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Epilepsy

How Is Epilepsy Treated?

Thursday, March 22, 2012 - 12:57

Contributing Author: Guy Slowik FRCS

Several treatments are available for epilepsy.

The key to finding an effective treatment is an accurate diagnosis of the type of epilepsy a person has.

Current treatment options can control seizures for about 80% of the people in the United States who have epilepsy. Once a diagnosis of epilepsy is established, it is important to begin treatment right away. The longer treatment is delayed, the more difficult the epilepsy is to treat.

Medications

Antiepileptic drugs are the most frequently used treatment of epilepsy. More than 20 such drugs are now available. The choice of drug is determined by:

  • The types of seizure a person has
  • How frequently they happen
  • Lifestyle and age
  • In a woman, whether she may become pregnant.

Long-term drug therapy is usually begun after a child or adult has had two or three seizures.

Most seizures can be controlled by single drug therapy, but drugs also may be used in combination for more serious types of seizures.

Below is a list of some of the most commonly prescribed antiepileptic drugs:

  • Carbamazapine is most effective against partial or tonic-clonic (grand mal) seizures. Side effects: double vision, headache, sleepiness, dizziness, and upset stomach. These usually subside in about a week.
  • Clonazepam is used to treat myoclonic and atonic seizures that cannot be controlled by other drugs. Side effects: About half the people who take clonazepam experience drowsiness, about a third have problems with balance, and about a third have personality changes like irritability. Children may become hyperactive.
  • Ethosuximide is used for treating absence (petit mal) seizures. It stops seizures for 60% of the people who take it and controls seizures for 90%. Side effects: stomach problems, dizziness, clumsiness, and lethargy (lack of energy and ambition).
  • Phenobarbital is used to treat tonic-clonic (grand mal) and simple partial seizures. Side effects: drowsiness, changes in behavior, rash, learning problems.
  • Phenytoin is most effective in treating tonic-clonic (grand mal) and simple and complex partial seizures. Side effects: High doses can cause drowsiness, staggering, nausea, shrinking gums, and growth of body hair.
  • Primidone has the same uses as phenobarbital, although it may not be as effective in some people.
  • Valproate is usually the first drug chosen to treat all generalized seizures. Side effects: can cause liver problems, stomach problems, blood disorders, tremor, and hair loss. For most people these side effects are minor and disappear after the first few weeks of treatment.

A number of new drugs have become available in recent years.Lamotriginegabapentin, and topiramate are among the many new drugs used in treating epilepsy. These drugs are often used in combination with older medications and are sometimes called "add-on" drugs.

Women who have more seizures during the menstrual cycle are sometimes prescribed drugs to stop the ovaries from producing eggs.

Side Effects

Most antiepileptic drugs have relatively minor side effects like tiredness, dizziness, or weight gain. Some drugs may affect thinking and reasoning, others may cause headache, double vision, and skin reactions. Some of these effects will subside after a short period of time; others can be moderated by adjusting dosage levels.

Anti-seizure medication can interfere with the efficacy of other prescription medication, including birth control pills; likewise, other medications can reduce the efficacy of the anti-seizure medicine. Drug interactions can also cause dangerous side effects, so it is important that people taking antiepileptic drugs tell their doctor about any other medications they might be taking, including over-the-counter medications and vitamins.

Need To Know:

  • Some doctors recommend stopping medication after two years have passed without a seizure. Others prefer to wait four or five years.
  • Medicine should never be stopped without a doctor's advice and supervision. People who have stopped having seizures often begin to have them again when they stop taking their medicine without talking to their doctors. These return seizures can be dangerous.
  • Over half of children whose epilepsy has been controlled with medication are able to stop taking medication without return of symptoms.
  • A study has shown that about two-thirds of adults who had been seizure-free for two years and about three-quarters who had been seizure-free for three years were able to stop taking medication.

Surgery

If seizures cannot be controlled by medication, doctors may recommend surgery.

Surgery usually isn't considered until the patient has tried two or three different medications for a period of time without success, and the seizures warrant consideration for surgery.

Need To Know:

The National Institutes of Health has concluded that the three main categories of epilepsy most likely to be treated successfully by surgery are:

  • Partial seizures
  • Seizures that begin as partial seizures and spread to the rest of the brain
  • Certain severe childhood epilepsies such as Rasmussen's encephalitis

In some people, epilepsy caused by condition such as a brain tumor or cyst also can be successfully treated with surgery.

Surgery has become a safer option in recent years because of advances in brain imaging and surgical techniques that make it possible to pinpoint the area of the brain where the seizures occur, and to remove just that area. The goal is to remove just enough of the damaged brain tissue to stop seizures.

The first step is to pinpoint the area of the brain where the abnormal electrical activity happens. This area can be found by long-term EEGmonitoring with help from MRI and PET scans. Functional MRI can be used to determine whether the affected brain cells perform a vital function. Surgeons avoid operating on areas of the brain that control speech, language, hearing, and other vital functions. There are several types of surgery:

Lesionectomy. The most frequently used type of surgery for epilepsy aims to remove a seizure focus; a small area of abnormality in the brain where seizures originate. These areas are called lesions, and the surgery is called a lesionectomy or lesion removal. This type of surgery is most appropriate for partial seizures.

Lobectomy. A lobectomy or lobe removal takes away a larger area of the brain but is still intended to remove only the area of seizure focus. Temporal lobectomy is the most frequently performed surgical procedure to treat epilepsy. Removal of the temporal lobe stops temporal lobe epilepsy about 90% of the time.

Corpus callosotomy. Corpus callosotomy is a surgical procedure that cuts the connection between the left and right sides, or hemispheres, of the brain. This procedure is most often used to treat children with severe seizures that start on one side of the brain and spread to the other. This procedure can end atonic seizures (drop attacks) and other generalized seizures. Partial seizures will still occur on one side of the brain.

Hemispherectomy. This procedure removes half of the cortex or outer layer of the brain. It is used only to treat children with conditions such as Rasmussen's encephalitis that cause catastrophic seizures that originate on one side of the brain. This procedure is used only as a last resort, but children often recover from it very well and can regain nearly normal abilities. This procedure is almost never done after a child has reached age 13.

Vagus Nerve Stimulation

The two vagus nerves run from the brain along each side of the neck and down the throat to the gastrointestinal tract (stomach and bowels). These nerves help control swallowing and speech. They are widely connected in the brain and seem to connect to the parts that are affected by epileptic seizures.

Electrical stimulation of the vagus nerve is helpful in controlling seizures that don't respond well to medication.

The vagus nerve stimulator is a battery-powered device somewhat like a pacemaker. It is implanted under the skin of the chest and attached to the vagus nerve in the lower part of the neck. It delivers short bursts of electrical energy along the vagus nerve to the brain.

The vagus nerve stimulator can cause shortness of breath, hoarseness, ear pain, a sore throat, coughing, and nausea and vomiting. These effects are usually mild and can be stopped by adjusting the strength of the electrical charge.

The batteries must be replaced every three to five years, a procedure that requires minor surgery that can usually be done in an outpatient facility such as the doctor's office.

The vagus nerve stimulator has been approved by the US Food and Drug Administration since 1997. It has been found to reduce seizures by about 20% to 40%.

Diet

Seizures have been treated by diet since ancient times. The earliest dietary treatment was fasting. The diet used most frequently in modern times is very low in sugars and proteins and high in fat.

The diet forces the body to burn fats for energy instead of sugars and is somewhat similar to currently popular weight-loss diets. It is known as the ketogenic diet because burning fats is thought to increase ketones in the body, a condition called ketosis. Ketones are thought to prevent irritation of the central nervous system, that is, the spinal column and the brain.

The ketogenic diet was first introduced in the 1920s but fell out of use after the introduction of antiepileptic drugs. It is currently being revived for treating children with severe seizures that do not respond to medications.

It is a very difficult diet to keep. The children are allowed to eat almost nothing but fat (butter, heavy cream) with very little meat and a limited range of low-sugar vegetables such as lettuce, celery, and cucumbers.

The diet often causes nausea and diarrhea. It can cause poor development from lack of nutrition and kidney stones from a build-up of uric acid in the system. Use of the diet must be supervised by a doctor.

The diet seems most effective in children under eight years old but it is occasionally helpful for adults. It has been shown to help 25% to 50% of children who have uncontrollable seizures.

Nice To Know:

Q. Do relaxation techniques, such as yoga or meditation, help stop seizures?

A. Stress is sometimes a trigger for seizures, and stress reduction techniques may be beneficial. Although relaxation techniques don't stop seizures, some people have found that they reduce their severity. However, deep breathing has been reported as a trigger for some people. Adequate and restful sleep is very important for people who have epilepsy.

 

Epilepsy