Epilepsy can be inherited. Certain genes responsible for inherited epilepsy were identified. But there is still a lot to be discovered about genetic aspects of epilepsy. Some epilepsy cases are acquired. Certain conditions such as a birth defects and injuries, head trauma, brain infections, and brain tumors can result in epilepsy. In more than two thirds of cases there is no identified underlying etiology for epilepsy.

Not everyone who has had a seizure has epilepsy. About 10% of people will have a seizure during their lifetime; most of these are “provoked” seizures. These people may never have another seizure, and therefore do not have epilepsy.

What Kind of Epilepsy I have?

In addition to seizure classification, experts developed classification of epilepsy syndromes.

International Classification of Epilepsies

1. Localization-related (focal, local, partial)

• Idiopathic
• Symptomatic
• Cryptogenic

2. Generalized

• Idiopathic
• Symptomatic
• Cryptogenic

3. Undetermined epilepsies

• With both generalized and focal seizures
• Without unequivocal generalized or focal features

4. Special syndromes

With both localized or generalized epilepsies, idiopathic subdivision means there is no known cause of seizures, but causes can be genetic. Symptomatic means there is a known cause. Cryptogenic means there is no visible cause, but there is a suspected or hidden cause.

Temporal lobe epilepsy fits well into symptomatic localization related epilepsy if MRI Brain shows scar tissue in the temporal lobe.

Autosomal dominant frontal lobe epilepsy is classified as idiopathic localization related epilepsy.

If tumor, stroke, or trauma related injury seen in frontal lobe is the cause of seizure, it will be considered as symptomatic localization related epilepsy.

Localization related epilepsies are those with area of abnormality in the brain where seizures originate. These regions can be frontal, temporal, occipital, or parietal lobes.

Generalized epilepsy means the seizures originate from both hemispheres at the onset. Generalized epilepsies are classified as idiopathic, symptomatic or cryptogenic. Idiopathic generalized epilepsy syndrome include juvenile myoclonic epilepsy, childhood absence epilepsy, and juvenile absence epilepsy syndromes. Under symptomatic generalized epilepsy classification, Lenox- Gastaut syndrome and infantile spasms are well known.

Landau-Kleffner syndrome is classified as an uncommon epilepsy syndrome.

Special epilepsy syndromes include febrile seizure and reflex epilepsy such as photosensitive epilepsy, reading epilepsy, and others.

Why experts did classify seizures and epilepsy syndromes? What was the purpose?

Classification of the epilepsy syndrome is very important in determining further tests for evaluation and choosing the most appropriate medication to control seizures. For classification routine EEG and clinical and family history may not be adequate. Further tests such as video EEG monitoring is the gold standard test in determining type of epilepsy syndrome and seizures you have. If you have partial seizures, imaging techniques such as magnetic resonance imaging of brain, PET scan will be utilized to localize focus of seizures. Ictal SPECT is another way to find seizure focus and performed when clinical seizure is captured.

International classification of epilepsy syndromes and seizures are used by your doctor not just classifying what kind of epilepsy and seizure type you have, but also conducting the needed tests and determining type of treatment.

Why do I have epilepsy? Why me?

This is one of the most common questions the patients ask. There are many different underlying causes of epilepsy. Often the cause of your epilepsy can not be identified. Some of the known causes of epilepsy are as follows:

• Head injuries: Concussion (brief loss of consciousness) is considered to be mild head trauma, and it may increase the risk of epilepsy slightly. Moderate or severe head injury with prolonged loss of consciousness or brain hemorrhage significantly increase the risk of epilepsy.
• Brain infections such as meningitis, encephalitis, and brain abscess
• Stroke: Ischemic (caused by lack of blood flow to parts of the brain) or hemorrhagic (bleeding into brain tissue) strokes increase the risk of epilepsy.
• Alcohol: Heavy drinking (intoxication) or abrupt stopping of alcoholic beverages (“withdrawal” seizures) can cause an increased risk of epilepsy.
• Brain tumors
• Degenerative brain diseases, such as Alzheimer Disease and Parkinson Disease
• Demyelinating diseases such as multiple sclerosis
• Mental retardation and cerebral palsy
• Cortical dysplasia and migration disorders: Here there is abnormality of brain growth, migration and maturation of the neuronal tissue. The neuronal tissue which migrated to inproper positions in brain result in “tangles” of neurons. These tangles have abnormal electrical connections, and therefore predispose brain to seizures.
• Genetic predisposition: Some types of epilepsy run in families. If you have generalized epilepsy such as juvenile myoclonic epilepsy or childhood absence seizures, there is three to four fold increase in your first-degree relatives (parents, siblings, and children). First-degree relatives of patients with partial seizures have higher risk of developing epilepsy as the general population.
• Age: The risk of seizures is highest in young children and in the elderly.
• Gender: The incidence of epilepsy is higher in males than females. This may suggest that gender may be important in the development of epilepsy.
• Febrile seizures during infancy increase the risk of epilepsy development later.
• Connective tissue disorders, like vasculitis are associated with increased risk of epilepsy, if there is central nervous system involvement.
• Cancer with spread to brain and side effects of chemotherapy
• Some other disorders such as mitochondrial diseases, migraine, and psychiatric conditions are also associated with increased risk of epilepsy.

Sometimes patients may feel déjà-vu, jama-vu or different psychic feelings. That means seizure originates in an area close the medial part of temporal lobe. As mentioned seizures can manifest different symptoms depending on the area of origin.

Seizures can occur at any time, often without warning. In most people, seizures are easily controlled with medication; in others, seizures continue despite treatment and may last a lifetime.

What is aura? Does everyone have aura?

Aura is the first sign of seizure. It means the seizure originates from an area which can make the patient feel symptoms before the full blown spell. Auras are usually followed by loss of awareness and sometimes by generalized convulsions. Sometimes auras can stop without any further clinical symptoms.

Not every epilepsy patient has aura prior to seizures. Some patients with auras may end up not having auras in the future. Auras can also change in features with time.

What Kind Of Seizure Do I Have ?

Seizures are classified as partial, generalized tonic clonic, absence, myoclonic, atonic and tonic seizures. Epileptic seizures are classified as follows:

International Classification of Epileptic Seizures

I. Partial seizure

• Simple partial seizures (consciousness not impaired): Motor, Sensory, Autonomic
• Complex partial seizures (with impairment of consciousness)
• Partial secondarily generalized seizures

II. Generalized seizures (bilaterally symmetrical and without local onset)

• Absence seizures
• Myoclonic seizures
• Clonic seizures
• Tonic seizures
• Tonic-clonic seizures
• Atonic seizures (astatic)

III. Unclassified epileptic seizures (inadequate or incomplete data)

A partial seizure starts when there is initial activation of a limited number of neurons in part of one hemisphere. It may spread to other parts and may become a generalized seizure.

A generalized seizure happens when there is involvement of both hemispheres at the onset of seizure.

If you preserve your awareness during your seizure that means you have a simple partial seizure. You may have motor, sensory, or autonomic or psychic symptoms during them.

There is loss of awareness during complex partial seizures. Sometimes they may start as simple partial and then evolve into complex partial seizures. Sometimes complex partial seizures end as it is or sometimes they progress into grand mal seizures.

After a complex partial seizure there is always some confusion which may last from few minutes to few hours. It is called postictal confusion. During complex partial seizures the patient may have aura followed by staring into face with or without automatisms. An automatism is a coordinated involuntary motor activity occurring during the state of clouding of consciousness. Most frequent automatisms are oro-facial or hand automatisms. The other kinds are gestural, ambulatory, or verbal automatisms.

Generalized tonic clonic seizures may start os grand mal or evolve from complex partial seizures. Initially the patient gets stiff during tonic phase. He may fall due to rigidity of body. During tonic phase all muscles contract including respiratory muscles. There is obstruction of airways due to muscle contraction. Tongue biting and urinary incontinence happen during this phase. The patient may sound crying, called ictal cry. Tonic phase is followed by generalized convulsions of all limbs. The clonic phase usually lasts few minutes. Then seizure ends and the patient goes into a deep sleep afterwards. There is confusion after seizures. Duration may vary form few minutes to hours. Usually headache occurs afterwards, too.

Absence seizures are brief seizures with staring spells. The patient returns to baseline very quickly. Kids who have absence seizures usually grow out of it. Myoclonic seizures are brief involuntary jerks of limbs. They are more frequent in the mornings. It may cause trouble while brushing teeth or drinking coffee in the mornings. Sometimes it can involve the legs then it may cause person to fall. Atonic seizures are associated with sudden loss of muscle tonus in body and may present as head drops or sudden falls with impaired awareness. On the other hand tonic seizures present as tonic posturing of extremities. They usually involve upper extremities and are very brief.

What should I do after first seizure?

After a first seizure anyone without a clear etiology (reason) should see a neurologist and have a full neurological evaluation to determine the cause of the seizure. The decision for further investigations and treatment will depend on this initial evaluation. The tests to consider in evaluation of patients with first seizures are Brain MRI, EEG, and certain laboratory tests.

What is my risk of having a second seizure after the first seizure?

If your first seizure occurred without any provoking factor, your recurrence (having another seizure) risk depends on various factors such as findings in your work up, brain imaging, EEG, neurological exam, family history, childhood history, developmental history, history of learning disability in the past, etc.

If all of factors mentioned above is negative that means you have a low risk for recurrence. If your EEG or your imaging is abnormal or if you have had two unprovoked seizures with all other factors above were normal puts you at medium risk for recurrence group.

If your EEG and imaging are abnormal or you have had two unprovoked seizures with either EEG or imaging abnormal that means you have a high risk for recurrence.

Your physician should make the decision whether or not to treat you after first seizure based on the risk of recurrence and also the impact of recurrence of a single seizure due to certain conditions such as socio-economic conditions, high risk occupation, risks of injuries due to falls in elderly and in patients on anticoagulation.

What factors can lower the seizure threshold?

Certain situations can lower the seizure threshold and therefore trigger a seizure in people with epilepsy:

• Lack of sleep or erratic sleep schedules
• Excessive alcohol
• Physical stress
• Emotional stress
• Flashing or flickering lights (rare, only in certain types of epilepsy)
• Hyperventilation
• Menstruation
• Recreational drugs
• Medications (Sudafed, sedating antihistamines, tricyclic antidepressants, wellbutrin, interferons, some antibiotics such as ciprofloxacin, levofloxacin etc.)

What are other conditions that may mimic epilepsy?

1. Cardiac syncope
2. Vasovagal syncope
3. Transient ischemic attacks and stroke
4. Complicated migraine
5. Transient global amnesia
6. Hyperventilation
7. Sleep disorders
8. Movement disorders
9. Panic attacks
10. Anxiety episodes
11. Mood disorders
12. Conversions
13. Malingering
14. Drug toxicity

The diagnosis of epilepsy is a clinical diagnosis. Your doctor will diagnose epilepsy based on the information from the history, physical examination, EEG, and brain imaging studies.

There are certain tests to support the diagnosis of epilepsy such as electroencephalogram (EEG) and brain imaging. EEG amplifies electrical activity in brain and records and displays them on a computer screen. In the past EEG displays were on paper. Abnormalities such as spikes, sharp and slow waves occur during seizures. In between seizures EEG may not show any abnormalities. EEGs in between seizures can be normal. Multiple repeats of EEG tests will increase the chance to catch abnormalities supporting epilepsy diagnosis. There is no blood test for epilepsy.

Imaging such as computed axial tomography of head and magnetic resonance imaging of brain provide detailed information about brain structure. They can reveal birth defects, tumor, scars, and stroke, all of which can cause epilepsy.

Why EEG? What is the purpose?

Electroencephalogram (EEG) is a test to record brain activities. It amplifies brain activities and displays them as waves. EEG machines record the brain activities through the electrodes. The electrodes are glued or pasted on the scalp. Amplifiers in the machine magnify the brain signals. The recordings are written on paper or digitized and displayed on the computer monitor. Spike and wave is a distinctive pattern and occurs in patients with epilepsy.

EEGs are to support and eventually confirm the diagnosis and also can be helpful to classify the type of epilepsy syndrome. For example typical pattern 3 Hz spike and wave is seen in patients with idiopathic generalized epilepsy. Determining the type of epilepsy is very important in choosing therapeutic options, becasue some anti-epileptics may not control certain seizures.

Before EEG test you may be asked to be sleep deprived. It is very well known that sleep deprivation is a seizure trigger. Also it will help you sleep during EEG test, which can improve chance of detecting abnormalities on EEG test.

During EEG test you may be provoked by flashing lights and hyperventilation. These provocative techniques can cause seizures in some patients. Flashing lights trigger seizures in patients with photosensitive epilepsy. Hyperventilation lowers seizure threshold and can cause seizures.

CAT Scan versus MRI? What is the difference?

CAT scan was the first Xray machine to rely on computer in brain imaging. It uses Xrays to take the picture of brain. It is very sensitive test in identifying acute changes such as bleeding in the brain or skull fractures.

On the other hand, magnetic resonance imaging (MRI) employs magnetic field to produce the image of brain. There is no risk of radiation with MRI. It is superior to CAT scan in delineating the structural abnormalities in the central nervous system suc h as scarring, inflammation, infection, stroke, and tumor. An MRI may need to be conducted in almost all patients with new ons et epilepsy.

Single Photon Emission Computed Tomography (SPECT)

SPECT is another nuclear medicine imaging study. It is used when patients are considered for epilepsy surgery. It identifies the seizure focus by detecting altered focal blood flow. Increased blood flow is seen in epileptic tissue as the seizure starts.

The drawback of this test is the patient must have had seizure few minutes prior to the testing. At the onset of seizure the patient is injected a radioactive material. SPECT tracks the uptake of this radioactive substance in the brain to identify the epileptic tissue. Like PET, SPECT is not a routine study, utilized when patients are considered for epilepsy surgery. It is performed in inpatient hospital setting.

Positron Emission Tomography (PET)

PET is a nuclear medicine imaging test that has been used to localize the area of abnormality causing seizures. It is an additional supportive study to EEG and brain MRI in localizing the seizure focus. This test is not a routine test and performed when epilepsy surgery is considered to optimize seizure control in patients with uncontrolled seizures.

The aim of treatment is to get the best seizure control with the possible least number of AEDs, with few or no side effects. In about 70 percent of patients this goal is achieved. In about remaining 30 percent the seizures can be hard to control. In these cases more than one AED will be needed to control seizures. About 30 percent of patients with epilepsy may remain refractory to medical treatment.

In refractory cases the other therapeutic options such as surgery and devices can be considered. The purpose of epilepsy surgery is to resect the focus of seizures. In majority of cases finding of focus is difficult. Also in some cases there may be more than one focus. Other types of surgery are callosotomy, subpial resection, and device placements.

Basic Ways to Control Your Seizures Better

Epilepsy treatment is comprehensive. The medications are the initial step to control seizures. If one medication fails, then another medication is tried. Sometimes two or more medications need to be used. If the medications fail, then other options should be considered. These include surgery, devices, and ketogenic diet.

Treatment of epilepsy requires collaboration between the patient and the doctor. To know your disease better is the first step to improve the control. You need to ask your doctor questions and ask guidance to obtain more information about your epilepsy. You need to learn and understand your medical condition, diagnostic, and therapeutic options.

You need to give your doctor the necessary and correct information about your condition. You should complete seizure calendar which enable you provide accurate information about the seizure frequency.

You need to communicate with your doctor and treatment team effectively and in time. Make sure you have enough refills and prescription before you leave the doctor’s office. Don’t wait until the last day so you can avoid running out of your medication. You should be proactive with your medications.

Try your best not to miss doctor appointments. If you miss an appointment that may mean you may not have enough supply of your antiepileptic medication until your next visit. You may also miss important blood tests which may be important and necessary for ideal treatment and adjustment of dose of your medication(s).

The basic ways to control your seizures better are as follows:

1. Take your medication in time and regularly. Have a pill box which will help you monitor whether you missed any dose or not. To remind yourself about taking medication, there are gadgets, that may help you such as setting a watch alarm, linking this activity to daily life such taking medications after brushing your teeth in the morning, before getting ready for bed, etc.
2. Stay away from alcohol and recreational drugs which can provoke seizures.
3. Avoid sleep deprivation.
4. Do not miss your regular appointments with your doctor.

What are risks of seizures?

You may harm yourself during a seizure due to falls and injuries. Also you may harm others if you have seizures while driving or using other machinery.

There is also increased risk of sudden unexplained death among patients with epilepsy. Seizures can also cause irregular heart rhythms and heart attacks.

Patients with epilepsy should not use bathtubs. They should not swim without supervision. They should avoid using heavy machines, contact sports, being near open water, or being at heights.

Ketogenic Diet

Treatment of seizures with diet has been tried for many years. The only diet proven to help control seizures is ketogenic diet. It has been more successful in helping children with epilepsy. Versions of ketogenic diet have also been tried in adults with epilepsy.

Ketogenic diet is low in carbohydrate and protein but high in fat. Fat portion occupies about up to five times more than combination of carbohydrate and protein. Due to calory restriction, high fat does not cause weight gain.  High fat causes ketone bodies production to accumulate in blood. Ketone bodies in blood are considered to have anti-seizure effect.

Ketogenic diet should be started under doctor’s supervision due to its complexity.  It requires few days of hospital admission to start this diet.  Dietitian assistance will be needed to stay on this diet. The diet has to be followed exactly.

The effect of diet starts to be seen in a month after being diet. At times, the child can be seizure free.  The effect of diet disappears after it is discontinued. This diet may not work in every child.

Not all patients with seizures require treatment with antiepileptic drugs throughout their lives. Most patients with epilepsy, however, will require one or more drugs for many years. Overall, there is about a 60-70 % chance of good seizure control with a single drug. About 30 % patients with epilepsy will not have good seizure control with single medication and will require addition of other AEDs.

There are many different AEDs approved for the treatment of seizures. The goal of treatment is the best seizure control with the least possible number of AEDs. Using two medications may improve seizure control, but can also greatly increase the chance of side effects.

Certain medications work best for certain types of seizures. Choosing the best medication for you will require taking many factors in consideration. This may require trying few AEDs until finding the best regimen or possible combination to control your seizures. It is generally agreed that using a single medication is best, when possible.

The most commonly used antiepileptic medications are listed below. Since antiepileptic drugs work by decreasing brain “hyperactivity,” it is common that many side effects are related to dulling of normal brain “activity.” Therefore, nearly all the antiepileptic drugs can cause sleepiness, difficulty with concentration and memory, blurred vision, and trouble with balance in some patients.

The “new” antiepileptic medications (Levetiracetam, Gabapentin, Lamotrigine, Topiramate, Pregabalin, Tiagabine, Lacosamide, Rufinamide) may be better tolerated than older medications.

Old Antiepileptic Drugs:

• phenobarbital
• phenytoin (Dilantin)
• primidone (Mysoline)
• carbamazepine (Tegretol)
• valproate (Depakote)
• felbamate (Felbatol)
• gabapentin (Neurontin)

New Antiepileptic Drugs:

• lamotrigine (Lamictal)
• topiramate (Topamax)
• tiagabine (Gabitril)
• oxcarbazepine (Trileptal)
• levetiracetam (Keppra)
• zonisamide (Zonegran)
• vigabatrin
• pregabalin (Lyrica)
• rufinamide (Banzel)
• Lacosamide (Vimpat)

How My Doctor Decides About The Best Medication For Me?

Your epilepsy physician considers multiple factors in deciding the most appropriate medication to treat your disease. These factors include age, gender, type of seizures, type of epilepsy syndrome, your other medical conditions, other medications you are on, your daily activity level, side effect profile, potential of pregnancy, need for breast feeding, and others.

Some AEDs are not the drug of choice to treat some types of seizures. For example, gabapentin, pregabalin, phenytoin, carbamazepine may make your seizures worse if you have myoclonic or absence seizures.  Lamotrigine may also decrease absence seizures control. So your doctor will choose the best medication to treat your seizures after considering all these factors mentioned.

The following table summarizes different spectrum of actions of antiepileptic drugs and choice of AEDs according to type of seizures:

What Are The Side Effects Of Antiepileptic Drugs?

Some common and serious side effects are listed below. As with all medications, you should discuss potential side effects fully with your doctor prior to beginning any antiepileptic medication.

There is a black box warning by FDA regarding increased risk of suicidal ideation associated with antiepileptic use in epilepsy patients. This result was concluded from drug trials for new investigational drugs to treat epilepsy.

Tips Not To Forget To Take Your Medication

1. Use a pill box with separate compartments for each day of the week. day and night sections of each day can be a big help. In this way you can keep track of the pills you’ve taken and the ones you haven’t.
2. Use a timer of your watch, computer, or daily organizer to remind you to take your medications.
3. Create your own habit: Associate taking your medication to a routine daily activity. For example, you may take your medications right after brushing your teeth in the morning or before preparing your bed at night.
4. Writing down your medication doses and schedule on a calendar in a sense, will help you remember to take your medicine.

• Tegretol tab 200 mg, chewtab 100 mg
• Tegretol XR 100, 200, 400 mg tab
• Carbatrol 100,200, 300 mg capsule
• Suspension 100mg/ ml

Used for partial seizures and generalized tonic clonic seizures. It can make absence and myoclonic seizures worse.

Common and rare side effects are summarized in the table.

It induces liver enzymes. The cytochrome P450 enzyme complex is induced by Carbamazepine. Due to this feature, it can cause drug and drug interactions. It can decrease the levels of some medications due to increased metabolism caused by cytochrome p450 enzyme induction. Some of the medications which may decrease due to this interactions are antipsychotics, antifungals, oral contraceptives, neuromuscular blockers, cyclosporine, warfarin, some antiepileptic drugs, theophylline, tricyclic antidepressants, and narcotics.

Certain medications can increase carbamazepine levels resulting in toxicity. Some of these medications are antifungal agents, cimetidine, diltiazem, erythromycin, clarithromycin, fluoxetine, omeprazole, propoxyphene, and verapamil.

Long term side effects are osteoporosis, bone marrow and liver failure, and hyponatremia. Patients on carbamazepine should be encouraged to use Vit D and Calcium supplementation to prevent osteoporosis in the long term. Routine blood tests shoud be performed every 6 months to check liver enzymes, electrolytes, and complete blood cell count as long as one is on this medication.

You can get more information from its official web site: http://www.carbamazepine.com/index.html

OXCARBAZEPINE (TRILEPTAL)

• Available as Tab 150, 300 and 600 mg, syrup 300mg/5mL

Used for treatment of partial seizures and generalized tonic clonic seizures.

It may make myoclonic and absence seizures worse.

Common and rare side effects are described in the table.

The drug-drug interactions are possible. While some of AEDS such as phenytoin, carbamazepine, phenobarbital, and verapamil lower blood levels of oxacarbazepine, on the other hand oxacarbazepine can lower blood levels of oral contraceptives, felodipine, and lamotrigine.

PHENYTOIN (DILANTIN, PHENYTEK)

• Cap ER 30 mg, 100 mg
• Chewtab 50 mg
• Suspension 125 mg/ ml
• Fosfenytoin injectable 50 mg PE/mL
  

Used for treatment of partial seizures and generalized tonic clonic seizures.

It may make myoclonic and absence seizures worse.

Common and rare side effects are in described in the table.

With the long term use osteoporosis is seen. Patients on phenytoin should be placed on Vit D and calcium supplementation to prevent osteoporosis. Other consequences with long term use are cerebellar atrophy, peripheral neuropathy, and folate deficiency.

Drug interactions are seen due to enzyme induction of cytochrome p 450 enzymes in the liver.

Certain medications such as cimetidine, amiodarone, diltiazem, felbamate, flucanazole, fluoxetine, isoniazid, omeprazole, phenobarbital, tcilodipine can increase phenytoin levels.

Phenytoin can lower levels of following medications: Antipsychotics, antifungal agents, carbamazepine, cyclosporine, felbamate, lamotrigine, narcotics, neuromuscular blockers, oral contraceptives, steroids, tiagabine, theophylline, topiramate, tricyclics, valproic acid, and warfarin.

You can gather more information about the drug from this website: http://www.phenytek.com/index2.htm

PHENOBARBITAL

• Available as Tab 30, 60mg, Elixir 20mg/5mL, Injectable form 200mg/mL
  

Used for treatment of partial seizures and generalized tonic clonic seizures.

Common and rare side effects are summarized in the table.

Long term side effects are osteoporosis, Dupuytren’s comtracture, frozen shoulder, and decreased libido.

Drug interactions are significant due to induction of cytochrome p 450 enzymes. Phenobarbital can lower levels of antipsychotics, antifungals, oral contraceptives, theophylline, warfarin, tricyclics, steroids, valproic acid, topiramate, phenytoin, felbamate.

Some medications such as phenytoin, valproic acid, and felbamate can increase phenobarbital levels.

VALPROIC ACID (DEPAKOTE, DEPAKENE)

• Available as
• Valproic acid ( Depakene): Cap 250 mg, Suspension 250 mg/5 ml
• Valproate Sodium ( Depacon) Injectable 100 mg/ml
• Divalproex Sodium ( Depakote) Tab 125, 250, 500 mg Cap 125 mg
• Depakote ER Tab 250, 500 mg

Used for partial seizures, primary generalized tonic clonic seizures, typical and atypical absences, atonic and myoclonic seizures

Common and rare side effects are summarized in table

Long term potential side effects are weight gain and polycystic ovarian syndrome.

The drug interactions are as follows: Felbamate and fluoxetine can increase levels of valproic acid. Phenobarbital, phenytoin, carbamazepine and lamotrigine can lower levels of valproic acid. It can increase levels of carbamezepine, epoxide, felbamate, lamotrigine, phenobarbital, and free phenytoin levels.

ZONISAMIDE (ZONEGRAN)

• Available as Cap 25, 100 mg

Used for partial seizures, generalized tonic clonic seizures, and myoclonic seizures

Common and rare side effects are summarized in the table.

Carbamazepine, phenobarbital, and phenytoin can lower zonisamide levels. Grapefuit juice can lower zonisamide levels.

ETHOSUXIMIDE(ZARONTIN)

• Available as Cap 250 mg/ Syrup 250mg/5 ml

Used for absence seizures.

Gastrointestinal distress, drowsiness, and sleep disturbance are the most common side effects.

Carbamazepine, phenytoin, and phenobarbital can lower ethosuximide levels.

FELBAMATE (FELBATOL)

• Available as Tab 400 and 600 mg, Suspension 600mg/5 ml

Used for partial seizures, primary generalized tonic clonic seizures, typical and atypical absences, atonic, and myoclonic seizures associated with Lennox-Gastaut syndrome.

Common and rare side effects are summarized in the table.

Felbamate can increase levels of Phenobarbital, phenytoin, valproic acid, and carbamazepine metabolite levels. Phenobarbital, phenytoin, and carbamazepine can lower levels of felbamate.

LAMOTRIGINE (LAMICTAL)

• Available as Tab 25,100,150,200 mg Chewtabs 2,25mg

Used for partial seizures, primary generalized tonic clonic seizures, typical and atypical absences, atonic and myoclonic seizures associated with Lennox-Gastaut syndrome.

Common and rare side effects are summarized in the table.

Phenytoin, phenobarbital, carbamazepine and primidone, and oral contraceptives can lower lamotrigine levels. Valproic acid can increase lamotrigine levels.

TIAGABINE (GABITRIL)

• Available as Tab 5,10,15 mg

Used for partial and generalized tonic clonic seizures

Phenytoin, phenobarbital, carbamazepine and primidone can lower tiagabine levels.

Occasionally it can cause spike and wave stupor.

GABAPENTIN (NEURONTIN)

• Available as Cap 100,300,400 mg

Used for partial seizures.

Not recommended in treatment of primary generalized epilepsy.

No drug interactions have been reported.

PREGABALIN (LYRICA)

• Available as Cap 25, 50,75,100,150 and 225 mg

Used for treatment of partial seizures.

Not recommended in treatment of primary generalized epilepsy.

Common and rare side effects are summarized in Table.

No reported drug- drug interactions.

LEVETIRACETAM(KEPPRA,KEPPRA XR)

• Available as 
• Tab 250,500,750, 1000 mg
• Keppra XR Tab 500 mg
• Solution 100mg/mL

Used for partial seizures, primary generalized tonic clonic seizures, typical and atypical absences, and myoclonic seizures

Common and rare side effects are summarized in the table.

No reported drug and drug interactions.

TOPIRAMATE (TOPAMAX)

• Available as Tab 25, 50, 100, 200 mg Sprinkle 15,25 mg

Used for partial seizures, primary generalized tonic clonic seizures, typical and atypical absences, atonic, and myoclonic seizures associated with Lennox-Gastaut syndrome.

Should not be used in patients with kidney stones.

Common and rare side effects are summarized in the table.

Can decrease levels of oral contraceptives. Phenytoin, phenobarbital, and carbamazepine can lower topiramate levels.

LACOSAMIDE (VIMPAT)

• Available as Tab 50, 100, 150 and 200 mg and Syrup 10mg/ml

Used to treat partial seizures and secondarily generalized tonic clonic seizures.

Common and rare side effect are summarized in the table.

No reported drugand drug interactions.

RUFINAMIDE (BANZEL)

• Available as Tab 200, 400 mg

Used to treat partial seizures and seizures with Lennox-Gastaut syndrome.

Common and rare side effects are summarized in the table.

It can decrease levels of carbamazepine and lamotrigine, and can increase phenytoin levels. Its level can be decreased by phenytoin, phenobarbital, and carbamazepine.

The purpose of the surgery is to remove abnormal part of the brain which is considered epileptic (source of the seizures). The pre-operative work up is comprehensive. You need to go through a pre-surgical evaluation to be identified as a surgical candidate or not. The outcome and seizure freedom after surgery depends on multiple factors, most important ones are epilepsy syndrome type, underlying pathology, surgical techniques and others.

What Are The Steps In Pre-Operative Evaluation?

1. Obtaining necessary and optimal clinical information about your seizures and epilepsy syndrome.
2. Classifying your epilepsy syndrome with EEG, clinical description of your seizures, and neuro-imaging such as magnetic resonance imaging of brain to localize the abnormal area, possible seizure focus.
3. To identify the focus of your seizures by performing video EEG monitoring in the hospital setting at epilepsy monitoring units(EMUs). By this way your seizures will be captured and your seizure type and epilepsy syndrome will be classified. Also if possible the epileptic focus will be identified.
4. Baseline neuropsychological evaluation will provide the information about your cognition and emotional functions. Sometimes it can find out a certain region of the brain which may not function well. That area may be the origin of your seizures. It can be used as reference point for postsurgical evaluation.
5. WADA test or intracranial amytal test is used to identify which side is responsible for language. It also assesses the memory function of temporal lobes.
6. Intracranial video EEG monitoring is performed when video EEG monitoring does not provide enough information about the origin and focus of seizures. It is performed by using intracranial electrodes as grids and/or strips, depth electrodes with enough coverage over the suspected area of origin of seizures.
7. SPECT (Single photon emission computed tomography) scans find the seizure focus by measuring cerebral blood flow. During a seizure there is selectively increased blood flow in the seizure focus. As seizure starts, the radioactive tracer has to be given very early in the seizure to localize the area of seizure focus. It helps to localize seizure focus in difficult cases but it has to be done at hospital settings due to requirements of specially trained personnel.
8. PET (Positron emission tomography) scans measure brain metabolism. Areas of seizure focus will require less energy, with decreased uptake of radioactive tracers. It can aid in deciding the seizure focus in surgical cases.

Surgical Techniques

1. Focal cortical resection
2. Anterior temporal lobectomy
3. Corpus callosotomy
4. Multiple subpial transection
5. Hemispherectomy
6. Vagus nerve stimulation and other devices

Focal cortical resection:

If an area of the brain is identified as the cause of seizures, focal resection is considered. But that area of the brain should not be an eloquent region. It should not carry important functions such as language, motor control, vision, or sensation. Removal of the area should not cause important permanent impairments. Certain tests can be done to find the functions of the region and the amount of impairment after resection. These tests are functional MRI and cortical motor and language mapping of the region with intracranial electrodes before resection if the area is or close to eloquent regions in the brain.

Anterior temporal resection:

If the seizures originate from the medial part of temporal lobe, this technique is used. The anterior part of temporal lobe is removed to provide better seizure control. The surgeon usually removes the lobe to a certain distance from the tip. Some surgeons may prefer to resect only the medial structures amygdala and hippocampus to cause less post surgical impairment and to preserve the language area if the surgery involves left temporal lobe.  That technique is called amygdalohippocampectomy.

Memory and language are very important functions of temporal lobe. Memory is one of the main functions of temporal lobes. With many years of seizures, patients with temporal lobe epilepsy already develop memory disturbances. For this reason, postsurgical memory disturbance may be minimal. To test the residual function and predict postsurgical impairment, WADA test is very helpful.

Corpus Callosotomy:

It was initially performed in 1939. In this technique the goal is to separate one hemisphere form another by cutting through the large bundle of connection fibers between these hemispheres. This fiber bundle structure is called corpus callosum. By this way seizure starting in one hemisphere will not spread to another therefore the patient will not have generalized seizures. It is successful in decreasing frequency of seizures with sudden loss of body tone, atonic seizures, tonic seizures, and generalized tonic clonic seizures. The patients will not fall during the seizures and will have less injuries. However corpus callosotomy does not make patients seizure free.

Hemispherectomy:

It is considered if seizures originate from large area of the hemisphere. It is usually caused by significant damage to one hemisphere such as birth trauma, malformations, strokes in utero, tuberous sclerosis, and Rasmussen encephalitis. This surgery is associated with significant residual deficits such as weakness, numbness, decreased vision, language and memory disturbance.

Nowadays to minimize the deficits, modified hemispherectomy is preferred. It involves separating upper lobes from deep central areas and from the other hemisphere. Upper lobes with blood supply area preserved on the other hand, the deep structures with corpus callosum are removed.

Multiple Subpial Transections:

If the seizure focus occupies an eloquent cortex, it cannot be removed.  Instead this technique was developed. It involves putting cuts parallel to each other over the cortex, being perpendicular to the long axis of the gyrus of the brain lobe. Postsurgical success varies and cannot be predicted. It can decrease the seizure frequency but unlikely it will provide seizure freedom. And its success can also be temporary.

Vagus Nerve Stimulator:

Vagus nerve stimulator (VNS) is a device that has been used in treatment of epilepsy.

It is designed to treat seizures by producing electrical signals transmitted to the brain through vagus nerve. It has been shown to decrease seizure frequency in humans.

VNS is an FDA approved electrical stimulation device to treat seizures. It is preferred in patients with refractory seizures but cannot be considered as surgical candidates. Also commonly used in patients who already have had brain surgery but still suffer from  refractory seizures.

VNS has two parts; generator (pacemaker) and wire. For the device insertion, two surgical incisions are made, one to implant the generator over the anterior left upper chest wall, the other one to wind the wire around vagus nerve on the left side of neck. VNS insertion is short procedure, taking about few hours. It is usually done as ambulatory surgery. The patient can go home the same day.

VNS is turned on two weeks after implantation. The interrogation and programming are done by the physician. The generator delivers stimulation automatically. VNS also has a magnet. If the magnet is wiped over the generator, it can cause generation of  extra stimulation by the device to stop seizures. The patient and families are instructed to wipe magnet over the generator when the patient feels aura or prodromal symptoms of seizures.

The other devices such as deep brain stimulation and neuropace have been used in clinical trials and have not been approved in the US yet.

Surgical Complications

Like any other type of surgery, the most common complications are bleeding and infection. This risk is about 1-2%. But these complications can be life threatening.

After brain surgeries, there may be leakage of cerebrospinal fluid through dura. It can cause persistent headaches and fluid collection under the scalp. This may require another surgery to stop leakage.

During the surgery nearby areas can be affected due to disturbed blood flow. It can manifest as a stroke. The patient may have motor and sensory symptoms or difficulty with language and vision. The symptoms depend on the location of surgery and proximity to eloquent regions.

Memory disturbance and loss of vision in the upper quadrants of visual fields can be seen after ATR. Psychiatric complications can also happen after ATR. It can vary from anxiety to psychosis.

Corpus callosotomy can cause lower extremity weakness which is usually temporary.  Also some patients may have disconnection syndrome such as trouble with following commands to perform certain tasks using arm, having trouble to control legs and arms from doing unintentional activities (Alien limb).

Hemispherectomy can cause significant motor and sensory function, vision loss on the opposite side of the surgery. The complications can be very debilitating, resulting in lower quality of life and functional status.

What Happens After Surgery?

Seizure outcome after surgery depends on epilepsy syndrome, type of surgical technique, and type of underlying pathology in the brain causing seizure. Seizure freedom or decrease seizure frequency can happen. Occasionally some patients may experience worsening of seizure control.

Surgery can be curative in resection of focal benign tumors. It may provide seizure freedom in about 90% of patients in 1 year after surgery. This is followed by antero-medial temporal lobe resection (ATR). ATR can provide seizure freedom about 65-80% in 1 year after surgery. After corpus callosotomy about 70-80% of patients experience around 50% decrease in seizure frequency. Usually tonic, atonic and generalized tonic clonic seizures decrease more than other seizure types after this procedure. Seizure freedom after hemispherectomy also depends on underlying syndrome and pathology.

• Should not have open fires.
• Have a soft, easy-to-clean carpet.
• Put safety glass in windows and doors.
• Try to use furniture with rounded corners.
• Avoid smoking or lighting fires when you’re by yourself.
• In bedrooms you should have a wide, low bed without top banks.
• Place night stands away from the bed.
• If you wander during seizures, make sure that outside doors are securely locked.
• In the kitchen try to limit use of electrical appliances only when someone else is in the house.
• Use a microwave if possible.
• Try not to use stove but if you will, use the back burners of the stove.
• Avoid carrying hot pans; serve hot food directly from the stove onto plates.
• Wear rubber gloves when handling knives or washing dishes or glasses in the sink and use pre-cut foods to limit the need for sharp knives
• Use plastic cups, dishes, and containers rather than breakable glass
• Inform  a family member or housemate before you take a bath or shower.
• Don’t lock the bathroom door instead hang an Occupied sign outside the door handle.
• Set the water temperature low so you won’t be hurt if you have a seizure while the water is running.
• Showers are generally safer than baths.

At work:

• You should inform and educate your co-workers about your condition-epilepsy and how to provide first aid for seizures.
• Avoid at being at height or near open places where fall can cause injury or drowning yourself.
• Avoid using heavy machinery.
• Wear protective clothing and helmet as needed.
• Try to avoid working long hours since sleep deprivation and physical stress can trigger your seizures.

Out and about:

• Carry only as many medications with you as you will need, and 2 spare doses.
• Wear a medical alert bracelet to let emergency workers and others know that you have epilepsy.
• Don’t isolate yourself without social life due to fear of having a seizure outside.

Sports:

• Exercise on soft surfaces.
• Wear a life vest when you are close to water.
• Avoid swimming alone without supervision.
• Wear head protection when playing contact sports or when there is a risk of falling.
• When riding a bicycle or rollerblading, wear a helmet, knee pads, and elbow pads.
• Avoid high traffic areas; while riding or skating.

The following tips will list the important things to balance your safety with the way to live your life with epilepsy. Some people with epilepsy may not make the changes below. Use this list to make your home and surroundings as safe as possible during or following a seizure.

Your family needs to be trained about your condition-epilepsy. These are the facts that everyone in your life should know:

1. What to expect when you have a seizure
2. How to provide seizure first aid
3. What to do to prevent choking during seizure
4. When to call 911 or  emergency help
5. If there is any rescue medication which can be provided by them during seizure such as diastat and wiping the magnet on your VNS during seizure

These  things increase the risk of a seizure, therefore you should avoid them:

• Missed medications
• Sleep deprivation
• Drinking a lot of alcohol
• Using illicit drugs
• Playing videogames or exposing to flashing lights if you have photosensitive epilepsy
• Emotional stress
• Missed meals

At home:

• Should not have open fires.
• Have a soft, easy-to-clean carpet.
• Put safety glass in windows and doors.
• Try to use furniture with rounded corners.
• Avoid smoking or lighting fires when you’re by yourself.
• In bedrooms you should have a wide, low bed without top banks.
• Place night stands away from the bed.
• If you wander during seizures, make sure that outside doors are securely locked.
• In the kitchen try to limit use of electrical appliances only when someone else is in the house.
• Use a microwave if possible.
• Try not to use stove but if you will, use the back burners of the stove.
• Avoid carrying hot pans; serve hot food directly from the stove onto plates.
• Wear rubber gloves when handling knives or washing dishes or glasses in the sink and use pre-cut foods to limit the need for sharp knives
• Use plastic cups, dishes, and containers rather than breakable glass
• Inform  a family member or housemate before you take a bath or  shower.
• Don’t lock the bathroom door instead hang an Occupied sign outside the door handle.
• Set the water temperature low so you won’t be hurt if you have a seizure while the water is running.
• Showers are generally safer than baths.

At work:

• You should inform and educate your co-workers about your condition-epilepsy and how to provide first aid for seizures.
• Avoid at being at height or near open places where fall can cause injury or drowning yourself.
• Avoid using heavy machinery.
• Wear protective clothing and helmet as needed.
• Try to avoid working long hours since sleep deprivation and physical stress can trigger your seizures.

Out and about:

• Carry only as many medications with you as you will need, and 2 spare doses.
• Wear a medical alert bracelet to let emergency workers and others know that you have epilepsy.
• Don’t isolate yourself without social life due to fear of having a seizure outside.

Sports:

• Exercise on soft surfaces.
• Wear a life vest when you are close to water.
• Avoid swimming alone without supervision.
• Wear head protection when playing contact sports or when there is a risk of falling.
• When riding a bicycle or rollerblading, wear a helmet, knee pads, and elbow pads.
• Avoid high traffic areas; while riding or skating.

Driving and Epilepsy

For you to be able to drive, your seizures should be well controlled. Every state has different rules administered by Department of Motor Vehicles(DMV). You should have seizure freedom to be able to drive. The duration of seizure freedom varies from 6 months to 2 years depending on each state’s DMV regulations.

The purpose of these regulations is to decrease the risk of harm to you and others due to your seizures while still realizing your need to drive to have your independence.

In most of states it is your responsibility to report DMV when you have your seizures. But your doctor may need to do so if he feels that you are jeopardizing your life with driving while your seizures are not well controlled.

Some type of seizures may be exceptions. If you have prolonged auras before your seizure or if you have seizures only in sleep, DMV may accept exceptions based on your doctor’s recommendations.

Once your license is suspended due to poorly controlled seizures, you need to make your best to take your medications in time, follow your doctor’s recommendations, keep your appointments, and fill your seizure calendar. Once you have optimal seizure control, you can contact DMW to appeal the suspension on your driving. And always wear a seatbelt while driving.

First Aid

The instruction for first aid should be known well by the patient’s family, friends and co-workers. Most of the time patients have brief GTC seizures which do not require hospitalization.

• Be calm and supportive. If you do not know the patient, check for medical alert bracelet or necklace. Call a family member or the patient’s doctor.
• If it is first seizure that the patient ever has had, call 911.
• Call 911 if the generalized tonic clonic seizures (GTC) last more than 3 minutes.
• Call 911 if the confusion state of complex partial seizure lasts more than 15 minutes.
• Turn the patient to his/her side during and after convulsion to prevent aspiration of saliva and patient’s own secretions.
• Do not put anything in mouth.
• Observe for injuries. If there is head and neck trauma, the patient should be immobilized.
• Remove any sharp items or furniture around the patient in case ongoing seizure or recurrent ones will cause injuries.

When to call 911, Emergency help?

If someone has a convulsive seizure for the first time, emergency help should always be asked. However in someone with established diagnosis of epilepsy, emergency help should be obtained under these conditions:

• If seizure lasts longer than 5 minutes
• If second seizure occurs before regaining consciousness after first seizure
• If there is significant injury during the seizure