Epilepsy: Fact, Causes, Treatment options and Coping Strategy

Epilepsy is a central nervous system disorder (neurological disorder) in which the nerve cell activity in your brain is disturbed, causing a seizure during which you experience abnormal behavior, symptoms and sensations, including loss of consciousness.

Seizure symptoms vary. Some people with epilepsy simply stare blankly for a few seconds during a seizure, while others repeatedly twitch their arms or legs.

About 1 in 100 people in the United States may have an unprovoked seizure once in life. However, a solitary seizure doesn't mean you have epilepsy. At least two unprovoked seizures are generally required for an epilepsy diagnosis.

Even mild seizures may require treatment because they can be dangerous during activities such as driving or swimming. Treatment, which generally includes medications or sometimes surgery, may eliminate or reduce the frequency and intensity of seizures. Some children with epilepsy even outgrow the condition with age.

Symptoms

Because epilepsy is caused by abnormal activity in brain cells, seizures can affect any process your brain coordinates. A seizure can produce symptoms such as:

• Temporary confusion
• A staring spell
• Uncontrollable jerking movements of the arms and legs
• Loss of consciousness or awareness
• Psychic symptoms

Symptoms vary depending on the type of seizure. In most cases, a person with epilepsy will tend to have the same type of seizure each time, so the symptoms will be similar from episode to episode.

Doctors generally classify seizures as either focal or generalized, based on how the abnormal brain activity begins.

Focal seizuresWhen seizures appear to result from abnormal activity in just one area of your brain, they're called focal (partial) seizures. These seizures fall into two categories.

• Simple focal seizures. These seizures don't result in loss of consciousness. They may alter emotions or change the way things look, smell, feel, taste or sound. They may also result in involuntary jerking of a body part, such as an arm or leg, and spontaneous sensory symptoms such as tingling, dizziness and flashing lights.
• Dyscognitive focal seizures. These seizures alter consciousness or awareness and may cause you to lose awareness for a period of time. Dyscognitive focal seizures often result in staring and purposeless movements — such as hand rubbing, chewing, swallowing or walking in circles.

Generalized seizuresSeizures that appear to involve all areas of the brain are called generalized seizures. Six types of generalized seizures exist.

• Absence seizures. Absence seizures, also called petit mal seizures, are characterized by staring and subtle body movement. These seizures can cause a brief loss of awareness.
• Tonic seizures. Tonic seizures cause stiffening of your muscles. These seizures usually affect muscles in your back, arms and legs and may cause you to fall to the ground.
• Clonic seizures. Clonic seizures are associated with rhythmic, jerking muscle movements. These seizures usually affect the neck, face and arms.
• Myoclonic seizures. Myoclonic seizures usually appear as sudden brief jerks or twitches of your arms and legs.
• Atonic seizures. Atonic seizures, also known as drop seizures, cause a loss of muscle control, which may cause you to suddenly collapse or fall down.
• Tonic-clonic seizures. Tonic-clonic seizures, also called grand mal seizures, are characterized by a loss of consciousness, body stiffening and shaking, and sometimes loss of bladder control or biting your tongue.

When to see a doctorSeek immediate medical help if any of the following occurs:

• The seizure lasts more than five minutes.
• Breathing or consciousness doesn't return after the seizure stops.
• A second seizure follows immediately.
• You have a high fever.
• You're experiencing heat exhaustion.
• You're pregnant.
• You have diabetes.
• You've injured yourself during the seizure.

If you experience a seizure for the first time, seek medical advice.

Causes

Epilepsy has no identifiable cause in about half of those with the condition. In about half the people with epilepsy, the condition may be traced to various factors.

• Genetic influence. Some types of epilepsy, which are categorized by the type of seizure you experience, run in families. In these cases, it's likely that there's a genetic influence.
  Researchers have linked some types of epilepsy to specific genes, though it's estimated that up to 500 genes could be tied to the condition. For most people, genes are only part of the cause of epilepsy. Certain genes may make a person more sensitive to environmental conditions that trigger seizures.
• Head trauma. Head trauma that occurs due to a car accident or other traumatic injury can cause epilepsy.
• Brain conditions. Brain conditions that result in damage to the brain, such as brain tumors or strokes, also can cause epilepsy. Stroke is a leading cause of epilepsy in adults older than age 35.
• Infectious diseases. Infectious diseases, such as meningitis, AIDS and viral encephalitis, can cause epilepsy.
• Prenatal injury. Before birth, babies are sensitive to brain damage that could be caused by several factors, such as an infection in the mother, poor nutrition or oxygen deficiencies. This brain damage can result in epilepsy or cerebral palsy.
• Developmental disorders. Epilepsy can sometimes be associated with developmental disorders, such as autism and neurofibromatosis.

Risk factors

Certain factors may increase your risk of epilepsy.

• Age. The onset of epilepsy is most common during early childhood and after age 60, but the condition can occur at any age.
• Family history. If you have a family history of epilepsy, you may be at an increased risk of developing a seizure disorder.
• Head injuries. Head injuries are responsible for some cases of epilepsy. You can reduce your risk by wearing a seat belt while riding in a car and by wearing a helmet while bicycling, skiing, riding a motorcycle or engaging in other activities with a high risk of head injury.
• Stroke and other vascular diseases. Stroke and other blood vessel (vascular) diseases can lead to brain damage that may trigger epilepsy. You can take a number of steps to reduce your risk of these diseases, including limiting your intake of alcohol and avoiding cigarettes, eating a healthy diet, and exercising regularly.
• Dementia. Dementia can increase the risk of epilepsy in older adults.
• Brain infections. Infections such as meningitis, which causes inflammation in your brain or spinal cord, can increase your risk.
• Seizures in childhood. High fevers in childhood can sometimes be associated with seizures. Children who have seizures due to high fevers generally won't develop epilepsy, although the risk is higher if they have a long seizure, other nervous system conditions or a family history of epilepsy.

Complications

Having a seizure at certain times can lead to circumstances that are dangerous to yourself or others.

• Falling. If you fall during a seizure, you can injure your head or break a bone.
• Drowning. If you have epilepsy, you're 15 to 19 times more likely to drown while swimming or bathing than is the rest of the population because of the possibility of having a seizure while in the water.
• Car accidents. A seizure that causes either loss of awareness or control can be dangerous if you're driving a car or operating other equipment.
  Many states have driver's-licensing restrictions related to your ability to control seizures and impose a minimum amount of time that you've been seizure-free, ranging from months to years, before you're allowed to drive.
• Pregnancy complications. Seizures during pregnancy pose dangers to both mother and baby, and certain anti-epileptic medications increase the risk of birth defects. If you have epilepsy and you're considering becoming pregnant, talk to your doctor as you plan your pregnancy.
  Most women with epilepsy can become pregnant and have a healthy baby. You'll need to be carefully monitored throughout pregnancy, and medications may need to be adjusted. It's very important that you work with your doctor to plan your pregnancy.
• Emotional health issues. People with epilepsy are more likely to have psychological problems, especially depression, anxiety and, in extreme cases, suicide. Problems may be a result of difficulties from dealing with the condition itself as well as medication side effects.

Other life-threatening complications from epilepsy are uncommon, but do occur.

• Status epilepticus. This condition occurs if you're in a state of continuous seizure activity lasting more than five minutes, or if you have frequent recurrent seizures without regaining full consciousness in between them. People with status epilepticus have an increased risk of permanent brain damage and death.
• Sudden unexplained death in epilepsy (SUDEP). People with epilepsy also have a small risk of sudden unexplained death. The cause is unknown, but some research shows it may occur due to heart or respiratory conditions.
  People with frequent generalized tonic-clonic seizures or people whose seizures aren't controlled by medications may be at higher risk of SUDEP. Overall, about 2 to 18 percent of people with epilepsy die of SUDEP.

Preparing for your appointment

You're likely to start by seeing your family doctor or a general practitioner. However, in some cases when you call to set up an appointment, you may be referred immediately to a specialist, such as a doctor trained in brain and nervous system conditions (neurologist) or a neurologist trained in epilepsy (epileptologist).

Because appointments can be brief, and because there's often a lot to talk about, it's a good idea to be well prepared for your appointment. Here's some information to help you get ready for your appointment, and what to expect from your doctor.

What you can do

• Keep a detailed seizure calendar. Each time a seizure occurs, write down the time, the type of seizure you experienced and how long it lasted. Also make note of any circumstances, such as missed medications, sleep deprivation, increased stress, menstruation or other events that might trigger seizure activity.
  Seek input from people who may observe your seizures, including family, friends and co-workers, so that you can record information you may not know.
• Be aware of any pre-appointment restrictions. At the time you make the appointment, ask if there's anything you need to do in advance, such as restrict your diet.
• Write down key personal information, including any major stresses or recent life changes.
• Make a list of all medications, vitamins or supplements that you're taking.
• Take a family member or friend along. Sometimes it can be difficult to remember all the information provided to you during an appointment. Someone who accompanies you may remember something that you missed or forgot.
  Also, because you may not be aware of everything that happens when you're having a seizure, your doctor may want to ask questions of someone who has witnessed them.
• Write down questions to ask your doctor.

Preparing a list of questions will help you make the most of your time with your doctor. List your questions from most important to least important in case time runs out. For epilepsy, some basic questions to ask your doctor include:

• What is likely causing my seizures?
• What kinds of tests do I need?
• Is my epilepsy likely temporary or chronic?
• What is the best course of action?
• What are the alternatives to the primary approach that you're suggesting?
• How can I ensure that I don't hurt myself if I have another seizure?
• I have these other health conditions. How can I best manage them together?
• Are there any restrictions that I need to follow?
• Should I see a specialist? What will that cost, and will my insurance cover it?
• Is there a generic alternative to the medicine you're prescribing?
• Are there any brochures or other printed material that I can take home with me? What websites do you recommend?

In addition to the questions that you've prepared to ask your doctor, don't hesitate to ask questions during your appointment at any time that you don't understand something.

What to expect from your doctorYour doctor is likely to ask you a number of questions:

• When did you first begin experiencing seizures?
• Do your seizures seem to be triggered by certain events or conditions?
• Do you have similar sensations just before the onset of a seizure?
• Have your seizures been frequent or occasional?
• What symptoms do you have when you experience a seizure?
• What, if anything, seems to improve your seizures?
• What, if anything, appears to worsen your seizures?

What you can do in the meantimeCertain conditions and activities can trigger seizures, so it may benefit you to:

• Avoid excessive alcohol consumption
• Avoid nicotine usage
• Get enough sleep
• Reduce stress

Also, it's important to start keeping a log of your seizures before you visit your doctor.

Tests and diagnosis

To diagnose your condition, your doctor will review your symptoms and medical history. Your doctor may order several tests to diagnose epilepsy and determine the cause of seizures.

• Neurological examination. Your doctor may test your behavior, motor abilities, mental function and other areas to diagnose your condition and determine the type of epilepsy you may have.
• Blood tests. Your doctor may take a blood sample to check for signs of infections, genetic conditions or other conditions which may be associated with seizures.

Your doctor may also suggest tests to detect brain abnormalities, such as:

• Electroencephalogram (EEG). This is the most common test used to diagnose epilepsy. In this test, doctors attach electrodes to your scalp with a paste-like substance. The electrodes record the electrical activity of your brain.
If you have epilepsy, it's common to have changes in your normal pattern of brain waves, even when you're not having a seizure. Your doctor may monitor you on video while conducting an EEG while you're awake or asleep, to record any seizures you may experience. Recording the seizures may help the doctor determine what kind of seizures you're having or rule out other conditions.
Your doctor may give you instructions to do something that will cause seizures, such as getting little sleep prior to the test.
• Computerized tomography (CT) scan. A CT scan uses X-rays to obtain cross-sectional images of your brain. CT scans can reveal abnormalities in your brain that might be causing your seizures, such as tumors, bleeding and cysts.
• Magnetic resonance imaging (MRI). An MRI uses powerful magnets and radio waves to create a detailed view of your brain. Your doctor may be able to detect lesions or abnormalities in your brain that could be causing your seizures.
• Functional MRI (fMRI). A functional MRI measures the changes in blood flow that occur when specific parts of your brain are working. Doctors may use an fMRI before surgery to identify the exact locations of critical functions, such as speech and movement, so that surgeons can avoid injuring those places while operating.
• Positron emission tomography (PET). PET scans use a small amount of low-dose radioactive material that's injected into a vein to help visualize active areas of the brain and detect abnormalities.
• Single-photon emission computerized tomography (SPECT). This type of test is used primarily if you've had an MRI and EEG that didn't pinpoint the location in your brain where the seizures are originating.
A SPECT test uses a small amount of low-dose radioactive material that's injected into a vein to create a detailed, 3-D map of the blood flow activity in your brain during seizures.
Doctors also may conduct a form of a SPECT test called subtraction ictal SPECT coregistered to magnetic resonance imaging (SISCOM), which may provide even more detailed results.
• Neuropsychological tests. In these tests, doctors assess your thinking, memory and speech skills. The test results help doctors determine which areas of your brain are affected.

Treatments and drugs

Doctors generally begin by treating epilepsy with medication. If medications don't treat the condition, doctors may propose surgery or another type of treatment.

MedicationMost people with epilepsy can become seizure-free by taking one anti-seizure medication, called anti-epileptic medication. Others may be able to decrease the frequency and intensity of their seizures by taking medications. Your doctor will advise you about the appropriate time to stop taking medications.

More than half the children with epilepsy who aren't experiencing epilepsy symptoms can eventually discontinue medications and live a seizure-free life. Many adults also can discontinue medications after two or more years without seizures.

Finding the right medication and dosage can be complex. Your doctor will consider your condition, frequency of seizures, your age and other factors when choosing which medication to prescribe. Your doctor will also review any other medications you may be taking, to ensure the anti-epileptic medications won't interact with them.

Your doctor likely will first prescribe a single medication at a relatively low dosage and may increase the dosage gradually until your seizures are well controlled.

Anti-seizure medications may have some side effects. Mild side effects include:

• Fatigue
• Dizziness
• Weight gain
• Loss of bone density
• Skin rashes
• Loss of coordination
• Speech problems
• Memory and thinking problems

More severe but rare side effects include:

• Depression
• Suicidal thoughts and behaviors
• Severe rash
• Inflammation of certain organs, such as your liver

To achieve the best seizure control possible with medication:

• Take medications exactly as prescribed.
• Always call your doctor before switching to a generic version of your medication or taking other prescription medications, over-the-counter drugs or herbal remedies.
• Never stop taking your medication without talking to your doctor.
• Notify your doctor immediately if you notice new or increased feelings of depression, suicidal thoughts, or unusual changes in your mood or behaviors.
• Tell your doctor if you have migraines. Doctors may prescribe one of the anti-epileptic medications that can prevent your migraines and treat epilepsy.

At least half of all people newly diagnosed with epilepsy will become seizure-free with their first medication. If anti-epileptic medications don't provide satisfactory results, your doctor may suggest surgery or other therapies. You'll have regular follow-up appointments with your doctor to evaluate your condition and medications.

SurgerySurgery is most commonly done when tests show that your seizures originate in a small, well-defined area of your brain that doesn't interfere with vital functions like speech, language, motor function, vision or hearing. In surgery, your doctor removes the area of your brain that's causing the seizures.

If your seizures originate in an area of the brain that controls movement, speech and other functions, you may be awake during part of the surgery. Doctors will monitor you and ask you questions during the procedure.

If your seizures originate in a part of your brain that can't be removed, your doctor may recommend a different type of surgery in which surgeons make several cuts in your brain (multiple subpial transection). These cuts are designed to prevent seizures from spreading to other parts of your brain.

Although many people continue to need some medication to help prevent seizures after successful surgery, you may be able to take fewer drugs and reduce your dosages.

In a small number of cases, surgery for epilepsy can cause complications such as permanently altering your thinking (cognitive) abilities. Talk to your surgeon about his or her experience, success rates and complication rates with the procedure you're considering.

Therapies

• Vagus nerve stimulation. In vagus nerve stimulation, doctors implant a device called a vagus nerve stimulator underneath the skin of your chest, similar to a heart pacemaker. Wires from the stimulator are connected to the vagus nerve in your neck.
The battery-powered device sends bursts of electrical energy through the vagus nerve and to your brain. It's not clear how this inhibits seizures, but the device can usually reduce seizures by 20 to 40 percent.
Most people still need to take anti-epileptic medication, although some people may be able to lower their medication dose. You may experience side effects from vagus nerve stimulation, such as throat pain, hoarse voice, shortness of breath or coughing.
• Ketogenic diet. Some children with epilepsy have been able to reduce their seizures by following a strict diet that's high in fats and low in carbohydrates.
  In this diet, called a ketogenic diet, the body breaks down fats instead of carbohydrates for energy. After a few years, some children may be able to stop the ketogenic diet and remain seizure-free.
  Consult a doctor if you or your child is considering a ketogenic diet. It's important to make sure that your child doesn't become malnourished when taking the diet.
  Side effects of a ketogenic diet may include dehydration, constipation, slowed growth because of nutritional deficiencies, and buildup of uric acid in the blood, which can cause kidney stones. These side effects are uncommon if the diet is properly and medically supervised.

Potential future treatmentsResearchers are studying brain stimulation as a potential treatment for epilepsy. In brain stimulation, surgeons implant electrodes into a specific part of your brain. The electrodes are connected to a generator implanted in your chest or the skull that sends electrical pulses to your brain and may reduce your seizures.

Researchers also study stereotactic radiosurgery as a potential treatment for some types of epilepsy. In this procedure, doctors direct radiation at the specific area of your brain that is causing your seizure.

Lifestyle and home remedies

Understanding your condition can help you control it.

• Take your medication correctly. Don't adjust your dosage levels before talking to your doctor. If you feel your medication should be changed, discuss it with your doctor.
• Get enough sleep. Lack of sleep can trigger seizures. Be sure to get adequate rest every night.
• Wear a medical alert bracelet. This will help emergency personnel know how to treat you correctly.
• Exercise. Exercising may help keep you physically healthy and reduce depression. Make sure to drink enough water and rest if you get tired during exercise.

In addition, make healthy life choices such as managing stress, limiting alcoholic beverages and avoiding cigarettes.

Coping and support

Uncontrolled seizures and their effect on your life may at times feel overwhelming or lead to depression. It's important not to let epilepsy hold you back. You can still live an active, full life. To help cope:

• Educate yourself and your friends and family about epilepsy so that they understand the condition.
• Try to ignore negative reactions from people. It helps to learn about epilepsy so that you know the facts as opposed to misconceptions about the disease. And try to keep your sense of humor.
• Live as independently as possible. Continue to work, if possible. If you can't drive because of your seizures, investigate public transportation options near you. If you aren't allowed to drive, you may want to consider moving to a city with good public transportation options.
• Find a doctor you like and with whom you feel comfortable.
• Try not to constantly worry about having a seizure.
• Find an epilepsy support group to meet people who understand what you're going through.

If your seizures are so severe that you can't work outside your home, there are still ways to feel productive and connected to people. You may consider working from home, through working on a computer.

Let people you work and live with know the correct way to handle a seizure in case they are with you when you have one. You may offer them suggestions, such as:

• Carefully roll the person onto one side.
• Place something soft under his or her head.
• Loosen tight neckwear.
• Don't try to put your fingers or anything else in the person's mouth. No one has ever "swallowed" his or her tongue during a seizure — it's physically impossible.
• Don't try to restrain someone having a seizure.
• If the person is moving, clear away dangerous objects.
• Stay with the person until medical personnel arrive.
• Observe the person closely so that you can provide details on what happened.
• Time the seizures.
• Be calm during the seizures.

Source: Mayo Foundation for Medical Education and Reasearch