Epilepsy

Overview

A seizure is a visible sign of a problem in the electrical system that controls your brain. A single seizure can have many causes (infection, stroke, or brain injury). Those who continue to have two or more unprovoked seizures may have a chronic disorder called epilepsy. Treatment with medications or sometimes surgery can control seizures for many people with epilepsy.

What is epilepsy?

Epilepsy is a disorder of the brain in which seizures occur repeatedly. A seizure is caused by an abnormal electrical discharge in the brain. This abnormal "short circuit" can cause a change in behavior without your being aware of what is happening. During a seizure you may fall down, stare off into space, or make jerking movements. Some people get a warning, called an aura that tells them when a seizure is about to happen. You cannot control what's happening while the seizure is occurring. If you witness someone having a seizure, see What to Do During a Seizure.

Seizures are classified as either focal, generalized, or unknown onset. Focal onset seizures arise from one part of the brain and include aware or impaired awareness (previously called “partial”). Generalized onset seizures involve both sides of the brain and cause impaired awareness or loss of consciousness. These include tonic-clonic, absence, myoclonic, tonic, clonic, and atonic seizures (see Seizures).

 

What are the symptoms?

An epilepsy syndrome is a collection of abnormal features such as seizure type, age of onset, symptoms, and EEG patterns that commonly occur together. While some types of “symptomatic” epilepsy may be caused by a brain tumor, stroke, or other neurological disorder, “idiopathic” epilepsy syndromes have no identifiable causes. Common syndromes include:

Temporal lobe epilepsy: most common type of focal seizure; onset in childhood following a fever with seizures or a brain injury; two thirds have complex focal seizures; one third have generalized seizures; auras are common (deja-vu, nausea, smell); mouth behaviors, lip smacking, finger picking; seizures last more than one minute followed by confusion or amnesia; often drug resistant, surgery may help.

Frontal lobe epilepsy: sudden onset and short duration seizures; rapid recovery of consciousness; twisting, turning, pedaling, or grimacing movements are common; risk for status epilepticus; may occur in clusters; seizures more common during sleep.

Reflex epilepsy: seizures triggered by the environment; photosensitivity (seizures in response to flashing lights, strobe lights, video games); begins in childhood; associated with absence epilepsy, and may disappear in adulthood.

Juvenile myoclonic epilepsy: most common generalized epilepsy; onset in puberty between 8-30 years; myoclonic, absence and generalized tonic clonic seizures; seizures occur on awakening or sleep deprivation / stress; alcohol or menstrual periods may be triggers.

Benign Rolandic epilepsy: one third of childhood epilepsy; onset 3-13 years of age and usually outgrow it by age 15; seizures occur during sleep; symptoms include numbness or tingling in the lips, gums and inner cheeks; simple focal seizures of face or face + hand; drooling, speech arrest and generalized tonic clonic seizures.

Lennox-Gastaut syndrome: represents 1% epilepsy and difficult to treat; onset in childhood around 1-5 years of age; mixed seizures: absence, tonic seizures causing stiffening, often during sleep; drop attacks, convulsive seizures on wakening; often have developmental problems; frequent seizures with a risk of status epilepticus.

Epilepsy Emergencies

Status epilepticus is a medical emergency! It occurs when seizures do not stop or happen repetitively without regaining consciousness in between. It is possible for brain damage to occur as a result of lack of oxygen to the brain. Call 911 if seizures last longer than is typical for that person, or if they last longer than 5 minutes. Timing the seizure with a watch is helpful because a brief seizure may seem longer than it really is.

Sudden unexpected death in epilepsy (SUDEP). People with frequent tonic-clonic seizures or people whose seizures aren't controlled by medications may be at higher risk of SUDEP. The cause is unknown, but it may occur due to heart or respiratory conditions.

If you have any suspicion that something is wrong, CALL. It is better to call too frequently than to avoid calling.

What are the causes?

There are many causes of epilepsy, including head trauma, stroke, birth injury, brain tumors, and infections. However, for approximately 70% of patients with epilepsy, the cause cannot is unknown.

Who is affected?

Epilepsy affects 3.4 million people in the U.S. Nationwide, 150,000 new cases of epilepsy are diagnosed every year. Epilepsy can begin at any age.

How is a diagnosis made?

Your doctor will take a complete medical history and perform a physical examination. This includes a review of medicines you’ve tried for seizure control (including side effects and efficacy), a description of the seizure activity, and any history of other family members with neurological problems. The physical exam includes a detailed neurologic examination, which tests specific functions of the nervous system. The following diagnostic studies may also be included in your initial evaluation.

Electroencephalogram (EEG) is a test that records electrical patterns in your brain called brain waves. Electrodes are placed on your scalp and then the signals picked up by the electrodes are amplified and recorded on paper. The procedure lasts about 40 minutes. An EEG is of value for diagnosing epilepsy only if it picks up patterns typical of epilepsy. If it doesn't pick up the right patterns, you may still have epilepsy and ambulatory monitoring (longer term EEG) may be necessary. Video/EEG monitoring, available in specialized centers for patients with frequent seizures, allows you to be observed during seizure activity so that your behavior can be measured/monitored at the same time as your EEG.

Blood tests are performed to assess your general health and check such things as infections, anemia, and chemical imbalances. These tests are helpful in ruling out a chemical cause of your seizures. When you start a new anticonvulsant medication, blood levels (electrolytes, liver and kidney function, blood cell counts, and drug levels) are checked frequently and will gradually taper to every month or so, depending on the physician’s protocols.

Magnetic resonance imaging (MRI) This is a noninvasive test that uses a magnetic field and radiofrequency waves to give a detailed view of your brain. It may or may not be performed with a dye (contrast agent) injected into your blood stream. MRI is helpful to determine if a tumor, arteriovenous malformation, or genetic defect of the brain is causing your seizures.

Positron emission tomography (PET) allows the doctor to study the brain’s function by observing how glucose (sugar) is metabo­lized. A small amount of radioactive glucose “tracer” is injected into your bloodstream and a computer creates pictures of the brain. Glucose use can increase (hypermetabolism) during a seizure and decrease (hypometabolism) when not having a seizure. These results may help show the location of focal areas of your brain that are not working properly or other differences that may correspond to EEG test results.

Single-photon emission computed tomography (SPECT)provides information about blood flow to brain tissue. Analyzing blood flow to the brain may help determine how specific areas are functioning. Blood flow to an area of the brain during a seizure increases, while blood flow to an area of the brain can decrease when a person is not having a seizure.

Who treats epilepsy?

A primary care doctor, pediatrician, family practitioner, internist, or neurologist may treat epilepsy. Neurologists who specialize in epilepsy, called epileptologists, are available in specialized epilepsy centers across the nation to treat patients with seizures that are not well controlled.

What treatments are available?

Epilepsy is usually treated with anti-epileptic medications. Approximately 70% of people with epilepsy have either complete or very good seizure control with medication. About 30% of people with epilepsy cannot control their seizures with medicine. Treatment options for these patients include epilepsy surgery, vagus nerve stimulation, and the ketogenic diet (used in children).

Medications
Once the exact seizure type and epilepsy syndrome has been determined, your doctor usually chooses the best medication effective for that type of seizure. Several other factors are considered such as cost, dosing schedule, patient age, previous drug interactions, other existing health conditions, and child bearing potential. One drug (monotherapy) is the ideal type of therapy to manage side effects and dosing more easily. About 50% of patients are free of seizures with one medication. It may be necessary to add a second drug if one drug does not work. The goal is to control the seizures with the fewest possible side effects.

Common anti-epileptic medications:

• Phenytoin (Dilantin, Phenytek) is one of the oldest and most commonly used drugs to treat seizures. It is most effective against tonic-clonic seizures or complex focal seizures.
• Phenobarbital is a barbiturate used to treat tonic-clonic and simple focal seizures. It was the first drug to be used to treat epilepsy, and it is known to cause drowsiness.
• Valproic acid (Depakote, Depakene) is used for focal and tonic/clonic seizures.
• Carbamazepine (Tegretol, Carbatrol) is another drug to treat some types of seizures.

There are over 25 different anti-epileptic drugs used to treat seizures; most only work for certain types of seizures. Finding the right drug and dosage can be complex. Your doctor likely will first prescribe a single medication at a relatively low dosage and then increase the dosage gradually until your seizures are well-controlled. Taking your medications as prescribed is the most important part of treatment.

As with all drugs, there are side effects and drug interactions. Most common side effects include fatigue, drowsiness, nausea, gum problems, weight gain and blurred vision. If you have unacceptable side effects with your medication, changing to another medication may improve these adverse effects. Also, these drugs may reduce the effectiveness of birth control pills. If you are pregnant or thinking about getting pregnant, you should not take any anti-seizure medications that are known to cause birth problems. You need to discuss this with your physician.

Surgery
If medication fails to control your seizures or the side effects become unacceptable, surgical treatments may be used.

• Vagus nerve stimulationinvolves implantation of a device that produces electrical signals to prevent seizures. VNS is similar to a heart pacemaker. A wire (lead) is wrapped around the vagus nerve in the neck. The wire is connected to a generator-battery implanted under the skin near the collarbone. The generator is programmed to produce intermittent electrical signals that travel along the vagus nerve to the brain. In addition, some patients may turn on the device with a magnet when feeling a warning (aura) that a seizure is about to start. VNS is not a cure for epilepsy, it does not work for everyone, and it does not replace the need for anti-epileptic drugs. This procedure is reserved for those who are not candidates for potentially curative brain surgery. VNS reduces seizure frequency by about 30% (similar to the results of the newer AEDs). Common side effects are a tingling sensation in the neck and mild hoarseness in the voice, both of which occur only during stimulation.
  
  
• Epilepsy surgery involves removing or disconnecting a portion of the brain that generates seizures. In addition to removing a small part of the brain where seizures begin, other procedures may be done to interrupt the spread of electrical energy/discharges in your brain. You can be considered for surgery only if you have seizures that arise from one focal area of the brain or that can be isolated from the other parts of the brain. Depending on the site of seizure onset and the underlying cause, 50-80% of patients who have epilepsy surgery can become seizure free. Surgery is especially beneficial for those with temporal lobe epilepsy (3).

Ketogenic diet
A ketogenic (high-protein/fat) diet may be a treatment option for children who have many side effects from anti-seizure drugs, or whose seizures cannot be controlled by them. This special restricted-calorie diet tricks the body into burning fat, instead of glucose, for energy. The diet is very high in fats and low in protein and carbohydrates. It produces a change in the body's chemistry called ketosis, which has the effect of controlling seizures or reducing their frequency, in two of three children placed on the diet. Although not all children benefit, parents report that children who do benefit are more alert and active than they were previously.

The ketogenic diet must be established by a dietitian, weighed out in grams by the family, and followed by a doctor just as if it were a course of drug treatment. Like other treatments, the ketogenic diet has some side effects, which are monitored through blood and urine tests and follow-up visits. The diet is used primarily to treat children for a limited period of time, after which the diet may be slowly tapered and regular food slowly reintroduced. If seizures return, the diet may be re-instituted.

Clinical trials

Clinical trials are research studies in which new treatments—drugs, diagnostics, procedures, and other therapies—are tested in people to see if they are safe and effective. Research is always being conducted to improve the standard of medical care. Information about current clinical trials, including eligibility, protocol, and locations, are found on the Web. Studies can be sponsored by the National Institutes of Health (see ClinicalTrials.gov) as well as private industry and pharmaceutical companies (see CenterWatch.com).

Recovery & prevention

What can I do if medications don’t control my seizures? Your goal should be freedom from seizures. Current recommendations (1) state that a patient who continues to have seizures after treatment with three antiepileptic drugs should be evaluated at a comprehensive epilepsy treatment program. Such programs are staffed by full-time epileptologists (neurologists who specialize in epilepsy) and neurosurgeon(s) who specialize in epilepsy surgery. These programs include an epilepsy monitoring unit with continuous video/EEG monitoring of your seizures. This testing requires hospitalization and is provided for adult patients. The specialized testing completed as part of epilepsy monitoring can help your doctor more successfully treat you in three ways:

1. Monitoring can define the specific type of seizure and help the doctor choose the best medication.
2. The monitoring can define the precise brain location of your seizure onset and lead to curative epilepsy surgery in selected patients.
3. Some patients have attacks that are not seizures; monitoring can provide the doctor with a more accurate diagnosis that leads to improved therapy.

Healthy habits

1. Take your medication every day as directed. Your medication helps to control seizures, but missing a dose can cause seizures.
2. Eat a healthy diet. Low blood sugar levels can cause seizures, so try not to miss a meal, especially if you taking part in sports.
3. Get enough sleep. Lack of sleep can be a seizure trigger.
4. Limit your use of alcohol. It can be risky to drink alcohol if you take certain medications. Talk to your doctor.
5. Avoid illegal drugs. They can cause seizures and interact poorly with your antiepilepsy medication.
6. Exercise regularly. You’ll feel good about yourself, alleviate depression, and control weight.
7. Learn relaxation techniques. Some seizures are triggered by stress.

Driving
When first starting AED medication you will not be able to drive. Each state has different rules as to how long a person must be seizure free before being allowed to drive (anywhere from 3 to 12 months) and may require a doctor’s evaluation of your ability to drive.

Work & school
Informing others around you about your medical condition is your decision. However, if your seizures are only moderately controlled someone may eventually witness you having a seizure. Educate your co-workers and teachers about how to recognize your specific kind of seizures and what to do when one occurs. Always wear your medical identification bracelet. It is against the law for you to be discriminated based on your medical condition.

Sources & links

If you have more questions, please contact Mayfield Brain & Spine at 800-325-7787 or 513-221-1100.

Sources

1. Browne TR, Holmes G: Handbook of Epilepsy. Philadelphia, Lippincott-Raven Publishers, 1997, pp. 175
2. Pellock JM, Dodson WE, Bourgeois F: Pediatric epilepsy, diagnosis and therapy. New York, Demos Medical Publishers, 2001, pp. 73-76
3. Wiebe S, Blume WT, Girvin JP, Eliasziw M: A randomized, controlled trial of surgery for temporal-lobe epilepsy. NEJM 345: 311–8, 2001
4. Fisher RS, et al: Operational classification of seizure types by the International League Against Epilepsy: Position Paper of the ILAE Commission for Classification and Terminology. Epilepsia 58:522-530, 2017

Links
Epilepsy Foundation, 800-332-1000 Epilepsy.com
AESnet.org (American Epilepsy Society)
Epilepsynse.org.uk (National Society for Epilepsy)

Glossary

antiepileptic drug (AED): a medication used to control epileptic seizures

aura: a "warning" that a seizure may be imminent, the beginning of a seizure. Auras ranging from abnormal smells or tastes, to a funny feeling in the stomach, to sounds, colors, or emotional rushes.

automatism: things people do during a seizure in a state of diminished consciousness, such as pulling at their clothes or chewing.

efficacy: the effectiveness of a drug therapy in accomplishing its intended purpose.

epileptologist: a neurologist who specializes in the treatment of epilepsy.

generalized seizure: a seizure involving the entire brain.

hypermetabolism: faster than normal metabolism.

hypometabolism: slower than normal metabolism.

ictal: that which happens during a seizure.

idiopathic: of unknown cause.

interictal: that which happens between seizures.

intractable: difficult to control.

localization: finding the location in the brain where epileptic seizures start.

monotherapy: treatment with only one drug.

partial seizure: a seizure involving only a portion of the brain.

status epilepticus: a seizure that lasts more than 5 minutes and requires immediate medical attention due to lack of oxygen to the brain.

video EEG monitoring: simultaneous monitoring of a patient’s behavior with a video camera and the patient’s brain activity by EEG.

---

updated > 7.2018
reviewed by > Maureen Gartner, RN and George Mandybur, MD, Mayfield Clinic, Cincinnati, Ohio