Taking control of seizures
An estimated 2.5 million Americans experience the fear and lack of control associated with epilepsy, a chronic disorder of recurring seizures. Epilepsy is a neurological (brain) condition arising from sudden and unpredictable abnormal electrical discharges in the brain that produces specific changes in behavior and bodily functions. These behavioral changes may range from a momentary loss of awareness to full body convulsions. Many of the causes of epilepsy have been identified, however there are many individuals who have epilepsy for whom no cause can be identified. While most causes of epilepsy are due to injury or chemical disorders, there are some seizure disorders like juvenile myoclonic epilepsy that is inherited. No cure currently exists for epilepsy, but many people maintain a significant degree of control over their seizures through the use of antiepileptic drugs (AEDs).
Epilepsy is a disorder characterized by recurring seizures (periodic episodes of repetitive, abnormal electrochemical disturbance in the central nervous system, beginning in the brain). Epileptic seizures take a variety of forms that can last from a few seconds to several minutes.
Seizures have three phases: the aura (symptoms that signal an approaching attack), the attack itself, and the recovery (postictal) period during which a headache, fatigue, and other symptoms can last for minutes, or less commonly, longer. Although no treatment plan exists to fully cure the disease, a combination of medical attention and drug therapy has shown promise in curbing the occurrence of seizures. However, there are side effects associated with these treatments. As many as 66% of people with epilepsy benefit from drug therapy, and only half of those who respond to anticonvulsive medications can eventually discontinue treatment with no relapses of seizures.
The number of seizures a person experiences varies substantially among individuals. While most people have one specific type of seizure, others experience a combination of types in various combinations. Seizures are classified as generalized (involving both sides of the brain with at least a momentary loss of consciousness) or focal (starting on one side of the brain or with a single symptom).
How Common Is Epilepsy?
Epilepsy currently affects about 2.5 million U.S. residents or 1% of the total population, with an estimated 125,000 new cases reported each year. The occurrence of a seizure, however, does not necessarily imply epilepsy. At least 8% of the general population will experience at least one seizure during their lifetime. Most will not have recurring seizures, or epilepsy. Children who have experienced an unprovoked first seizure, or idiopathic seizure, and who have a normal electroencephalogram (EEG) have a particularly favorable prognosis. While seizures may strike at any age, 75% of first seizures occur during childhood and adolescence with no identifiable cause. There is no data to suggest that epilepsy preferentially affects one gender over another.
Goals of Treatment
Although there is no known cure for primary epilepsy, it can usually be managed with medication. Most people with epilepsy can achieve complete control of their seizures while others can have partial control. For the small number of people for whom medication can't control their seizures, surgical procedures may be an alternative and are very effective.
Complete prevention of seizures is one of the primary goals of treatment. If this is not possible, a marked reduction in their frequency is the next goal. Because each person with epilepsy has a unique set of seizure patterns, therapy must be tailored to the individual. The drugs used to control epilepsy are selected according to the specific patterns and type of seizures the person experiences, and the issues of side effects and drug tolerance are determined on an individual case-by-case basis. The ideal treatment would be complete control of seizures with one drug, but this is possible in only 85% of the cases. Psychological factors that may decrease the frequency of seizures in susceptible people can be addressed through support groups, education, and self-awareness.
While antiepileptic drugs (AEDs) do not constitute a comprehensive cure for epilepsy, they have been proven effective in reducing the frequency and severity of seizures. Uncontrolled convulsions can provoke additional injury and brain damage. Side effects associated with the use of AEDs include, but are not limited to, impaired cognitive ability, hyperactivity, skin rashes, weight gain, nausea, insomnia, headaches, and digestive discomfort. Side effects of properly prescribed AEDs are usually tolerable. Abrupt AED withdrawal can trigger a severe condition of prolonged continual seizures without interruption, known as status epilepticus.
It is important that antiepileptic drug therapy be adhered to rigidly as prescribed by the doctor. Any deviation from the schedule can hasten a spontaneous recurrence of seizure activity. Periodically blood tests are necessary in order to determine if the prescribed drugs are being properly absorbed and eliminated. These tests help determine the optimal dosage for each drug, and thereby establishing a drug level that will ensure freedom from seizures without toxic drug effects.
|Drugs most commonly prescribed|
Depending on the type of seizure you have drugs prescribed may include:
A craniotomy is sometimes recommended if medication is ineffective in controlling seizures. This type of surgery removes a structure or lesion that causes seizures. These surgeries are performed at the specialized epilepsy treatment facilities of large medical centers. Anticonvulsant drugs may still be prescribed after the surgery.
Activity & Diet Recommendations
Restricting daily activities is not recommended for most epileptic people, as it can lead to isolation and feelings of exclusion. You may need to restrict a few activities, however, for your own safety and the safety of others:
- Driving with the threat of seizures can be dangerous, but once the seizures are under control, driving is possible. Most states allow people with epilepsy to drive once they have been seizure-free for one year.
- Avoid swimming alone.
- Avoid working at heights (for example, don't climb a ladder to paint your house).
- Avoid operating heavy or dangerous machinery.
- Wear a helmet when biking, skating, or doing other rigorous physical activity.
There are several nutritional elements that can be helpful in the treatment of epilepsy. You should attempt to eat regular meals to keep blood sugar levels constant for energy and consistent brain neuron transmission.
- Ketogenic diet: In some children, seizures have been controlled when the child fasted or avoided eating. Obviously this is an impossible long-term treatment. However, neurologists at Johns Hopkins University devised a diet that mimics the metabolism of a person who is fasting. This diet includes a high intake of fats, only enough protein for growth, and few-to-no carbohydrates. Recommended for some children, this diet provides an alternative for those who have severe side effects from anticonvulsant drugs or whose seizures cannot be controlled by medication. It's also important that the diet be tailored individually to each person. After two years on the diet, most people experience control of their seizures and can return to a normal diet without a recurrence of seizures.
- Alcohol Avoidance: Alcohol can decrease the effectiveness of your medication and could provoke seizures.
Quality of Life
People who experience the fear and loss of control associated with seizures can have difficulty in social, work, and intimate settings. Because of this, epilepsy can have a catastrophic impact on important aspects of the quality of life. A lack of understanding by others can leave the person with epilepsy feeling isolated and excluded from human contact, career opportunities, and educational possibilities. Supportive friends and family, education, and psychotherapeutic counseling may all help increase the quality of life for a person with epilepsy. Controlling seizures as much as possible can increase confidence and help the person function as normally as possible.
The issue of pregnancy is complicated for women with epilepsy. While over 90% of women taking antiepileptic drugs during pregnancy give birth to normal infants, it is important to note that birth defects are two to three times higher in children whose mothers took phenytoin, trimethadione, or valproic acid during pregnancy. You should talk to your doctor before you get pregnant, as the question of drug use during pregnancy poses some serious questions. The risk of seizures could be more harmful to the fetus than the risk of drug-induced birth defects; the risk of seizures to the mother also needs to be considered.
Many antiepileptic drugs are secreted to the baby during breastfeeding, which should be discussed with a doctor. If a mother taking anticonvulsive medication is breastfeeding, the drug concentration in the infant may require monitoring if problems, such as sedation, occur.
Considerations for Children and Adolescents
Every attempt should be made to provide your child with normal opportunities for growth, learning, and development. Insuring the child's safety by making sure he or she doesn't swim alone, wears a helmet when biking or skateboarding, and doesn't get in situations that would be dangerous if a seizure occurs, are all important elements in helping the child cope with epilepsy. Make sure that your child always wears a Medic-Alert bracelet or pendant that mentions epilepsy, in case your child has a seizure.
Inform your adolescent of the danger of drinking alcohol. Explain how it decreases the effectiveness of medication and may provoke a seizure.
Considerations for Older People
Strokes, tumors, and degenerative disease are likely causes of 90% of new-onset seizures found in older people. If antiepileptic drugs are necessary, you will likely begin with small doses and increase your dosage gradually to control tolerance.
Self care & Prevention
The majority of epilepsy cases are incurable. The principal methods of prevention are genetic counseling and family planning. Avoidance of head injury and containment of risk factors can reduce the risk of contracting secondary epilepsy.
Avoiding environmental and lifestyle triggers can help decrease the occurrence of seizures. Alcohol and drugs should be eliminated as they can effect medication and cause seizures. Vigorously treat infections anywhere in your body. Eat a consistent, healthy diet with regularly scheduled meals. In addition, the following tactics may help:
- If you've ever had a seizure, wear a Medic-Alert bracelet or necklace so that first-aid providers will know that you have seizure disorder.
- Just about anything can trigger seizures, notably stress, but also fatigue, alcohol or drug consumption, flashing lights, even certain television programs. Record your triggers and work to avoid them.
- Manage your stress. Get regular exercise it helps control stress.
- Eat regular meals and snacks. Several studies show that low blood sugar (hypoglycemia) is a risk factor for seizures. Keep your blood sugar up by not skipping meals. In addition, snack between meals.
- As a last resort, try increasing the fat in your diet. Use this approach carefully, though, as a high-fat diet can contribute to heart disease, many cancers, stroke, obesity, diabetes, arthritis, and many other ills. However, it also helps to prevent seizures. If your seizures cannot be controlled in other ways, consult your doctor and a clinical nutritionist about a monitored program for increasing the fat in your diet.
Psychological issues such as fear and exclusion that arise from experiencing seizures in public can be addressed by educating those in your life about epilepsy. Personal counseling, support groups, and an understanding group of friends and family can all help in dealing with the emotional impact of the unpredictable nature of epileptic seizures.
Last updated 11 November 2011
- Seizure disorder and convulsive disorder are two terms used synonymously to describe epilepsy
- Grand mal epilepsy is also known as tonic-clonic seizure disorder
- Petit mal epilepsy has been referred to as pyknoepilepsy or absence epilepsy
Genetic factors may play a role in predisposing one to epilepsy, however a definite cause of the illness remains unknown in up to 70% of cases. A clinical reason for the illness can be determined in approximately 25% of all cases. The most clearly established causes of seizures include severe head trauma, central nervous system infections, brain tumors, chemical changes in the blood, and stroke. Anything that disrupts the natural condition (homeostasis) of nerve cells in the brain can trigger abnormal cellular activity and lead to a seizure. Alcohol and drug abuse can trigger seizures. Kidney or liver damage that leads to elevated concentrations of toxins in the blood, can also induce seizure activity.
Other causes include vascular abnormalities; excessive insulin levels (applies to people with diabetes); an allergic response to medications including antiepileptic (AED) drugs; lead ingestion; a sudden withdrawal from alcohol, street drugs, antidepressants, antipsychotics, or AEDs.
Evidence suggests that genetic factors may predispose you to a seizure disorder. The cellular mechanisms of primary epilepsy are not understood. A change in the chemical content of the blood that reaches the brain has been cited as a possible source of seizures. These chemical triggers may include hormone imbalances that become prevalent during puberty, menstruation, and pregnancy.
A family history of epilepsy is one of the main risk factors. Stress and fatigue may also elevate a person's susceptibility to developing a seizure disorder. Bright sunshine, flickering lights, or loud sounds can provoke seizures in certain individuals. Many of the established causes of epilepsy are also factors that may put you at risk.
Risk factors are traits or behaviors that may make you statistically more likely than others in the general population to have a certain condition. They are not necessarily "causes" of the condition.
Symptoms & Diagnosis
Signs that warn of an upcoming seizure can include headache, listlessness, mood alterations, or sporadic muscle twitching; these signs can occur hours before an attack happens. Just moments before an attack, some people report having a "funny feeling" or feelings of fear and doom. They also report the presence of an aura, which may take the form of a visual or auditory hallucination, unpleasant odor, or bizarre illusion.
The onset of a seizure is marked by an alteration in normal cognitive function, ranging from a brief lapse of awareness to a total loss of consciousness. Depending on the type of seizure, involuntary muscle spasms ranging from localized twitching to violent convulsions, or psychological aberrations ranging from brief disorientation to abnormal behavior can occur. Seizures are commonly classified into four types that vary in their duration and severity. Symptoms associated with each are described in detail below:
- Grand mal seizures, also known as generalized tonic-clonic seizures. These involve the entire brain and subsequently, the entire body in convulsive activity. This type of seizure, often preceded by an aura, is accompanied by a sudden loss of consciousness followed by total body rigidity (tonic phase) and synchronous muscle jerking (clonic phase). Signs include increased salivation as indicated by a frothing at the mouth, abnormal breathing, dilated pupils, and bluish skin tone with possible loss of bladder or bowel control. The attack typically lasts 30 seconds to five minutes. After the episode, the individual awakens spontaneously, feeling confused and exhausted, unable to remember the seizure. Afterwards, most people will want to go to sleep and may sleep for several hours.
- Petit mal or absence seizures. Like grand mal seizures, these also involve the entire brain but are comparably mild and relatively common among prepubescent children. Episodes are characterized by a brief lapse of consciousness that may include staring, rapid blinking, minor twitching of an eyelid or facial muscles, chewing movements, or a jerk of a hand or arm, but falls and/or convulsions do not generally occur. Episodes may happen more than 100 times a day.
Absence seizures occur when a person experiences a sudden brief absence of awareness. The blank stare, a primary feature of this type of seizure, never lasts longer than 15 or 30 seconds. Immediately after each of these seizures, normal functioning returns. The individual may be aware that his or her mind "went blank." Absence seizures are often seen in children, beginning between ages 2 and 14. A large portion of children with absence seizures will experience grand mal seizures before they reach age 21.
- Simple partial seizures. Localized to one area of the brain, simple partial seizures are not accompanied by a loss of consciousness. You may experience an altered sensory perception including hallucination, flashing lights, tingling sensations, the smell of foul odors, dizziness, deja vu, time distortions, fear, and anger. Alternatively, you may be subjected to convulsions originating in one part of the body and progressing to other parts. This can develop into a grand mal seizure, involving your entire body in seizure activity.
- Complex partial seizures or temporal lobe seizures. These seizures combine impaired consciousness with all the symptoms associated with simple partial seizures. During a seizure of this type, abnormal and automated behaviors such as lip smacking, ripping paper, buttoning and unbuttoning a shirt, or repetitive chewing motions take place. Behavior may suddenly be altered, and speech, hearing, memory, and emotional responses may become impaired. An episode may begin with distorted vision, smelling unpleasant odors or hallucinations. The hallucinations can be visual or aural. Irrational speech, walking aimlessly, and inappropriate laughter or actions may also occur. A lack of consciousness, falling and fainting will be seen on occasion. Between episodes, those with temporal lobe epilepsy will sometimes display unusual behavior such as being overly sensitive, intensely religious, or obsessive. Complex partial seizures usually last a minute or two, rarely as long as five minutes. They are followed by a slow reorientation, with fatigue and headache.
Conditions That May Be Mistaken for Epilepsy
Seizures associated with fever do not constitute epilepsy. Febrile seizure, a type of seizure common among children, is not associated with any kind of neurological dysfunction but is the result of a rapid increase in temperature, which causes epileptic-like symptoms including convulsions, rolled-back eyes, and possibly vomiting, urination, or defecation. Other conditions that may be misdiagnosed as epilepsy are:
- Syncope (fainting), including:
- Orthostatic hypotension
- Heart rhythm disturbances
- Sleep disorders: nightmares, narcolepsy, cataplexy
- Psychiatric disorders: panic attacks, fugue states, psychogenic seizures
- Transient ischemic attacks (TIAs): brief interruptions of blood flow to the brain
- Migraine headaches
- Childhood breath-holding episodes
How Epilepsy Is Diagnosed
It is helpful if an eyewitness to the seizure can give a detailed report to the doctor of exactly what took place since the person experiencing the seizure usually cannot. The doctor can determine the type of seizure that probably took place if the witness can give an accurate description of the episode and the person experiencing the seizure tells what he or she experienced before and after the seizure.
Aside from noting the details of the seizure, a doctor uses an electroencephalogram (EEG) which measures the electrical activity in the brain to determine if there are any abnormalities. Routine blood tests are taken to measure the levels of calcium, sugar, and sodium in the blood and to determine if kidney and liver functions are normal. Blood tests are useful in identifying the sources of seizures like hypoglycemia, hyperglycemia, or electrolyte abnormalities. Other tests can also determine whether other causes of epilepsy are present such as lead ingestion, infection, and alcohol or drug abuse. A high white blood cell count may indicate the presence of infection and be the cause of the seizure.
Other tests the doctor may conduct are an electrocardiogram to determine if there evidence of an abnormal heart rhythm and an inadequate flow of blood to the brain, or a lumbar puncture (spinal tap) if infection is suspected. An electroencephalogram (EEG) is essential in properly classifying seizure types, particularly in distinguishing partial from generalized seizure patterns. It is important to note that a normal EEG does not eliminate the possibility of a seizure disorder, nor does an abnormal EEG necessarily confirm that you do have a seizure disorder.
In some cases it may be necessary to conduct a 24-hour EEG monitoring in order to determine the precise frequency and nature of abnormal electrical activity in the brain. Continuous videotaping may also be necessary in order to distinguish epileptic seizures from nonepileptic events. In addition, a psychological evaluation may be considered if the patient exhibits signs of an epileptic-like condition called hysterical epilepsy. This disorder, while mimicking the symptoms associated with epilepsy, is emotionally based, and does not result from abnormal neurological dysfunction.
An array of imaging techniques including computed tomography (CT) scan, positron emission tomography (PET) scan, single positron emission computed tomography (SPECT), magnetic resonance imaging (MRI), and cerebral angiograms are available for locating structural abnormalities such as tumors, strokes or abnormal blood vessels, that may be causally linked to seizures.