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 anticonvulsant medicine to prevent further seizures. If anticonvulsant 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.

How is epilepsy treated?

Most epileptic seizures are controlled with drug therapy, especially anticonvulsant 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®)
  • Clobazam
  • 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®)
  • Phenobarbital
  • Phenytoin (Dilantin® or Phenytek®)
  • Pregabalin (Lyrica®)
  • Primidone (Mysoline®)
  • Rufinamide (Banzel®)
  • Tiagabine (Gabitril®)
  • Topiramate (Topamax®)
  • Valproic acid (Depakene®)
  • Vigabatrin
  • 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.

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
  • Fatigue/sleepiness
  • Unsteadiness
  • Stomach upset
  • Skin rashes
  • Low blood cell counts
  • Liver problems
  • Swelling of the gums
  • Hair loss
  • Weight gain
  • Tremor

When is surgery for epilepsy considered?

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.

What types of epilepsy surgery are performed?

Surgery usually involves resection (removing the abnormal portion of brain) that is responsible for the abnormal electrical signals that cause seizures. This region of brain is called the epileptogenic zone. 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. Epilepsy surgery can provide a "cure" for epilepsy, in that it can eliminate the source of seizures and epilepsy.

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.

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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