients. (See Progress in Pediatric Neurology II, PNB Publ, 1994;pp60-61).