Hypermotor seizures primarily arise from the frontal lobe; however, they have been shown to arise outside the frontal lobe in up to a third of patients. The insular cortex can be part of the hypermotor seizure network, acting either as a diffusion zone or as the seat of the seizure onset zone. Most patients experience predominantly nocturnal seizures with complex and stereotyped hypermotor behaviors with or without tonic or dystonic features. Although the hypermotor semiology of a seizure originating from the insulo-opercular region is often indistinguishable from that of a frontal onset, certain clinical features are paramount in recognizing an extra-frontal onset. In this chapter, we will review electro-clinical findings and semiology patterns of hypermotor seizures that suggest an insulo-opercular onset.