1. What is epilepsy?
Epilepsy is a chronic (long-lasting) medical condition marked by recurrent (repeating) epileptic seizures. An epileptic seizure is a change in the function of the brain caused by abnormal or excessive electrical discharges from brain cells. Epilepsy is one of the most common neurologic (nervous system) disorders, affecting up to one percent of people in the United States.
There are different types of seizures, different types of epilepsy syndromes, and different causes of epilepsy. For example, both brain tumors and stroke can cause seizures and lead to chronic epilepsy. Some of the causes can be diagnosed and treated with medicines, and some have to be treated with surgery.
2. What are some of the causes of epilepsy?
About 65 percent of new epilepsy cases have no obvious cause. Of the rest, the more common reasons include stroke, congenital abnormalities (those we are born with), brain tumors, trauma, and infection. It is important to determine the cause to help guide treatment.
3. Who treats epilepsy?
A neurologist, a doctor who specializes in diseases of the brain and nervous system, best decides the diagnosis of epilepsy. Some neurologists take advanced training and become board-certified epileptologists. These doctors specialize in the diagnosis and treatment of epilepsy. This involves finding the cause of the epilepsy and starting anti-convulsant medicine to prevent further seizures. If anti-convulsant medications prove ineffective, epileptologists may recommend special tests to determine if surgery or other forms of treatment should be considered. Many internists and family practice doctors also treat epilepsy.
4. How is epilepsy diagnosed?
The evaluation of patients with epilepsy is aimed at learning the type of seizures (epileptic or non-epileptic) and their cause, since various seizure types respond best to certain treatments. The diagnosis is based on:
The patient's medical history, including any family history of seizures, associated medical conditions, and current medicines the patient is taking. The doctor will ask you some important questions, including the following:
- At what age did the seizures begin?
- What circumstances surrounded your first seizure?
- What factors seem to bring on the seizures?
- What do you feel before, during, and after the seizures?
- How long do the seizures last?
- Have you been treated for epilepsy before?
- What medicines were prescribed and in what dosages?
- Was the treatment effective?
- Others who have often seen you before, during, and after seizures, such as family and close friends, should be with you at the appointment to give details of your seizures if they involve loss of consciousness (if you passed out).
A complete physical and neurological exam of muscle strength, reflexes, eyesight, hearing, and ability to detect various sensations is used so that your doctors can better understand the cause of your seizures. Additional testing often includes:
- An electroencephalogram (EEG), which measures electrical activity in the brain
- Imaging studies of the brain, such as magnetic resonance imaging (MRI)
- Blood tests to measure red and white blood cell counts, blood sugar, blood electrolyte levels, and to check how well your liver and kidney are functioning. Blood tests also help rule out other illnesses.
- Other tests are used as needed, including magnetic resonance spectroscopy (MRS), positron emission tomography (PET), and single photon emission computed tomography (SPECT).
The most important part of the evaluation is the electroencephalogram (EEG) because it is the only test that directly detects electrical activity in the brain (seizures are defined by abnormal electrical activity in the brain). During an EEG, electrodes (small metal disks) are attached by glue to specific locations on your head. The electrodes are also attached to a monitor to record the brain's electrical activity. The EEG is useful to confirm a diagnosis of epilepsy and to determine the type of epilepsy.
The routine EEG procedure takes about 90 minutes and allows for about 20 minutes of brain wave recording. The results of a short recording may be normal even in people who are known to have epilepsy. Therefore, a repeat EEG recording of 180 minutes or more might be necessary.
Prolonged EEG-video monitoring is an even better diagnostic method. During this type of monitoring, an EEG monitors (checks) the brain's activity and cameras videotape body movements and behavior during a seizure. In order to perform prolonged monitoring, the patient may have to spend several days in a special hospital facility. Prolonged EEG-video monitoring is sometimes required to definitively diagnose epilepsy and to choose the best treatment option.
5. How is epilepsy treated?
Most epileptic seizures are controlled with drug therapy, especially anti-convulsant drugs. The type of treatment will depend on several factors, including:
- The type of epilepsy (focal/partial or generalized)
- How often the patient has a seizure
- How severe the seizures are, and
- The person's age, overall health, and medical history
The correct diagnosis of the type of epilepsy (not just the type of seizure, since most seizure types occur in different types of epilepsy) is very important to help choose the best treatment.
There are many drugs available to treat epilepsy, including:
- Carbamazepine (Tegretol® or Carbatrol®)
- Diazepam (Valium®) and related medications such as clonazepam (Klonopin®), and clorazepate (Tranxene®)
- Divalproex (Depakote®, Depakote ER®)
- Ethosuximide (Zarontin®)
- Felbamate (Felbatol®)
- Gabapentin (Neurontin®)
- Lacosamide (Vimpat®)
- Lamotrigine (Lamictal®)
- Levetiracetam (Keppra®)
- Phenytoin (Dilantin® or Phenytek®)
- Pregabalin (Lyrica®)
- Primidone (Mysoline®)
- Rufinamide (Banzel®)
- Tiagabine (Gabitril®)
- Topiramate (Topamax®)
- Valproic acid (Depakene®)
- Zonisamide (Zonegran®)
In most cases, for a given type of epilepsy, there are only minor differences among appropriate drugs. The choice most often depends on the patient; for instance, which side effects he or she can tolerate, and which delivery method he or she prefers.
Although the types of epilepsy are widely different, in general, medicines can control seizures in about 70 percent of epilepsy patients.
It might take a few months before the best drug and dosage are determined for you. During this adjustment period, you might be monitored with frequent blood tests. It is very important to keep your follow-up appointments with your doctor and the laboratory to minimize your risk for serious side effects and to prevent complications.
When seizures continue even after treatment, the patient may have medically refractory seizures, or the episodes that are thought to be seizures are actually non-epileptic. In such cases, you should get a second opinion from an epilepsy specialist and undergo EEG-video monitoring so that the diagnosis can be re-evaluated. In specialized centers, about 15 percent to 20 percent of patients referred for persistent, refractory or intractable seizures ultimately prove to have non-epileptic conditions instead.
6. What are the side effects of epilepsy medicine?
As is true of all drugs, epilepsy drugs may have side effects, which depend on the dose, type of medicine, and length of treatment. The side effects get worse with higher doses of medicine, but tend to be less severe over time as the body adjusts to the medicine. Anti-epileptic drugs are usually started at lower doses and increased gradually to make this adjustment easier.
Side effects of epilepsy drugs can include:
- Blurry or double vision
- Stomach upset
- Skin rashes
- Low blood cell counts
- Liver problems
- Swelling of the gums
- Hair loss
- Weight gain, and
7. What precautions should pregnant women who have epilepsy take?
Women who have seizures can have healthy children, as long as they receive good prenatal care. It is very important that women who have epilepsy discuss pregnancy with their doctors BEFORE getting pregnant. All women of child-bearing age who have epilepsy should take a multivitamin containing folic acid every day, because some epilepsy medicines drain the body of important vitamins.
Many seizure medicines can prevent birth control pills from working effectively, which might lead to unplanned pregnancy. If a woman becomes pregnant unexpectedly, she should NOT stop taking her seizure medicine without first talking to her doctor. Suddenly stopping seizure medicine commonly leads to more frequent seizures, which can also harm the baby.
The frequency of seizures usually does not change a great deal during pregnancy. Medicine blood levels should be checked often; levels gradually go down during pregnancy, and reach their lowest level around the time of delivery, which might result in breakthrough seizures. All seizures that occur during pregnancy should be reported to your doctor. Women should NEVER discontinue seizure medicines without consulting their doctors.
Most pregnant women with epilepsy have normal vaginal deliveries, although cesarean sections (removal of the baby through an incision made in the abdomen) must be done in some cases.
Women who take seizure medicines can breast feed their infants. Some medicines can cause babies to become very sleepy and irritable after feedings. If these effects occur, stop breast feeding until you talk to your doctor.
8. What is epilepsy surgery?
In epilepsy surgery, the surgeon takes out the part of the brain that is responsible for the abnormal electrical signals that cause seizures. This region of brain is called the epileptogenic zone. It is found through neuroimaging studies, electrical recordings from the scalp (EEG), and clinical signs during a seizure. Epilepsy surgery can provide a "cure" for epilepsy, in that it can eliminate the source of seizures and epilepsy.
9. Who can have epilepsy surgery?
Generally, patients who have seizures that start in a focal area of the brain, and that have not been controlled with medicine, are considered for surgery. This region might be small or might involve several lobes of the brain. A thorough evaluation — starting with EEG-video monitoring and high-resolution brain MRI at an experienced epilepsy surgery center — is usually performed before a patient is recommended for epilepsy surgery.
10. What types of epilepsy surgery are performed?
Surgery usually involves resection (removing the abnormal portion of brain that is causing the seizures). Brain tumors, vascular (blood vessel) abnormalities, old strokes, and congenital (inherited) irregularities might also be treated if they are believed to be causing the seizures.
The most common type of resective epilepsy surgery is the temporal lobectomy, in which a portion of the temporal lobe is removed, usually for a syndrome called mesial temporal sclerosis. Resection can be performed in other brain regions, such as the frontal lobe (frontal lobectomy), depending on where the epileptogenic zone is located.
Before resection, surgery might be necessary to implant EEG electrodes directly on or in the brain to help pinpoint the seizures. After seizures are recorded from these implanted electrodes, another surgery is performed to remove the electrodes and perform the resection.
Other types of surgery might involve removal of more than one lobe or brain region. In severe cases, when an entire cerebral hemisphere (half of the brain) is involved in the epilepsy, surgery might involve disconnecting that hemisphere from the rest of the brain.
11. What are other surgeries for epilepsy?
Vagal nerve stimulation (VNS) is another surgical treatment for epilepsy. In VNS, an electrode is implanted to stimulate the vagus nerve (a nerve that travels through the neck and is connected to various areas of the brain). With this new treatment, seizures might become less frequent or less severe in approximately 40 to 60 percent of patients. VNS is typically reserved for epilepsy patients who are not candidates for resective surgery.
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This information is provided by the Cleveland Clinic and is not intended to replace the medical advice of your doctor or health care provider. Please consult your health care provider for advice about a specific medical condition. This document was last reviewed on: 7/17/2014...#12264