EPILEPSY
INFORMATION FOR, FAMILY. FRIENDS, AND CAREGIVERS
Introduction
Few experiences match the drama of a convulsive seizure. A person having a severe seizure may cry out, fall to the floor unconscious, twitch or move uncontrollably, drool, or even lose bladder control. Within minutes, the attack is over, and the person regain consciousness but is exhausted and dazed. This is the image most people have when they hear the word epilepsy. However, this type of seizure - a generalized tonic-clonic seizure - is only one kind of epilepsy. There are many other kinds, each with a different set of symptoms.
Epilepsy was one of the first brain disorders to be described. It was mentioned in ancient Babylon more than 3,000 years ago. The strange behaviour caused by some seizures has contributed through the ages to many superstitions and prejudices. The word epilepsy is derived from the Greek word for "attack." People once thought that those with epilepsy were being visited by demons or gods. However, in 400 B.C., the early physician Hippocrates suggested that
epilepsy was a disorder of the brain - and we now know that he was right.
What is Epilepsy?
Epilepsy is a brain disorder in which clusters of nerve cells, or neurons, in the brain sometimes signal abnormally. Neurons normally generate electrochemical impulses that act on other neurons, glands, and muscles to produce human thoughts, feels, and actions. In epilepsy, the normal pattern of neuronal activity becomes disturbed, causing strange sensations, emotions and behaviour, or sometimes convulsions, muscle spasms, and loss of consciousness. During a
seizure, neurons may fire as many as many as 500 times a second, much faster than the normal rate of about 80 times a second. In some people, this happens only occasionally; for others, it may happen up to hundreds of times a day.
More than 2 million people in the United States - about 1 in 100 – have experienced an unprovoked seizure or been diagnosed with epilepsy. For about 80 percent of those diagnosed with epilepsy, seizures can be controlled with modern medicines and surgical techniques. However, about 20 percent of people with epilepsy will continue to experience seizures, even with the best available treatment. Doctors call this situation Intractable epilepsy. Having a seizure does not necessarily mean that a person has epilepsy. Only when a person has had two or more seizures is he or she considered to have epilepsy.
Epilepsy is not contagious and is not caused by mental illness or mental retardation. Some people with mental retardation may experience seizures, but seizures do not necessarily mean the person has or will develop mental impairment. Many people with epilepsy have normal or above-average intelligence. Famous people who are known or rumoured to have had epilepsy
include the Russian writer Dostoyevsky, the philosopher Socrates, the military General Napoleon, and the inventor of dynamite, Alfred Nobel, who established The Nobel Prize. There are several Olympic medallists and other athletes who have had epilepsy. Seizures sometimes do cause brain damage, particularly if they are severe. However, most seizures do not seem to have a detrimental- effect on the brain. Any changes are caused by the seizures themselves or by the underlying problem that caused the seizures.
While epilepsy cannot currently be cured, for some people it does eventually go away. One study found that children, with idiopathic epilepsy, or epilepsy with an unknown cause, had a 68 to 92 percent chance of becoming seizure-free by 20 years after the diagnosis. The odds of becoming seizure-free are not good for adults, or for children with severe epilepsy syndromes, but is nonetheless possible that seizures may decrease or even stop over time. This is more likely if the epilepsy has been well controlled by medication or if the person has had epilepsy surgery.
What Causes Epilepsy?
Epilepsy is a disorder with many possible causes. Anything that disturbs the
normal pattern of neuron activity - from illness to brain damage to abnormal
brain development - can lead to seizures.
Epilepsy may develop because of an abnormality in brain wiring, an imbalance of nerve signaling chemicals called neurotransmitters, or some combination of these factors. Researchers believe that some people with epilepsy have an
abnormally high level of excitatory neurotransmitters that increase neuronal
activity, while others have an abnormally low level of inhibitory neurotransmitters
that decrease neuronal activity in the brain. Either situation can result in too much neuronal activity and cause epilepsy. One of the most-studied
neurotransmitters that plays a role in epilepsy is GABA, or gamma-aminobutyric
acid, which is a neurotransmitter. Research on GABA has led to drugs that
alter the amount of this neurotransmitter in the brain or change how the brain
responds to it. Researchers also are studying excitatory neurotransmitters such as glutamate.
In some cases, the brain's attempts to repair itself after a head injury, stroke, or
other problem may inadvertently generate abnormal nerve connections that lead
to epilepsy. Abnormalities in brain wiring that occur during brain development also may disturb neuronal activity and lead to epilepsy.
Research has shown that the cell membrane that surrounds each neuron plays
an important role in epilepsy. Cell membranes are crucial for neurons to
generate electrical impulses. For this reason, researchers are studying details of
the membrane structure, how molecules move in and out of membranes, and
how the cell nourishes and repairs the membrane. A disruption in any of these
processes may lead to epilepsy. Studies in animals have shown that, because
the brain continually adapts to changes in stimuli, a small change in neuronal
activity, if repeated, may eventually lead to full-blown epilepsy. Researchers are
investigating whether this phenomenon, called kindling, may also occur in
humans.
In some cases, epilepsy may result from changes in non-neuronal brain cells
called glia. These cells regulate concentrations of chemicals in the brain that can
affect neuronal signaling.
About half of all seizures have no known cause. However, in other cases, the
seizures are clearly linked to infection, trauma, or other identifiable problems.
Genetic Factors
Research suggests that genetic abnormalities may be some of the most important factors contributing to epilepsy. Some types of epilepsy have been traced to an abnormality in a specific gene. Many other types of epilepsy tend to
fun in families, which suggests that the genes influence epilepsy. Some
researchers estimate that more than 500 genes could play a role in this disorder.
However, it is increasingly clear that, for many forms of epilepsy, genetic
abnormalities play only a partial role, perhaps by increasing a person's
susceptibility to seizures that are triggered by an environmental factor.
Several types of epilepsy have now been linked to defective genes for ion
channels, the "gates" that control the flow of ions in and out of cells and regulate
neuron signaling. Another gene, which is missing in people with progressive
myoclonus epilepsy, codes for a protein called cystatin B. This protein which
regulates enzymes that break down other proteins. Another gene, which is
altered in a severe form of epilepsy called Lafora's disease, has been linked to a
gene that helps to break down carbohydrates.
While abnormal genes sometimes cause epilepsy, they also may influence the
disorder in subtler ways. For example, one study showed that many people with epilepsy have an abnormally active version of a gene that increases resistance to
drugs. This may help explain why anticonvulsant drugs do not work for some
people. Genes may also control other aspects of the body's response to
medications and each person's susceptibility to seizures, or seizure threshold. Abnormalities in the genes that control neuronal migration -a critical step in brain
development - can lead to areas of misplaced or abnormally formed neurons, or
dysplasia, in the brain that can cause epilepsy. In some cases, genes may
contribute to development of epilepsy even in people with no family history of the
disorder. These people may have a newly developed abnormality, or mutation, in an epilepsy-related gene.
Other Disorders
In many cases, epilepsy develops as a result of brain damage from other
disorders. For example, brain tumours, alcoholism, and Alzheimer’s disease
frequently lead to epilepsy because they alter the normal workings of the brain.
Strokes, heart attacks, and other conditions that deprive the brain of oxygen also
can cause epilepsy in some cases. About 32 percent of all newly developed
epilepsy in elderly people appears to be due to cerebrovascular disease, which
reduces the supply of oxygen to brain cells. Meningitis, AIDS, viral encephalitis,
and other infectious diseases can lead to epilepsy, as can hydrocephalus - a
condition in which excess fluid builds up in the brain. Epilepsy can also result from a parasitic infection of the brain called neurocysticercosis. Seizures may
stop once these disorders are treated successfully. However, the odds of
becoming seizure-free after the primary disorder is treated are uncertain and vary
depending on the type of disorder, the brain region that is affected, and how
much brain damage occurred prior to treatment.
Epilepsy is associated with a variety of developmental and metabolic disorders,
including cerebral palsy, neurofibromatosis, pyruvate deficiency, tuberous
sclerosis, Landau-Kleffner syndrome, and autism. Epilepsy is just one set of
symptoms commonly found in people with these disorders.
In some cases, head injury can lead to seizures or epilepsy. Safety measures
such as wearing seat belts in cars and using helmets when riding a motorcycle or
playing competitive sports can protect people from epilepsy and other problems
that result from head injury.
Prenatal Injury and Developmental Problems
The developing brain is susceptible to many kinds of injury. Maternal infections,
poor nutrition, and oxygen deficiencies are just some of the conditions that may
take a toll on the brain of a developing baby. These conditions may lead to
cerebral palsy, which often is associated with epilepsy, or they may cause epilepsy that is unrelated to any other disorders. About 20 percent of seizures in
children are due to cerebral palsy or other neurological abnormalities. Abnormalities in genes that control development may also contribute to epilepsy.
Advanced brain imaging has revealed that some cases of epilepsy that occur with no obvious cause may be associated with areas of dysplasia in the brain
that probably develop before birth.
Poisoning
Seizures can result from exposure to lead, carbon monoxide, and many other
poisons. They can also result from exposure to street drugs and from overdoses
of antidepressants and other medications.
Seizures are often triggered by factors such as lack of sleep, alcohol
consumption, stress, or hormonal changes associated with the menstrual cycle.
These seizure triggers do not cause epilepsy but can provoke first seizures or
cause breakthrough seizures in people who otherwise experience good seizure
control with their medication. Sleep deprivation in particular is a universal and
powerful trigger in seizures. For this reason, people with epilepsy should make
sure to get enough sleep and should try to stay on a regular sleep schedule as
much as possible. For some people, light flashing at a certain speed or the
flicker of a computer monitor can trigger a seizure: this problem is called
photosensitive epilepsy. Smoking cigarettes also can trigger seizures. The
nicotine in cigarettes acts on receptors for the excitatory neurotransmitter
acetylcholine in the brain, which increases neuronal firing. Seizures are not
triggered by sexual activity except in very rare instances.
What Are the Different Kinds of Seizures?
Doctors have described more than 30 different types of seizures. Seizures are
divided into two major categories - partial seizures and generalized seizures.
However, there are many different types of seizures in each of these categories.
Partial Seizures
Partial seizures occur in just one part of the brain. About 60 percent of people with epilepsy have partial seizures. These seizures are frequently described by
the area of the brain in which they originate. For example, someone might be
diagnosed with partial frontal lobe seizures.
In a simple partial seizure, the person will remain conscious but may experience
unusual feelings or sensations that can take many forms. The person may
experience sudden and unexplainable feelings of joy, anger, sadness, or nausea. He or she may hear, smell, taste, see, or feel things that are not real.
In a complex partial seizure, the person has a change in or loss of
consciousness. His or her consciousness may be altered, producing a dreamlike
experience. People having a complex partial seizure may display strange,
repetitious behaviours such as blinks, twitches, mouth movements, or even walking in a circle. These repetitious movements are called automatisms. They
may also fling objects across the room or strike out at walls or furniture as though
they are angry or afraid. These seizures usually last just a few seconds.
Some people with partial seizures, especially complex partial seizures, may
experience auras - unusual sensations that warn of an impending seizure.
These auras are actually simple partial seizures in which the person maintains
consciousness. The symptoms an individual person has, and the progression of
those symptoms, tends to be stereotyped, or similar every time.
The symptoms of partial seizures can easily be confused with other disorders.
For instance, dreamlike perceptions associated with a complex partial seizure
may be misdiagnosed as migraine headaches, which also can cause a dreamlike
state. The strange behaviour and sensations caused by partial seizures also can
be mistaken for symptoms of narcolepsy, fainting, or even mental illness. It may take many tests and careful monitoring by a knowledgeable physician to tell the difference between epilepsy and other disorders.
Generalized Seizures
Generalized seizures are a result of abnormal neuronal activity in many parts of
the brain. These seizures may cause loss of consciousness, falls, or massive
muscle spasms.
There are many kinds of generalized seizures. In absence seizures, the person
may appear to be staring into space and/or having jerking or twitching muscles.
These seizures are sometimes as petit mat seizures, which is an older term.
Tonic seizures cause stiffening of muscles of the body, generally those in the
back, legs, and arms. Clonic seizures cause repeated jerking movements of
muscles on both sides of the body. Myoclonic seizures cause jerks or twitches of the upper body, arms, or legs. Atonic seizures cause a loss of normal muscle tone. The affected person will fall down and may nod his or her head
involuntarily. Tonic-clonic seizures cause a mixture of symptoms, including
stiffening of the body and repeated jerks of the arms and/or legs as well as loss of consciousness. Tonic-clonic seizures are sometimes referred to by an older term: grand mat seizures.
Not all seizures can be easily defined as either partial or generalized. Some
people have seizures that begin as partial seizures and then spread to the entire brain. Other people may have both types of seizures but with no clear pattern.
Society's lack of understanding about the many different types of seizures is one of the biggest problems for people with epilepsy. People who witness a non convulsive seizure often find it difficult to understand that behaviour which looks deliberate is not under the person's control. In some cases, this has led to the affected person being arrested, sued, or placed in a mental institution. To combat these problems, people everywhere need to understand that many different types of seizures and how they may appear.
What Are the Different Kinds of Epilepsy?
Just as there are many different types of seizures, there are many different kinds
of epilepsy. Doctors have identified hundreds of different epilepsy syndromes -
disorders characterized by a special set of symptoms that include epilepsy. Some of these symptoms appear to be hereditary. For other symptoms; the
cause is unknown. Epilepsy syndromes are frequently described by their
symptoms or by where in the brain they originate. People should discuss the
implications of their type of epilepsy with their doctors to understand the full
range of symptoms, the possible treatments, and the prognosis.
People with absence epilepsy have repeated absence seizures that cause
momentary lapses of consciousness. These seizures almost always begin in
childhood or adolescence, and they tend to run in families, suggesting that they
may be least partially due to a defective gene or genes. Some people with
absence seizures have purposeless movements during their seizures, such as a jerking arm or rapidly blinking eyes. Others have no noticeable symptoms except
for brief times when they are "out of it." Immediately after a seizure, the person
can resume whatever he or she was doing. However, these seizures may occur
so frequently that the person cannot concentrate in school or other situations.
Childhood absence epilepsy usually stops when the child reaches puberty.
Absence seizures usually have no lasting effect on intelligence or other brain functions.
Psychomotor epilepsy is another term for recurrent partial seizures, especially
seizures of the temporal lobe. The term psychomotor refers to the strange
sensations, emotions, and behaviour seen with these seizures.
Temporal lobe epilepsy, or TLE, is the most common epilepsy syndrome with
partial seizures. These seizures are often associated with auras. TLE often
begins in childhood. Research has shown that repeated temporal lobe seizures
can cause a brain structure called the hippocampus to shrink over time. The
hippocampus is important for memory and learning. While it may take years of
temporal lobe seizures for measurable hippocampal damage to occur, this finding underlines the need to treat TLE early and as effectively as possible.
Frontal lobe epilepsy usually involves a cluster of short seizures with a sudden onset and termination. There are many subtypes of frontal lobe seizures. The
symptoms depend on where in the frontal lobe the seizures occur.
Occipital lobe epilepsy usually begins with visual hallucinations, rapid eye
blinking, or other eye-related symptoms. Otherwise, it resembles temporal or
frontal lobe epilepsy.
The symptoms of parietal lobe epilepsy closely resemble those of other types of epilepsy. This may reflect the fact that the parietal lobe seizures tend to spread
to other areas of the brain.
There are many other types of epilepsy, each with its own characteristic set of
symptoms. Many of these, including Lennox-Gastuat syndrome and Rasmussen's encephalitis, begin in childhood. Children with Lennox-Gastuat
syndrome have severe epilepsy with several different types of seizures, including
atonic seizures, which cause sudden falls an are also called drop attacks. This
severe form of epilepsy an be very different to treat effectively. Rasmussen's
encephalitis is a progressive type of epilepsy in which half of the brain shows continual inflammation. It sometimes is treated with a radical surgical procedure
called hemispherectomy (see the section on surgery). Some childhood epilepsy
syndromes, such as childhood absence epilepsy, tend to go into remission or
stop entirely during adolescence, whereas other syndromes, such as juvenile
myoclonic epilepsy are usually present for life once they develop. Seizure
syndromes do not always appear in childhood. For example, Ramsay Hunt
syndrome type II is a rare and severe progressive type of epilepsy that generally
begins in early adulthood and leads to reduced muscle co-ordination and
cognitive abilities in addition to seizures.
Epilepsy syndromes that do not seem to impair cognitive functions or development are often described as benign. Benign epilepsy syndromes include
benign infantile encephalopathy, including neurological and developmental problems. However, these problems may be cause by underlying neuro degenerative processes rather than by the seizures. Epilepsy syndromes
in which the seizures and/or the person's cognitive or motor abilities get worse
over time are called progressive epilepsy.
Several types of epilepsy begin in infancy. The most common type of infantile
epilepsy is infantile spasms, clusters of seizures that usually begin before the
age of 6 months. During the seizures the infant may bend and cry out. Anticonvulsant drugs often do not work for infantile spasms, but the seizures can be treated with ACTH (adrenocorticotropic hormone) or prednisone.
When Are Seizures Not Epilepsy?
While any seizure is cause for concern, having a seizure does not by itself mean
a person has epilepsy. First seizures, febrile seizures, non-epileptic events, and eclampsia are examples of seizures that may not be associated with epilepsy.
First Seizures
Many people have had a single seizure at some point in their lives. Often these
seizures occur in reaction to anesthesia or a strong drug, but they also may be
unprovoked, meaning that they occur without any obvious triggering factor.
Unless the person has suffered brain damage or there is a family history of
epilepsy or other neurological abnormalities, these single seizures usually are not
followed by additional seizures. One recent study that followed patients for an
average of 8 years found that only 33 percent of people who have had a second
seizure within 4 years after an initial seizure. People who did not have a second
seizure within the time remained seizure-free for the rest of the study. For
people who did have a second seizure, the risk of a third seizure was about 73
percent on average by the end of the 4 years.
When someone has experienced a first seizure, the doctor will usually order an
electroencephalogram, or EEG, to determine what type of seizure the person
may have had and there are any detectable abnormalities in the person's brain
waves. The doctor also may order brain scans to identify abnormalities that may
be visible in the brain. These tests may help the doctor decide whether or not to
treat the person with anti-epileptic drugs. In some cases, drug treatment after the
first seizure may help prevent future seizures and epilepsy. However, the drugs
also can cause detrimental side effects, so doctors prescribe them only when
they feel the benefits outweigh the risks. Evidence suggests that it may be
beneficial to begin anticonvulsant medication once a person has had a second
seizure, as the chance of future seizure increases significantly after this occurs.
Febrile Seizures
Sometimes a child will have a seizure during the course of an illness with a high
fever. These seizures are called febrile seizures (febrile is derived the Latin word
for "fever") and can be very alarming to the parents and other caregivers. In the
past, doctors usually prescribed a course of anticonvulsant drugs following a
febrile seizure in the hope of preventing epilepsy. However, most children who
have a febrile seizure do not develop epilepsy, and long-term use of
anticonvulsant drugs in children may damage the developing brain or cause
other detrimental side effects. Experts at a 1980 consensus conference coordinated by the National Institutes of Health concluded that preventative treatment after a febrile seizure is generally not warranted unless certain other conditions are present: a family history of epilepsy, signs of nervous system
impairment prior to the seizure, or a relatively prolonged or complicated seizure. The risk of subsequent non-febrile seizures is only 2 to 3 percent unless one of these factors is present.
Researchers have now identified several different genes that influence the risk of febrile seizures in certain families. Studying these genes may lead to new
understanding of how febrile seizures occur and perhaps point to ways of
preventing them.
Non-epileptic Events
Sometimes people appear to have seizures, even though their brains show no seizure activity. This type of phenomenon has various names, including
non-epileptic events and pseudo-seizures. Both of these terms essentially mean
something that looks like a seizure but isn't one. Non-epileptic events that are
psychological in origin may be referred to as psychogenic seizures. Psychogenic seizures may indicate dependence, a need for attention, avoidance of stressful
situations, or specific psychiatric conditions. Some people with epilepsy have
psychogenic seizures in addition to their epileptic seizures. Other people who
have psychogenic seizures do not have epilepsy at all. Psychogenic seizures
cannot be treated in the same way as epileptic seizures. Instead, they are often treated by mental health specialists.
Other non-epileptic events may be cause by narcolepsy. Tourette's syndrome,
cardiac arrhythmia, and other medical conditions with symptoms that resemble
seizures. Because symptoms of these disorders can look very much like
epileptic seizures, they are often mistaken for epilepsy. Distinguishing between true epileptic seizures and non-epileptic events can be very difficult and requires a thorough medical assessment, careful monitoring, and knowledgeable health
professionals. Improvements in brain scanning and monitoring technology may
improve diagnosis of non-epileptic events in the future.
Eclampsia
Eclampsia is a life-threatening condition that can develop in pregnant women. Its
symptoms include sudden elevations in blood pressure and seizures. Pregnant
women who develop unexpected seizures should be rushed to a hospital
immediately. Eclampsia can be treated in a hospital setting and usually does not result in additional seizures or epilepsy once the pregnancy is over.
How is Epilepsy Diagnosed?
Doctors have developed a number of different tests to determine whether a person has epilepsy and, if so, what kind of seizures the person has. In some cases, people may have symptoms that look very much like a seizure but in fact are non-epileptic events caused by other disorders. Even doctors may not be able to tell he difference between these disorders and epilepsy without close observation and intensive testing.
EEG Monitoring
An EEG records brain waves detected by electrodes placed on the scalp. This is the most common diagnostic test for epilepsy and can detect abnormalities in the
brain's electrical activity. People with epilepsy frequently have changes in their
normal pattern of brain waves, even when they are not experiencing a seizure.
While this type of test can be very useful in diagnosing epilepsy, it is not foolproof. Some people continue to show normal brain wave patterns even after they have experienced a seizure. In other cases, the unusual brain waves are
generated deep in the brain where the EEG is unable to detect them. Many
people who do not have epilepsy also show some unusual brain activity on an
EEG. Whenever possible, an EEG should be performed within 24 hours of a
patient's first seizure. Ideally, EEGs should be performed while the patient is
sleeping as well as when he or she is awake, because brain activity during sleep
is often quite different than at other times.
Video monitoring is often used in conjunction with EEG to determine the nature
of a person's seizures. It also can be used in some cases to rule out other
disorders such as cardiac arrhythmia or narcolepsy that may look like epilepsy.
In some cases, doctors may use an experimental diagnostic technique called a
magneto encephalogram, or MEG. MEG detects the magnetic signals generated
by neurons to allow doctors to monitor brain activity at different points in the brain
over time, revealing different brain functions. While MEG is similar in concept to
EEG, it does not require electrodes and it can detect signals from deeper in the brain than an EEG.
Brain Scans
One of the most important ways of diagnosing epilepsy is through the use of
brain scans. The most commonly used brain scans include CT (computed tomography), PET (positron emission tomography) and MRI (magnetic
resonance imaging). CT and MRI scans reveal the structure of the brain, which can be useful for identifying brain tumours, cysts, and other structural abnormalities. PET and an adapted kind of MRI called functional MRI (fMRI) can
be used to monitor the brain's activity and detect abnormalities in how it works.
SPECT (single photon emission computed tomography) is a relatively new kind
of brain scan that is sometimes used to located seizure foci in the brain. Doctors
are also experimenting with brain scans called magnetic resonance spectroscopy
(MRS) that can detect abnormalities in the brain's biochemical processes, and with near-infrared spectroscopy, a technique that can detect oxygen levels in
brain tissue.
Medical History
Taking a detailed medical history, including symptoms and duration of the seizures, is still on the best methods available to determine if a person has
epilepsy and what kind of seizures they have. The doctor will ask questions
about the seizures and any past illnesses or other symptoms a person may have
had. Since people who have suffered a seizure often do not remember what
happened, caregivers' accounts of the seizure are vital to this evaluation.
Blood Tests
Doctors often take blood samples for testing, particularly when they are
examining a child. These blood samples are often screened for metabolic or
genetic disorders that may be associated with the seizures. They also may be
used to check for underlying problems such as infections, lead poisoning,
anemia, and diabetes that may be causing or triggering the seizures.
Developmental, Neurological, and Behavioural Tests
Doctors often use tests devised to measure motor abilities, behaviour, and intellectual capacity as a way to determine how the epilepsy is affecting the
person. These tests also can provide clues abut what kind of epilepsy the
person has.
Can Epilepsy be Prevented?
Many cases of epilepsy can be prevented by wearing seatbelts and bicycle helmets, putting children in car seats, and other measures that prevent head
injury and trauma. Prescribing medication after first or second seizures or febrile seizures also may help prevent epilepsy in some cases. Good prenatal care,
including treatment of high blood pressure and infections during pregnancy, can prevent brain damage in the developing baby that may lead to epilepsy and other neurological problems later. Treating cardiovascular disease, high blood pressure, infections, and other disorders that can affect the brain during
adulthood and ageing may prevent many cases of epilepsy. Finally, identifying the genes for many neurological disorders can provide opportunities for genetic
screening and prenatal diagnosis that may ultimately prevent many cases of epilepsy.
How can Epilepsy be Treated?
Accurate diagnosis of the type of epilepsy a person has is crucial for finding an
effective treatment. There are many different ways to treat epilepsy. Currently
available treatments can control seizures at least some of the time in about 80
percent of people with epilepsy. However another 20 percent - about 600,000
people with epilepsy in the United States - have intractable seizures, and
another 400,000 feel they get inadequate relief from available treatments. These
statistics make it clear that improved treatments are desperately needed.
Doctors who treat epilepsy come from many different fields of medicine. They
include neurologists, pediatricians, pediatric neurologists, internists, and family
physicians, as well as neurosurgeons and doctors called epileptologists who
specialize in treating epilepsy. People who need specialized or intensive care in
treating epilepsy may be treated at large medical centres and neurology clinics at
hospitals, or by neurologists in private practice. Many epilepsy treatment centres
are associated with university hospitals that perform research in addition to
providing medical care.
Once epilepsy is diagnosed, it is important to begin treatment as soon as
possible. Research suggests that medication and other treatments may be less
successful in treating epilepsy once seizures and their consequences become
established.
Medications
By far the most common approach to treating epilepsy is to prescribe anti-epileptic drugs. The first effective anti-epileptic drugs were bromides, introduced by an English physician named Sir Charles Lacock in 1857. He noticed that bromides had a sedative effect and seemed to reduce seizures in some patients. More than 20 different anti-epileptic drugs are now on the market, all of with different benefits and side effects. The choice of which drug to prescribe, and at what dosage, depends on many different factors, including type of seizures a person has, the person's lifestyle and age, how frequently the seizures occur, and, for a woman, the likelihood that she will become pregnant. People with epilepsy should follow their doctor's advice and share any concerns they may have regarding their medication.
Doctors seeing a patient with newly developed epilepsy often prescribe carbamazapine, valproate, or phenytoin first, unless the epilepsy is a type that is known to require a different kind of treatment. Other commonly prescribed drugs
include clonazepam, phenobarbital, and primidone. In recent years, a number of
new drugs have become available. These include tiagabine, lamotrigine,
gabapentin, topiramate, levetiracetam, and felbamate, as well as oxcarbazapine,
a drug that is similar to carbamazapine but has fewer side effects. These new
drugs have advantages for many patients. Other drugs are used in combination
with one of the standard drugs or for intractable seizures that do not respond to
other medications. A few drugs, such as fosphenytoin, are approved for use only
in hospital settings to treat specific problems such as status epilepticus (see section, "Are There Special Risks Associated With Epilepsy?"). For people with
stereotyped recurrent severe seizures that can be easily recognized by the
person's family, the drug diazepam is now available as a gel that can be
administered rectally by a family member. This method of drug delivery may be
able to stop prolonged seizures before they develop into status epilepticus.
For most people with epilepsy, seizures can be controlled with just one drug at the optimal dosage. Combining medications usually amplifies side effects such
as fatigue and decreased appetite, so doctors usually prescribe monotherapy, or
the use of just one drug, whenever possible. Combinations of drugs are sometimes prescribed if monotherapy fails to effectively control a patient's
seizures.
The number of times a person needs to take medication each day is usually determined by the drug's half-life, or the time it takes for half the drug dose to be metabolized or broken down into other substances in the body. Some drugs,
such as phenytoin and phenobarbital, only need to be take once a day, while
others such as valproate must be taken more frequently.
Most side effects of anti-epileptic drugs are relatively minor, such as fatigue,
dizziness, or weight gain. However, severe and life-threatening side effects such
as allergic reactions can occur. Epilepsy medication also may predispose people
to developing depression or psychoses. People with epilepsy should consult a
doctor immediately if they develop any king of rash while on medication, or if they
find themselves depressed or otherwise unable to think in a rational manner.
Other danger signs that should be discussed with a doctor immediately are
extreme fatigue, staggering or other movement problems, and slurring of words.
People with epilepsy should be aware that their epilepsy medication can interact
with many other drugs in potentially harmful ways. For this reason, people with
epilepsy should always tell doctors who treat them which medications they are
taking. Women should also know that some anti-epileptic drugs can interfere with
the effectiveness of oral contraceptives, and they should discuss this possibility
with their doctors.
Since people can become more sensitive to medications as they age, they should have their blood levels of medication checked occasionally to see if the
dose needs to be adjusted. The effects of a particular medication also
sometimes wear off over time, leading to an increase in seizures if the dose is
not adjusted. People should know that some citrus fruit, in particular grapefruit juice, may interfere with the breakdown of many drugs. This can cause too much of the drug to build up in their bodies, often worsening the side effects.
Tailoring the Dosage of Anti-epileptic Drugs
When a person starts a new epilepsy drug, it is important to tailor the dosage to
achieve the best results. People's bodies react to medications in very different
and sometimes unpredictable ways, so it may take some time to find the right
drug at the right dose to provide optimal control of seizures while minimizing side
effects. A drug that has no effect or very bad sad effects at one dose may work
very well at another dose. Doctors will usually prescribe a very low dose of the
new drug initially and monitor blood levels of the drug to determine when the best possible dose has been reached.
Generic versions are available for many anti-epileptic drugs. The chemicals in generic drugs are exactly the same as in the brand-name drugs, but they may be absorbed or processed differently in the body because of the way they are
prepared. Therefore, patients should always check with their doctors before
switching to a generic version of their medication.
Discontinuing Medication
Some people will advise people with epilepsy to discontinue their anti-epileptic drugs after two years have passed without a seizure. Others feel it is better to
wait for four to five years. Discontinuing medication should only be done with a
doctor's advice and supervision. It is very important to continue taking epilepsy medication for as long as the doctor prescribes it. People should also ask the doctor or pharmacist ahead of time what they should do if they miss a dose.
Discontinuing medication without a doctor's advice is one of the major reasons people who have been seizure-free begin having new seizures. Seizures that
result from suddenly stopping medication can be very serious and can lead to
status epilepticus. Furthermore, there is some evidence that uncontrolled
seizures trigger changes in neurons that can make it difficult to treat seizures in
the future.
The chance that a person will eventually be able to discontinue medication varies depending on the person's age and his or her type of epilepsy. More than half of children who go into remission with medication can eventually stop their
medication without having new seizures. One study showed that 68 percent of adults who had been seizure-free for 2 years before stopping medication were
able to do so without having more seizures and 75 percent could successfully discontinue medication if they had been seizure-free for at least 3 years.
However, the odds of successfully stopping medication are not as good for people with a family history of epilepsy, those who need multiple medications, those with partial seizures, and those who continue to have abnormal EEG
results while on medication.
Surgery
When seizures cannot be adequately controlled by medications, doctors may
recommend that the person be evaluated for surgery. Most surgery for epilepsy is performed by a team of doctors at medical centres. To decide if a person may
benefit from surgery, doctors consider the type or types of seizures he or she has. They also take into account the brain region involved and how important
that region is for every day behaviour. Surgeons usually avoid operating in areas
of the brain that are necessary for speech, language, hearing, or other important
abilities. Doctors may perform tests such as a WADA test (administration of the
drug amorbarbitol into the carotid artery) to find areas in the brain that control
speech and memory. They often monitor the patient intensively prior to surgery
in order to pinpoint the exact location in the brain where seizures begin. They
may also use implanted electrodes to record brain activity form the surface of the
brain. This yields better information than an external EEG.
A 1990 National Institutes of Health consensus conference on surgery for
epilepsy concluded that there are three broad categories of epilepsy that can be
treated successfully with surgery. These include partial seizures, seizures that
begin as partial seizures before spreading to the rest of the brain, and unilateral
multi-focal epilepsy with infantile hemiplegia (such as Rasmussen's encephalitis).
Doctors generally recommend surgery only after patients have tried two or three
different medications without success, or if there is an identifiable brain lesion - a
damaged or abnormally functioning area - believed to cause the seizures.
If a person is considered a good candidate for surgery and has seizures that cannot be controlled with available medication, experts generally agree that
surgery should be performed as early as possible. It can be difficult for a person who has had years of seizures to fully re-adapt to a seizure-free life if the surgery
is successful. The person may never have had an opportunity to develop independence and he or she may have had difficulties with school and work that
could have been avoided with earlier treatment. Surgery should always be
performed with support from rehabilitation specialists and counselors who can
help the person deal the many psychological, social, and employment issues he or she may face.
While surgery can significantly reduce or even halt seizures for some people, it is important to remember that any kind of surgery carries some amount of risk (usually small). Surgery for epilepsy does not always successfully reduce
seizures and it can result in cognitive or personality changes, even in people who
are excellent candidates for surgery. Patients should ask their surgeons about
his or her experience, success rates, and complication rates with the procedure they are considering.
Even when surgery completely ends a person's seizures, it is important to
continue taking seizure medication for some time to give the brain time to re-
adapt. Doctors generally recommend medication for 2 years after a successful
operation to avoid new seizures.
Seizures to Treat Underlying Conditions
In cases where seizures are caused by a brain tumour, hydrocephalus, or other conditions that can be treated with surgery, doctors may operate to treat these
underlying conditions. In many cases, once the underlying condition is treated
successfully treated, a person's seizures will stop as well.
Surgery to Remove a Seizure Focus
The most common type of surgery for epilepsy is removal of a seizure focus, or
the small area of the brain where seizures originate. This type of surgery, which doctors may refer to as a lobectomy or leisonectomy is appropriate only for
partial seizures that originate in just one area of the brain. In general, people
have a better chance of becoming seizure-free after surgery if they have a small,
well-defined seizure focus. Lobectomies have a 55-70 percent success rate
when the type of epilepsy and the seizure focus is well-defined. The most
common type of lobectomy is a temporal lobe resection, resection leads to a
significant reduction or complete cessation of seizures about 70-90 percent of the time.
Multiple Subpial Transection
When seizures originate in a part of the brain that cannot be removed, surgeons
may perform a procedure called a multiple subpial transection. In this type of
operation, which was first described in 1989, surgeons make a series of cuts that
are designed to prevent seizures from spreading into other parts of the brain while leaving the person's normal abilities intact. About 70 percent of patients
who undergo a multiple subpial transection have satisfactory improvement in seizure control.
Corpus Callosotomy
Corpus callosotomy, or severing the network of neuronal connections between
the right and left halves, or hemispheres, of the brain, is done primarily in
children with severe seizures that start in one half of the brain and spread to the
other side. Corpus callosotomy can end drop attacks and other generalized
seizures. However, the procedure does not stop seizures in the side of the brain where they originate, and these partial seizures may even increase after surgery.
Hemispherectomy
This procedure, which removes half of the brain's cortex, or outer layer, is used
only for children who have Rasmussen's encephalitis or other severe damage to
one brain hemisphere and who also have seizures that do not respond well to
medication. While this type of surgery is very radical and is performed only as a
last resort, children often recover very well from the procedure, and their seizures are usually greatly reduced or may cease altogether. With intense rehabilitation, they often recover nearly normal abilities. Since the chance of a full recovery is best in young children, hemispherectomy should be performed as early in a child's life as possible. It is almost never performed in children older than 13.
Devices
The vagus nerve stimulator was approved by the U.S. Food and Drug
Administration (FDA) in 1997 for use in people with seizures that are not well-
controlled by medication. The vagus nerve stimulator is a battery-powered
device that is surgically implanted under the skin of the chest, much like a
pacemaker, and is attached to the vagus nerve in the lower neck. This device
delivers short bursts of electrical energy to the brain via the vagus nerve. On
average, this stimulation reduces seizures about 20-40 percent. Patients usually
cannot stop taking epilepsy medication because of the stimulator, but they often
experience fewer seizures and they may be able to reduce the dose of their
medication. Side effects of the vagus nerve stimulator are generally mild, but
may include ear pain, a sore throat, or nausea. Adjusting the amount of
stimulation can usually eliminate these side effects. The batteries in the vagus
nerve stimulator need to be replaced about once every 5 years; this requires a
minor operation that can usually be performed as an outpatient procedure.
Several new devices may become available for epilepsy in the future.
Researchers are studying whether transcranial magnetic stimulation, a
procedure which uses a strong magnet held outside the head to influence brain
activity, may reduce seizures. They also hope to develop implantable devices that can deliver drugs to specific parts of the brain.
Diet
Studies have shown that, in some cases, children may experience fewer seizures if they maintain a strict diet rich in fats and low in carbohydrates. This unusual diet, called the ketogenic diet, causes the body to break down fats instead of carbohydrates to survive This condition is called ketosis. One study of 150 children whose seizures were poorly controlled by medication found that about one-fourth of the children had a 90 percent or better decrease in seizures with the ketogenic diet, and another half of the group had a 50 percent or better
decrease in their seizures. Moreover, some children can discontinue the
ketogenic diet after several years and remain seizure-free. The ketogenic diet is
not easy to maintain, as it requires strict adherence to an unusual and limited
range of foods. Possible side effects include retarded growth due to nutritional
deficiency and a build-up of uric acid in the blood, which can lead to kidney
stones. People who try the ketogenic diet should seek the guidance of a dietician
to ensure that it does not lead to serious nutritional deficiency.
Researchers are not sure how ketosis inhibits seizures. One study showed that
a by-product of ketosis called beta-hydro butyrate (BHB) inhibits seizures in
animals. If BHB also works in humans, researchers may eventually be able to
develop drugs that mimic the seizure-inhibiting effects of the ketogenic diet.
Other Treatment Strategies
Researchers are studying whether biofeedback - a strategy in which individuals
learn to control their own brain waves - may be useful in controlling seizures.
However, this type of therapy is controversial and most studies have shown
discouraging results. Taking large does of vitamins generally does not help a
person's seizures and may even be harmful in some cases. However, a good
diet and some vitamin supplements, particularly folic acid, may help reduce some
birth defects and medication-related nutritional deficiencies. Use of non-vitamin
supplements such as melatonin is controversial and can be risky. One study
showed that melatonin may reduce seizures in some children, while another found that the risk of seizures increased measurably with melatonin. Most non-
vitamin supplements, such as those found in health food stores are not regulated
by the FDA, so their true effects and their interactions with other drugs are
largely unknown.
How Does Epilepsy Affect Daily Life?
Most people with epilepsy lead outwardly normal lives. Approximately 80 percent can be significantly helped by modern therapies, and some may go months or years between seizures. However, epilepsy can and does effect daily life or people with epilepsy, their families, and their friends. People with severe seizures that resist treatment have, on average, a shorter life expectancy and an
increase risk of cognitive impairment, particularly if the seizures developed in
early childhood. These impairments may be related to the underlying conditions that cause epilepsy or to epilepsy treatment rather than the epilepsy itself.
Behaviour and Emotions
It is not uncommon for people with epilepsy, especially children, to develop
behavioural and emotional problems. Sometimes these problems are caused by
embarrassment or frustration associated with epilepsy. Other problems may
result from bullying, teasing, or avoidance in school and other social settings. In
children, these problems can be minimized if parents encourage a positive
outlook and independence, do not reward negative behaviour with unusual
amounts of attention, and try to stay attuned to their child's needs and feelings.
Families must learn to accept and live with the seizures without blaming or
resenting the affected person. Counseling services can help families cope with
epilepsy in a positive manner. Epilepsy support groups can also help by
providing a way for people with epilepsy and their family members to share their
experiences, frustrations, and tips for coping with the disorder.
People with epilepsy have an increased risk of poor self-esteem, depression, and suicide. These problems may be a reaction to a lack of understanding or
discomfort about epilepsy that may result in cruelty or avoidance by other people.
Many people with epilepsy also live with the ever-present fear that they will have
another seizure.
Driving and Recreation
For many people with epilepsy, the risk of seizures restricts their independence,
in particular, the ability to drive. Most states and the District of Columbia will not
issue a driver's license to someone with epilepsy unless the person can
document that they have gone a specific amount of time without a seizure (the waiting period varies from a few months to several years). Some states make
exceptions for this policy when seizures don't impair consciousness, occur only
during sleep, or have long auras or other warning signs that allow the person to
avoid driving when a seizure is likely to occur. Studies have shown that the risk
of having a seizure-related accident decreases as the length of time since the
last seizure increases. One study found that the risk of having a seizure-related
motor vehicle accident is 93 percent less in people who wait at least 1 year after
their last seizure before driving, compared to people who wait shorter intervals.
The risk of seizures also restricts people's recreational choices. For instance,
people with epilepsy should not participate in sports such as skydiving or motor racing where at a moment's inattention could lead to injury . Other activities, such as swimming and sailing, should be done only with precautions and/or supervision. However, jogging, football and many other sports are reasonably
safe for a person with epilepsy. Studies to date have not shown any increase in seizures due to sports, although these studies have not focused on any activity in
particular. There is some evidence that regular exercise may even improve
seizure control in some people. Sports are often such a positive factor in life that
it is best for the person to participate, although the person with epilepsy and the
coach or other leader should take appropriate safety precautions. It is important to take steps to avoid potential sports-related problems such as dehydration,
overexertion, and hypoglycemia, as these problems an increase the risk of
seizures.
Education and Employment
By law, people with epilepsy or other handicaps in the United States cannot be
denied employment or access to any educational, recreational, or other activity
because of their seizures. However, one survey showed that only about 56 percent of people with epilepsy finish high school and about 15 percent finish
college - rates much lower than those for the general population. The same
survey found that that about 25 percent of working-age people with epilepsy are
unemployed. These numbers indicate that significant barriers still exist for
people with epilepsy in school and work. Restrictions on driving limit the
employment opportunities for many people with epilepsy, and many find it
difficult to face the misunderstandings and social pressures they encounter in
public situations. Anti-epileptic drugs also may cause side effects that interfere with concentration and memory. Children with epilepsy may need extra time to
complete schoolwork, and they sometimes may need to have instructions or
other information repeated for them. Teachers should be told what told do if a
child in their classroom has a seizure, and parents should work with the school
system to find reasonable ways to accommodate many special needs their child
may have.
Pregnancy and Motherhood
Women with epilepsy are often concerned about whether they can become
pregnant and have a healthy child. This is usually possible. While some seizure
medications and some types of epilepsy may reduce a person's interest in sexual
activity, most people with epilepsy can become pregnant. Moreover, women with
epilepsy have a 90 percent or better chance of having a normal, healthy baby,
and the risk of birth defects is only about 4-6 percent. The risk that children of
parents with epilepsy will develop epilepsy themselves is only about 5 percent
unless the parent has a clearly hereditary form of the disorder. Parents who are worried that their epilepsy may be hereditary may wish to consult a genetic counselor to determine what the risk might be. Amniocentesis and high-level ultrasound can be performed during pregnancy to ensure that the baby is
developing normally, and a procedure called a maternal serum alpha-fetoprotein test can be used for prenatal diagnosis of many conditions if a problem is
suspected.
There are several precautions women can take before and after pregnancy to
reduce the risks associated with pregnancy and delivery. Women who are
thinking about becoming pregnant should talk with their doctors to learn any
special risks associated with their epilepsy and the medications they may be
taking. Some seizure medications, particularly valproate, trimethadione, and
phenytoin, are known to increase the risk of having a child with birth defects such
as cleft palate, heart problems, or finder and toe defects. For this reason, a
women's doctor may advise switching to other medications during pregnancy.
Whenever possible, a woman should allow her doctor enough time to properly
change medications, including phasing in the new medications and checking to
determine when blood levels are stabilized, for she tries to become pregnant.
Women should also begin prenatal vitamin supplements - especially with folic
acid, which may reduce the risk of some birth defects - well before pregnancy.
Women who discover that they are pregnant but have not already spoken with
their doctor about ways to reduce the risks should do so as soon as possible.
However, they should continue taking seizure medication as prescribed until that
time to avoid preventable seizures. Seizures during pregnancy can harm the
developing baby or lead to miscarriage, particularly if the seizures are severe.
Nevertheless, many women who have seizures during pregnancy have normal,
healthy babies.
Women with epilepsy sometimes experience a change in their seizure frequency
during pregnancy, even if they do not change their medications. About 25 to 40
percent of women have an increase in their seizure frequency while they are
pregnant, while other women may have fewer seizures during pregnancy. The
frequency of seizures during pregnancy may be influenced by a variety of factors,
including the woman's increased blood volume during pregnancy, which can
dilute the effect of medication. Women should have their blood levels of seizure
medication monitored closely during and after pregnancy, and the medication
dosage should be adjusted accordingly.
Pregnant women with epilepsy should take prenatal vitamins an get plenty of
sleep to avoid seizures caused by sleep deprivation. They also should take
vitamin K supplements after 34 weeks of pregnancy to reduce the risk of a blood-
clotting disorder in infants called neonatal coagulopathy that can result from fetal
exposure to epilepsy medications. Finally, they should get good prenatal care,
avoid tobacco, caffeine, alcohol, and illegal drugs, and try to avoid stress.
Labour and delivery usually proceed normally for women with epilepsy, although there is a slightly increased risk of hemorrhage, eclampsia, premature labour, and caesarean section. Doctors can administer anti-epileptic drugs intravenously and monitor blood levels of anticonvulsant anti-epileptic drugs during labour to
reduce the risk that the labour will trigger a seizure. Babies sometimes have
symptoms of withdrawal from the mother's seizure medication after they are
born, but these problems wear off in a few weeks or months and usually do not
cause serious long-term effects. A mother's blood levels of anticonvulsant
medications should be checked frequently after delivery as medication often
needs to be decreased.
Epilepsy medications need not influence a women's decision about breast-
feeding her baby. Only minor amounts of epilepsy medications are secreted in
breast milk; usually not enough to harm the baby an much less than the baby
was exposed to in the womb. On rare occasions, they baby may become
excessively drowsy or feed poorly, and these problems should be closely
monitored. However, experts believe the benefits of breast-feeding outweigh the
risks except in rare circumstances.
Women with epilepsy should be aware that some epilepsy medications can
interfere with the effectiveness of oral contraceptives. Women who wish to use
oral contraceptives to prevent pregnancy should discuss this with their doctors,
who may be able to prescribe a different kind of anti-epileptic medication or
suggest other ways of avoiding an unplanned pregnancy.
Are There Special Risks Associated With Epilepsy?
Although most people with epilepsy lead full, active lives, they are at special risk for two life-threatening conditions: status epilepticus and sudden unexplained
death.
Status Epilepticus
Status epilepticus is a severe, life-threatening condition in which a person either
has prolonged seizures or does not fully regain consciousness between seizures. The amount of time in a prolonged seizure must pass before a person should be
diagnosed with status epilepticus is a subject of debate. Many doctors now
diagnose status epilepticus if a person has been in a prolonged seizure for 5
minutes. However, other doctors use more conservative definitions of this
condition and may not diagnose status epilepticus unless the person has had a
prolonged seizure of 10 minutes or even 30 minutes.
Status epilepticus affects about 195,000 people each year in the United States
and results in about 42,000 deaths. While people with epilepsy are at an
increased risk for status epilepticus, about 60 percent of people who develop this condition have no previous seizure history. These cases often result from tumours, trauma, or other problems that affect the brain and may themselves be
life-threatening. While most seizures do no require emergency medical treatment, someone with a prolonged seizure lasting more than 5 minutes may be in status epilepticus and should be taken to an emergency room immediately. It is important to treat a person with status epilepticus as soon as possible. One study showed that 80 percent of people in status epilepticus who received medication within 30 minutes of seizure onset eventually stopped having seizures, whereas only 40 percent recovered if 2 hours had passed before they received medication. Doctors in a hospital setting can treat status epilepticus with several different drugs and can undertake emergency life-saving measures, such as administering oxygen, if necessary.
People in status epilepticus do not always have severe convulsive seizures. Instead, they may have repeated or prolonged nonconvulsive seizures. This type
of status epilepticus may appear as a sustained episode of confusion or agitation
in someone who does not ordinarily have that kind of mental impairment. While this type of episode may not seem as severe as convulsive status epilepticus, it should still be treated as an emergency.
Sudden Unexplained Death
For reasons that are poorly understood, people with epilepsy have an increased risk of dying suddenly for no discernible reason. This condition, called sudden unexplained death, can occur in people without epilepsy, but epilepsy increases
the risk about two-fold. Researchers are still unsure why sudden unexplained
death occurs. One study suggested that use of more than two anticonvulsant
drugs may be a risk factor. However, it is not clear whether the use of multiple
drugs causes the sudden death, or whether people who use multiple
anticonvulsants have a greater risk of death because they have more severe
types of epilepsy.
What Research Is Being Done On Epilepsy?
While research has led to many advances in understanding and treating
epilepsy, there are many unanswered questions about how and why seizures
develop, how they can be treated or prevented, and how they influence other
brain activity and brain development. Researchers, many of whom are
supported by the National Institute of Neurological Disorders and Stroke
(NINDS), are studying all of these questions. They are also working to identify
and test new drugs and other treatments for epilepsy and to learn how those treatments affect brain activity and development. NINDS's Epilepsy Therapeutics Research Program studies potential anti-epileptic drugs with the goal of enhancing treatment for epilepsy. Since it began in 1975, this program has
screened more than 22,000 compounds for their potential as anti-epileptic drugs
and has contributed to the development of five drugs that are now approved for
use in the United States as well as others that are still being developed or tested.
Scientists continue to study how excitatory and inhibitory neurotransmitters
interact with brain cells to control nerve firing. They can apply different chemicals to cultures of neurons in laboratory dishes to study how those chemicals
influence neuronal activity. They are studying how glia and other non-neuronal
cells in the brain contribute to seizures. This research may lead to new drugs
and other new ways of treating seizures.
Researchers are also working to identify genes that may influence epilepsy in
some way. Identifying these genes can reveal the underlying chemical processes that influence epilepsy and point to new ways of preventing or treating
the disorder. Researchers can also study rats and mice that have missing or
abnormal copies of certain genes to determine how these genes affect normal
brain development and resistance to damage from disease and other
environmental factors. Researchers may soon be able to use devices that called
gene chips to determine each person's genetic makeup or to learn which genes
are active. This information may allow doctors to prevent epilepsy or to predict which treatments will be most beneficial.
Doctors are now experimenting with several new types of therapies for epilepsy. In one preliminary clinical trial, doctors have begun transplanting fetal pig neurons that produce GABA into the brains of patients to learn whether the cell
transplants can help control seizures. Preliminary research suggests that the
stem cell transplants also may prove beneficial for treating epilepsy. Research
showing that the brain undergoes subtle changes prior to a seizure has led to a
prototype device that may be able to predict seizures up to 3 minutes before they
begin. If this device works, it could greatly reduce the risk of injury from seizures
by allowing people to move to a safe area before seizures start. This type of
device also may be hooked up to a treatment pump or other device that will
automatically deliver an anti-epileptic drug or an electric impulse to forestall the
seizures.
Researchers are continually improving MRI and other brain scans. Pre-surgical
brain imaging can guide doctors to abnormal brain tissue and away from
essential parts of the brain. Researchers also are using brain scans such as
magneto encephalograms (MEG) and magnetic resonance spectroscopy (MRS)
to identify and study subtle problems in the brain that cannot otherwise be
detected. Their findings may lead to a better understanding of epilepsy and how it can be treated.
How Can I Help Research On Epilepsy?
There are many ways that people with epilepsy and their families can help with
research on this disorder. Pregnant women with epilepsy who are taking
anti-epileptic drugs can help researchers learn how these drugs affect unborn
children. People with epilepsy that may be hereditary can aid research by
participating in the Epilepsy Gene Discovery Program, which is supported by the
Epilepsy Foundation. This project helps to educate people with epilepsy about
new genetic research. People who enroll in this project are asked to create a family tree showing which people in their family have or have had epilepsy.
Researchers then examine this information to determine if the epilepsy is in fact
hereditary, and then they may invite participants to enroll in genetic research
studies. In many cases, identifying the gene defect responsible for epilepsy in an
individual family leads researchers to new clues about how epilepsy develops. It
can also provide opportunities for early diagnosis and genetic screening of
individuals in the family.
People with epilepsy can help researchers test new medications, surgical
techniques, and other treatments by enrolling in clinical trials. Information on
clinical trials can be obtained from the NINDS as well a many private
pharmaceutical and biotech companies, universities, and other organizations. A
person who wishes to participate in a clinical trial must ask his or her regular
physician to refer him or her to the doctor in charge of that trial and to forward all
necessary medial records. While experimental therapies may benefit those who
participate in clinical trials, patients and their families should remember that all
clinical trials also involve some risks. Therapies being tested in clinical trails may
not work, and in some cases doctors may not yet be certain that the therapies
are safe. Patients should be certain they understand the risks before agreeing to
participate in a clinical trial.
Patients and their families an also help epilepsy research by donating their brain
to a brain tank after death. Brain tanks supply researchers with tissue they can
use to study epilepsy and other disorders.
What To Do If You See Someone Having A Seizure
If you see someone having a seizure with convulsions and/or a loss of
consciousness, here's how you can help:
1. Roll the person on his or her side to prevent choking on any fluids or
vomit.
2. Cushion the person's head.
3. Loosen any tight clothing around the neck.
4. Keep the person's airway open. If necessary, grip the person's jaw
gently and tilt his or her head back.
5. Do NOT restrict the person from moving unless he or she is in danger
6. Do NOT put anything into the person's mouth, not even medicine or
liquid. These can cause choking or damage to the person's jaw,
tongue, or teeth. Contrary to widespread belief, people cannot swallow
their tongue during a seizure or any other time.
7. Remove any sharp or solid objects that the person might hit during the
seizure.
8. Note how long the seizure lasts and what symptoms occurred so you
can tell a doctor or emergency personnel if necessary.
9. Stay with the person until the seizure ends.
Call 911 if:
• The person is pregnant or has diabetes.
• The seizure happened in water.
• The seizure lasts longer than 5 minutes.
• The person does not begin breathing again and return to
consciousness after the seizure stops.
• Another seizure starts before the person regains
consciousness.
• The person injures himself or herself during the seizure.
• This is a first seizure or you think it might be. If in doubt, check
to see if the person has medical identification card or jewelry
stating that they have epilepsy or a seizure disorder.
After the seizure ends, the person will probably be groggy and tired. He or she
may also have a headache and be confused or embarrassed. Be patient with the
person and try to help him or her find a place to rest if he or she is tired or doesn't feel well. If necessary, offer to call a taxi, a friend, or a relative to help the person get home safely.
If you see someone having a non-convulsive seizure, remember that the
person's behaviour is not intentional. The person may wander aimlessly or make alarming or unusual gestures. You can help by following these guidelines:
1. Remove any dangerous objects from the area around the
person or in his or her path.
2. Don't try to stop the person from wandering unless he or she is
in danger.
3. Don't shake the person or shout.
4. Stay with the person until he or she is completely alert.
Conclusion
Many people with epilepsy lead productive and outwardly normal lives. Many medical and research advances in the past two decades have lad to a better
understanding of epilepsy and seizures than ever before. Advanced brain scans and other techniques allow greater accuracy in diagnosing epilepsy and determining when a patient may be helped by surgery. More than 20 different
medications and a variety of surgical techniques are now available and provide good control of seizures for most people with epilepsy. Other treatment options
include the ketogenic diet and the first implantable device, the vagus nerve
stimulator. Research on the underlying causes of epilepsy, including
identification of genes for some forms of epilepsy and febrile seizures, has led to
a greatly improved understanding of epilepsy that may lead to more effective treatments or even new ways of preventing epilepsy in the future.
