Epilepsy with generalized tonic-clonic seizures during awakening, i.e., epilepsy with grand mal seizures during awakening (EGMA): adolescent and adolescent onset, mostly after awakening, is an idiopathic generalized epilepsy syndrome. According to the classic work of Janz (1969), post-awakening grand mal seizures account for approximately 33% of all generalized tonic-clonic epilepsy, but other authors have reported as low as 16.8% and as high as 53%. In Central São Paulo, the incidence of awakening grand mal seizures was reported to be lower than that of juvenile myoclonic epilepsy, with 41 patients with awakening grand mal seizures and 140 patients with juvenile myoclonic epilepsy among those referred for epilepsy in the last 15 years (1986-2000). Most had no etiology to be found. Family members with febrile convulsions or epilepsy were significantly higher than patients with grand mal seizures occurring in sleep and waking states, and similar to other idiopathic generalized epilepsies such as childhood and juvenile aphasic epilepsy and juvenile myoclonic epilepsy, suggesting that the onset of the disorder is related to genetic susceptibility to convulsions. In addition to the intrinsic genetic susceptibility, some extrinsic factors have a triggering or predisposing effect on the seizures of EGMA. The most important predisposing factor is sleep deprivation, such as sleep deprivation or chronic sleep deprivation. Polysomnography studies have shown that sleep in EGMA patients is particularly unstable and susceptible to external factors. In addition, light stimulation, fatigue, and alcohol abuse also tend to trigger seizures. Clinical manifestations of epilepsy with awakening grand mal seizures: 1. The age of onset ranges from 6 to 35 years, with most onset at the age of 10 to 20 years, with an average of 17.1 years. It is slightly more common in boys (62.2% to 65.6%). Several recognized idiopathic age-related generalized epilepsy syndromes have overlapping ages of onset, with EGMA being the last of these peak age groups. 2. Seizure presentation: Most seizures in patients are temporally related to the sleep-wake state shift, not whether they occur during the day or at night. The seizures can occur during daytime sleep-wake, nighttime brief awakening and early morning awakening, and often occur within a short period of time about one hour after waking up, which is typical of generalized tonic-clonic seizures. Patients can have only one type of generalized tonic-clonic seizure (simple type) or a combination of typical akathisia, myoclonic seizures and partial seizures (combined type). It is not clear whether the presence of other seizure types (akathisia and myoclonic jerks) leads to a poor prognosis. In some children with EGMAr, GTCS is often preceded by conscious continuous myoclonic jerking (myoclonic persistence) or persistent haze of consciousness (aphasic persistence) and ends with GTCS; a few patients also develop aphasic persistence after GTCS. The frequency of EGMA episodes is low, with one episode in a few months or only one to two episodes a year. Patients often complain of triggers such as fatigue, staying up late, waking up early, work-study stress or family conflicts before the onset; some patients also have episodes mainly on weekends or holidays, when they are mentally relaxed and wake up too late. However, careful analysis reveals that various factors eventually lead to sleep disorders, sleep deprivation or changes in sleep habits, so sleep abnormalities are the most important and direct factors triggering grand mal seizures during the waking period. Patients with EGMA generally have normal psychomotor development and no abnormal findings on neuroimaging and neurological examination. However, it has been reported that some problems may exist in the behavioral personality of this group of patients, such as lazy life, irregularity, and unstable personality. EEG features: normal or mildly non-specific abnormal background EEG, mostly increased slow waves or mild disorders of sleep structure. The simple type of EGMA has no epileptiform electrical activity in 18% of the interictal period, while the combined type has no discharge in only 3%. The abnormal discharges are mainly all-conducting 3-5 Hz spikes or multi-spike slow waves, hyperventilation and increased sleep periods, and positive photosensitivity responses. Restricted discharges are rare. EEG during seizures is difficult to capture and is typical of the EEG presentation during GTCS seizures. Waking grand mal epilepsy is identical to juvenile myoclonic epilepsy in that withdrawal of medication in patients with effective medication leads to recurrence of symptoms (Janz et al. 1983 found recurrence in 83% of patients). Patients with grand mal seizures after waking therefore need to receive long-term treatment. However, further studies are needed to confirm how the condition evolves after middle age. Overall the prognosis for this type is good.