Epilepsy

Epilepsy Overview

Epilepsy is a neurological condition defined by spontaneous, repeated seizures that happen as a result of abnormal electrical impulses in the brain.

The two most prominent types of epileptic seizures are generalized seizures and focal or partial seizures. Generalized seizures are when abnormal electrical impulses “storm” or spread through the brain on both sides. In contrast, focal or partial seizures happen when abnormal electrical impulses are limited to one side of the brain.

How a seizure looks depends on the type of seizure someone is having—in fact, there are more than 30 different types of epileptic seizures. While some can look as harmless as a staring spell, others can cause a person to collapse, shake, and become unaware of what’s happening around them.

Epilepsy is a chronic condition that requires regular monitoring and care. While there’s no cure, the condition is often well-managed with medication and supplemental treatments.

What causes epilepsy?

Many factors can contribute to epilepsy, like:

• A traumatic brain injury (TBI) or other head trauma
• Brain scarring after a brain injury, known as post-traumatic epilepsy
• A brain tumor or cyst
• Stroke, heart attacks, and conditions that deprive the brain of oxygen
• Serious illness or a very high fever
• A lack of oxygen to the brain
• Dementia, including Alzheimer’s disease

It’s not always easy to tell when someone is having a seizure—they can look like they’re staring at something that isn’t there, or seem unusually confused or unresponsive. Other, stronger seizures can cause a person to fall, spasm, or have uncontrollable muscle twitching. Seizures can last just a few seconds or several minutes, and after they happen, there may be no memory of them happening.

Auras and Epilepsy

Many people with epilepsy experience warning signs before a seizure, known as an aura. An aura can actually be helpful to someone diagnosed with epilepsy because it allows them to prepare themselves and, ideally, prevent injury.

An aura can include a change in vision, hearing, or taste. It can be a steady or flashing light, a color, or a shape in a person’s field of vision. It might be a specific feeling in the stomach or a strong emotion that comes “out of the blue,” like feeling fearful or a sense of de ja vu. It may be a particular or unusual smell or a feeling of dizziness. Some people with epilepsy might even see things that aren’t there in the form of a hallucination.

Not everyone with epilepsy will experience auras, and their nature can vary from person to person, or even from one seizure to another in the same individual.

What to Do When Someone is Having a Seizure

It’s important to know that a seizure can’t be stopped once it’s in progress and, thankfully, that most seizures don’t require emergency medical attention.

When you’re with somebody having a mild seizure, it’s critical you:

• Stay with the person until their seizure ends and they’re awake.
• Check for a medical bracelet.
• Speak calmly, stay calm, and try to keep others calm.
• Once they’re awake, guide the person to a safe place and tell them about what happened.
• Offer to help them get home safely

Epilepsy Diagnosis

Epilepsy is usually diagnosed after someone experiences two or more seizures at least 24 hours apart that have no other identifiable cause.

While a physical examination and complete medical history can be enough to indicate epilepsy, diagnostic tests can provide a more complete conclusion and help inform treatment. These tests include:

• Imaging: A computed tomography (CT) scan or magnetic resonance imaging (MRI) can identify whether brain abnormalities, like a lesion or tumor, are responsible for your seizures.
• Electroencephalography: Electroencephalography (EEG), the most common test for diagnosing epilepsy, records the electrical activity in the brain through electrodes on the scalp and then uses that data to look for abnormal patterns in brain waves.
• Magnetoencephalography: Magnetoencephalography (MEG) is a brain-mapping technique that measures the magnetic field generated by nerve cells’ electrical activity and can help identify where in the brain seizures originate. Barrow is home to the only MEG device in Arizona. 
• Neuropsychological Evaluation: Because people with epilepsy often experience cognitive difficulties—problems with memory, understanding spatial patterns, or language functions—a neuropsychological examination helps explain those difficulties by identifying a seizure focus. For example, people with left temporal lobe epilepsy will commonly show a different pattern of results on these tests than those with right temporal lobe epilepsy.

Epilepsy Monitoring Unit

In the case of epilepsy that’s difficult to diagnose and treat, or if you are considering epilepsy surgery, admission to an inpatient epilepsy monitoring unit (EMU) is recommended. This allows epilepsy specialists to perform an in-depth evaluation over an extended period.

During inpatient monitoring, brain wave patterns and physical activity are observed 24 hours a day using simultaneous EEG and audio/video monitoring. This information is then used to evaluate and diagnose seizure activity, create a treatment plan, and coordinate ongoing care.

If you have epilepsy that’s not well-controlled with medication, or if multiple medications’ side effects are overwhelming, you may be eligible for other treatments, such as:

• Epilepsy surgery (including minimally invasive procedures and laser-based approaches)
• Deep brain stimulation (DBS)
• Vagal nerve stimulation (VNS)
• Responsive neurostimulation (RNS)
• Dietary modifications

Medications

Finding not only the right medication, but the correct dose can significantly improve your epilepsy prognosis. While some may respond well to their first medication, others may need to try multiple medications—or combinations of medications—to provide enough seizure control or relief.

Antiepileptic medications, or anticonvulsants, are usually first-in-line treatment for epilepsy. These medications stabilize your brain’s electrical activity while reducing the likelihood of seizures. Choosing the right medication requires careful discussion with your healthcare team and careful monitoring over time to ensure you experience relief from your symptoms with minimal side effects. 

Commonly used antiseizure medications include:

• Carbamazepine / Tegretol / Carbatrol / Tegretol XR:
• Clobazam / Onfi
• Gabapentin / Neurontin
• Lacosamide / Vimpat
• Lamotrigine / Lamictal / Lamictal XR
• Levetiracetam / Keppra / Keppra XR / Roweepra / Roweepra XR / Spritam
• Oxcarbazepine / Trileptal / Oxtellar XR
• Pregabalin / Lyrica
• Topiramate / Topamax / Trokendi XR / Qudexy
• Valproate / Depakote / Depakote ER / Depakene
• Zonisamide / Zonegran
• Brivaracetam / Briviact

Less commonly used antiseizure medications include:

• Acetazolamide / Diamox
• Cannabidiol / Epidiolex
• Cenobamate / Xcopri
• Clonazepam / Klonopin
• Clorazepate /Tranxene
• Eslicarbazepine / Aptiom
• Ethosuximide / Zarontin
• Felbamate /Felbatol
• Fenfluramine
• Perampanel / Fycompa
• Phenobarbital / Mysoline
• Phenytoin / Dilantin / Phenytek
• Primidone / Mysoline
• Rufinamide / Banzel
• Stiripentol / Diacomit
• Tiagabine / Gabitril
• Vigabatin / Sabril
• Perampanel / Fycompa

For seizures that don’t respond well to medication therapy, specialty care from an epilepsy team will be recommended. This multidisciplinary epilepsy team can include:

• EEG Technologists
• Neurologists / Epileptologists
• Neuropsychiatrists
• Neuropsychologists
• Neuroscience Nurses
• Neurosurgeons
• Research Nurses
• Social Workers

Specialty care is also recommended for those who are pregnant or who have considerable comorbidities, like depression and anxiety.

Surgery

While surgery is not usually the first line of treatment for epilepsy, your care team might consider epilepsy surgery if you meet the following criteria:

• Seizures not controlled by medication: For most people, this means a trial of at least two medications that are appropriate for the type of seizure and used in adequate doses.
• Intolerable medication side effects: If your epilepsy medications produce symptoms that interfere with your ability to live normally, then epilepsy surgery might be an option.
• Identifiable Epileptic Focus: For epilepsy surgery to be successful, a single spot or region in the brain can be identified as causing the seizures.
• Operable Epileptic Focus: The region causing the seizures must be accessible without causing harm or loss of essential functions such as speech or movement for surgery to proceed.

That said, surgery to treat epilepsy is not always possible—for example, neurosurgeons rarely advise surgery for generalized epilepsy, where both sides of the brain are involved.

Vagal Nerve Stimulation (VNS)

This treatment involves a pacemaker-like device that’s implanted under the skin of the chest and attached by a wire to the vagus nerve in the neck. The device sends mild pulses of electrical activity to the brain via the vagus nerve, which can help regulate the abnormal electrical activity causing seizures.

Deep Brain Stimulation (DBS)

Deep brain stimulation (DBS) involves electrodes implanted in an area of the brain, then connected to a pacemaker-like device called a pulse generator that creates electrical impulses in the affected area of the brain. As of 2018, DBS has been FDA-approved for patients over 18 years of age with focal onset seizures who have also failed to respond to three or more antiepileptic medications.

Dietary Treatments

A ketogenic (or similar) diet can be used along with medications to help manage epilepsy in children and adolescents, monitored by a physician and dietitian. The ketogenic diet is a high-fat, low-carbohydrate diet that creates a state of ketosis, and in this state, the body uses fats (ketones) for energy rather than carbohydrates. Why the brain responds this way to the ketogenic diet is not fully understood.

Women and Epilepsy

Women diagnosed with epilepsy can face an extra set of challenges, as cyclical fluctuations in hormones can trigger more seizures, especially during menstruation.

There are also specific considerations when it comes to pregnancy, as certain antiseizure medications can increase the risk of fetal harm. Communication with your healthcare team is vital to track progress, adjust treatment plans as needed, and address changes in condition.