Epilepsy

About epilepsy

Epilepsy is a common condition of the brain in which a person has a tendency to have recurrent unprovoked seizures.

The brain controls the body’s thoughts, actions, sensations and emotions through nerve cells (neurones) that carry messages between the brain and the body. These messages are transmitted through regular electrical impulses. A seizure occurs when the normal pattern of these impulses is disrupted by sudden excessive bursts of electrical activity in the brain.

The kind of seizure and how the body is affected relates to the part of the brain in which the seizure occurs. Seizures can involve loss of consciousness, a range of unusual movements, odd feelings and sensations, or changed behaviours.

Many people have seizures that are not diagnosed as epilepsy. These seizures often have a known cause or provocation and will not occur again unless the same provoking situation occurs. An example of this is febrile convulsions seen in infants.

The likelihood of being diagnosed with epilepsy at some point in life is about 3 per cent.

The main treatment for epilepsy is medication, which can control seizures in about 70 per cent of people with epilepsy. Surgery and other treatment options may be a possibility for a small number of people if medication fails to control their seizures.

Seizure types

There are many different types of seizures. Many people think a ‘seizure’ means a convulsion, where someone becomes unconscious and falls, with stiffness and jerking. However, this is just one type of seizure, and is called a tonic-clonic seizure (previously known as grand mal).

Some people may have episodes where they ‘go blank’ for a few seconds, while others remain fully conscious during a seizure and can describe their experience. For many, consciousness is impaired, and they may be confused and disorientated during and after the seizure.

A seizure may involve both sides of the brain (generalised onset seizure) or a small part of the brain (focal onset seizure). Sometimes seizures start as one type and evolve into another. Some people can have more than one seizure type.

Generalised onset seizures

These seizures begin in both hemispheres of the brain simultaneously. There are several types of generalised onset seizures, including:

• Tonic-clonic seizure – consciousness is lost at the beginning. The muscles stiffen, and the person may fall if standing followed by rhythmic jerking. The person may bite their tongue or become incontinent. They are often confused and very tired afterwards.
• Absence seizure – these occur mostly in children. The person will ‘go blank’ for a brief time, during which they may stare, and their eyelids may flicker. These seizures can mimic daydreaming and go unnoticed.
• Tonic seizure – the body suddenly stiffens briefly, and the person may fall stiffly if standing, often causing injury. Recovery is usually quick.
• Atonic seizure – this is a sudden loss of muscle tone causing the person to fall if standing, or have head drops if sitting. Injuries are common. Recovery is usually rapid.
• Myoclonic seizures – brief, sudden jerks of a muscle or a group of muscles, usually involving the upper body. These can occur in isolation or clusters.

Focal onset seizures

Only a part of the brain is affected during a focal seizure. The signs and symptoms will depend on which part of the brain the seizure occurs, and which body functions are controlled by that part of the brain. Symptoms can vary from person to person.

The 2 main types of focal onset seizures are:

• Focal aware seizure – the person will remain aware, but they may have unusual sensations or movements, such as pins and needles, unpleasant smells or taste, hallucinations, nausea, deja vu or experience emotions such as fear. A focal aware seizure may precede a different seizure type, so often these can be called an ‘aura’.
• Focal seizures (impaired awareness) – the person’s conscious state is impaired so they can appear confused or vague, and may do strange and repetitive actions such as fiddling with their clothes, making chewing movements or uttering unusual sounds. The person may be confused and drowsy after the seizure and have little or no memory of the seizure or the events just before and after it.

Causes of epilepsy

Anything that causes damage or scarring to the brain may lead to seizures and epilepsy. There are many causes for seizures and not everyone has a clear reason why they have epilepsy. In fact, up to half of people with epilepsy don’t know the cause of their condition.

Known causes of epilepsy can include:

• brain injury
• stroke
• brain infection
• structural abnormalities of the brain
• genetic factors.

Seizures may appear to be triggered by circumstances including lack of sleep or significant stress. Identifying and avoiding individual seizure triggers can help reduce the risk of seizures in people with epilepsy. Keeping a seizure diary or record can highlight seizure patterns and help identify possible triggers.

Diagnosis of epilepsy

It’s not always easy to confirm if a person has had a seizure, especially if there are no witnesses. Seizures are often unpredictable and can be infrequent, therefore difficult to diagnose. Often test results can return normal, but the doctor may be confident the person has had a seizure, based on their history and a good description of the event.

A variety of tests and investigations may be used to diagnose or rule out epilepsy, including:

• medical history, including a detailed description of the event
• neurological examination
• electroencephalogram (EEG).

Sometimes:

• brain imaging such as computed tomography (CT) or magnetic resonance imaging (MRI)
• pathology tests.

Although medical examinations may help identify the cause of a seizure, in many cases they may not.

Treatment of epilepsy with medication

Medication is the main type of treatment for epilepsy with up to 70 per cent of people gaining seizure control with the right medication. However, medication is not prescribed for everyone who has a seizure, it depends on the risk of that person having further seizures.

When deciding whether or not to prescribe medication, or which one to prescribe, your doctor will consider various issues, including your:

• type of epilepsy, if known
• likely risk of having further seizures
• age, gender
• general health and lifestyle
• treatment side effects, preferences and cost of medication.

Some people may need to trial more than one medication before they obtain seizure control.

Antiseizure medication

Medications to control seizures are called antiseizure medications (ASMs). This is generally the first treatment option for epilepsy. These medications are not a cure for epilepsy; they aim to control or reduce seizures.

Many people with epilepsy achieve seizure control with one medication. However, for some, more than one medication may be needed.

Epilepsy treatment may be lifelong for some, but some types of epilepsy are age-related and seizures resolve by a certain age. Other people may have a lengthy remission from seizures. Two in three people with epilepsy gain seizure control with medication.

If you haven’t had seizures for a long time, you may question the need for ongoing treatment. Discontinuing antiseizure medication should be discussed with your specialist. Each person’s circumstances need to be assessed and it’s important that you make this decision fully informed.

It’s vital you keep taking your medication exactly as prescribed until you have discussed this issue with your doctor. Any withdrawal from antiseizure medication should be done slowly and always under the advice and supervision of the prescribing doctor. Suddenly stopping medication can provoke a seizure and possibly a medical emergency

Antiseizure medication side effects and interactions

You may have unwanted side effects from your medication. These can vary, depending on which medication you are prescribed.

Possible side effects can include:

• tiredness
• dizziness
• weight changes
• mood disturbance
• blurred vision
• skin rash.

Unwanted effects or side effects, often occur when starting a medication. They should lessen or disappear after the first few weeks of treatment, but you should inform your GP or prescribing doctor if the side effects persist, are intolerable or are listed as serious. In these cases, the medication dose may be lowered or withdrawn, and the unwanted symptoms will usually resolve.

Antiseizure medications can interact with other medications and with each other. This changes the way they work by either reducing the effectiveness of other medication, for example the contraceptive pill, or changing the effect of the antiseizure medication, making it less effective or potentially toxic. Some common over-the-counter treatments can also affect your epilepsy medication.

These interactions are highly variable and sometimes unpredictable. Tell your doctor and pharmacist about any other medications you take, including vitamin supplements or herbal treatments.

Taking antiseizure medication

Some general points about starting antiseizure medication include:

• Medication is usually started on a low dose, with a gradual increase over time using the ‘start low, go slow’ approach until the medication is effective, or starts to cause troublesome side effects.
• Your doctor should guide dosage changes – don’t alter the dose yourself.
• Avoid changing to another brand of the same medication, even if it’s offered by your pharmacist, especially if you have seizure control. There are minor differences in these medications and substituting your medication may cause a seizure or worsen side effects.
• Do not stop antiseizure medications suddenly, unless your doctor advises you to.
• A new medication is usually introduced before or while the old medication is being reduced.
• Sometimes a combination of medications is used.
• Try not to miss a dose. Ask your doctor what to do if this happens.
• A dosette box or Webster pack can help you remember your medication.
• Your doctor will discuss potential medication side effects. The pharmacist can also provide information.
• Tell your doctor if side effects occur. Changes can be made if the side effects are persistent, serious or troubling.
• If you still have seizures while taking medication, tell your doctor.
• Plan ahead so you don’t run out of your medication.
• Illness, diarrhoea and vomiting may affect the absorption of medication. Check with your doctor about what to do in these circumstances.
• Medication changes may need to be made for women planning a pregnancy to minimise the risk to mother and baby.

Treatment of epilepsy with surgery

Some people are unable to get good seizure control despite trying a number of medications.

Epilepsy is sometimes caused by an area of abnormal brain tissue. If surgery can remove this tissue, seizures can often be significantly reduced or even stopped. Surgery is not intended to be a substitute for medication – it’s usually investigated as a treatment option when medication fails, especially for people with focal onset seizures.

You will need to have several tests before a decision is made for your suitability for epilepsy surgery. Generally, these tests need to confirm your seizures are all coming from the same place in your brain and that this area isn’t involved with important functions, such as speech or movement. Your doctor will then discuss with you the possible outcomes of surgery, so that you can make an informed choice. Only a small percentage of people with epilepsy are suitable candidates for epilepsy surgery.

Vagus nerve stimulation (VNS) for epilepsy

The vagus nerve stimulator (VNS) is a device that is implanted in the upper chest, which regularly sends out electrical signals to the vagus nerve and brain. The VNS may be used when a person has poor seizure control and is not a candidate for epilepsy surgery.

It's uncommon for the VNS to stop someone’s seizures completely, but people can have fewer and less severe seizures. The device also has the ability to let the person trigger additional stimulation if they feel a seizure starting, which may abort or lessen the severity of the seizure and recovery time. Other benefits of the VNS include an improvement in alertness, memory, energy levels and mood.

VNS can take 18 months to 2 years to achieve the best effect.

This procedure is not a substitute for medication and is only considered when medication is not effective. Check with your specialist about the suitability of this procedure for you.

Dietary treatment for epilepsy

The ketogenic diet is a recognised and proven therapy for epilepsy and has been reported to reduce seizures in some people with poorly-controlled epilepsy. The diet creates ketones when the body burns fat for a source of energy. This state is known as 'ketosis' and causes changes in body chemistry that may help to control seizures.

The traditional ketogenic diet is strict, challenging and requires a strong commitment from the whole family. Like other therapies for epilepsy, it has side effects and needs to be closely monitored by a dietitian. The diet is often started in hospital under medical supervision, and blood sugar and ketone levels are monitored. The ketogenic diet is mostly used in children who have unsuccessfully trialled many medications, and is the treatment of choice for specific rare syndromes.

Dietary options for epilepsy have expanded in recent years to include the ‘modified Atkins diet’ and the ‘low-glycaemic index’ treatment diet. These are less-restrictive and more-palatable diets and are usually better options for adults and adolescents with epilepsy.

Recent studies have shown that the modified Atkins diet lowers seizure rates in nearly half of adults that try it. Unlike the ketogenic diet, there is no hospital stay involved, no fasting to get started, no food weighing, and no counting of calories or fluids. Adults can also lose weight on the diet if desired.

Avoiding triggers for epileptic seizures

There are a number of factors reported by people with epilepsy that can provoke seizures. These are called seizure triggers and can vary from person to person. Avoiding or reducing triggers may help to reduce seizures in some people, but not all triggers can be avoided, and seizures can still occur without any obvious triggers.

Some commonly reported seizure triggers include:

• lack of sleep
• missed medication or medication changes
• alcohol
• certain drugs (prescription and recreational)
• flickering lights or patterns
• stress
• menstruation
• illness (especially with diarrhoea or vomiting)
• significant changes in temperature and overheating.

Complementary medicine therapies and epilepsy

Complementary medicine therapies may help a person by improving overall health and wellbeing, which can also help improve seizure control.

Many people believe that these therapies are safe because they more 'natural', but this isn’t always true. Complementary therapies contain active ingredients and can also cause unwanted side effects, including allergic reactions, whether it’s ingested, inhaled or applied to your skin.

There is also a risk they may not mix well with your antiseizure medication, and may affect the way it is absorbed, metabolised or excreted from your body. Always seek advice from your specialist or a health care professional before commencing any complementary therapy.

Where to get help

• In an emergency, call triple zero (000)
• Your GP (doctor)
• Neurologist
• Epilepsy Action Australia Tel. 1300 37 45 37
• Epilepsy Action Australia have produced animated seizure first-aid videos aimed at both adults and children
• The National Epilepsy Support Service (NESS) Tel. 1300 761 487 – available Mon to Sat, 9 am to 7 pm (AEST), to provide support and information across Australia. Email: support@epilepsysmart.org.au
• Epilepsy Foundation Information Line Tel. 1300 761 487 or (03) 8809 0600