Emotional experiences during focal seizures are often misinterpreted as psychiatric disorders. We aimed to evaluate symptoms involving affective symptoms at seizure onset. We aimed to identify the most prevalent affective symptoms at seizure onset and characterize their localizing and lateralizing value. We performed a scoping review based on Preferred Reporting Items for Systematic reviews and Meta-Analyses-extension for Scoping Reviews guidelines. A systematic search identified records from 4 databases: PubMed, Embase, CINAHL (via EBSCOhost), and Web of Science. Two reviewers independently screened titles/abstracts and full texts; discrepancies were resolved by consensus. This review focused on patients with focal seizures, as affective symptoms may occur in generalized epilepsies. The affective symptoms: fear, anxiety, panic, sadness, mystic, ecstatic, sexual, and mirth were identified, and semiology was evaluated in accordance with ILAE guidelines. Symptom onset, frequency, brain localization, and video-EEG monitoring technique were evaluated to assess localization and lateralization of regional networks. Scalp EEG, invasive EEG recordings, and electrical stimulation were analyzed. A total of 1276 documents were identified, with 98 studies included for review. Fear was the most frequently reported ictal emotion, identified in 274 patients (66%), predominantly in temporal lobe epilepsy. Sadness and sexual, ecstatic symptoms were also consistently associated with temporal networks. Mirth was more frequently reported with frontal onset seizures. Evidence, primarily from Class IV studies, reported right hemispheric predominance for ecstasy, mystic, and sexual symptoms at seizure onset. Ictal affective symptoms at seizure onset yield localizing information. The limbic system, especially the temporal lobe, followed by the frontal lobe, was the most common site of origin. Fear was the most common spontaneous and electrically elicited symptom, followed by anxiety. While bi-hemispheric lateralization occurred, right lateralization predominated. Recognizing paroxysmal affective symptoms as ictal phenomena may reduce misdiagnosis and aid presurgical evaluation in drug-resistant focal epilepsy.

Despite advances in EEG, neuroimaging, and other diagnostic technologies, a carefully obtained clinical history remains the cornerstone of diagnosis, classification, and treatment planning. However, structured guidance on history-taking that integrates state-of-the-art evidence and the updated 2025 International League Against Epilepsy (ILAE) seizure classification is limited. We performed a review of evidence published between January 2000 and April 2026, supplemented by landmark earlier studies, ILAE position papers, and National Institute for Health and Care Excellence (NICE) guidelines. Evidence was synthesized to develop a practical framework for obtaining and interpreting the clinical history in adolescents and adults presenting with a first seizure, recurrent seizures, or established epilepsy. We present a structured approach that follows the sequence of a clinical consultation, encompassing the presenting complaint, detailed event reconstruction, semiology, collateral witness accounts, smartphone video recordings, seizure triggers and temporal patterns, past medical history, medication review, family history, social factors, and safety issues. We discuss the diagnostic value of individual history elements, practical strategies for distinguishing epileptic seizures from functional/dissociative seizures and syncope, and the contribution of history-taking to seizure classification under the updated 2025 ILAE framework. We also summarize clinically relevant risk factors, comorbidities, and management implications that influence diagnostic accuracy and individualized care. Practical diagnostic questionnaires are provided to facilitate differential diagnosis and seizure classification, particularly for clinicians without specialist epilepsy expertise. A systematic clinical history, obtained from the individual and eyewitnesses and complemented by video recordings when available, remains the single most important diagnostic tool in epilepsy. Structured history-taking improves diagnostic accuracy, reduces misdiagnosis, supports accurate seizure classification, guides appropriate investigations, and provides the foundation for personalized management. This practical framework offers an evidence-based approach that can be readily incorporated into routine clinical practice and education across diverse healthcare settings.