EPILEPSY : BASIC FACTS
 Wendy W. Able
A patient with Epilepsy

Published by the Children's Clinic of Ocean Springs

Pediatrician Dr. George D. Fain, M.D.

Office Telephone (228) 875-1184 or 1185 -- 24 hours

OVERVIEW OF EPILEPSY

 Epilepsy is a chronic disorder of the brain that is characterized by the tendency to have recurrent seizures. The term epilepsy is interchangeable with the term seizure disorder. Epilepsy is not an illness or disease that you can catch from another person. Seizures are sudden, uncontrolled episodes of electrical discharges of brain cells which cause sensory, motor, and/or behavioral changes. Just as a fever is a sign of an infection, a seizure is a sign of a disorder, not the disorder itself. There are over 30 different types of seizures, but not all seizures indicate that the person has epilepsy.

A single seizure that does not recur would not be classified as epilepsy. The chance of having a single seizure during one's life is about 10%. The prevalence of epilepsy in the general population is about one percent or less (in the United States about two million people have seizure disorders). People of all nations and races can develop epilepsy. The disorder can develop at any time of life, but three-quarters of the 100,000 new cases every year begin in childhood, particularly in early childhood and around the time of adolescence.

Most people with epilepsy live normal lives except that they need to take medication on a daily basis. IQ tests of people with epilepsy indicate that their range of intelligence is similar to people without epilepsy. People with epilepsy are usually not mentally retarded or brain damaged. Seizures cannot usually cause brain damage even when they last for a long time (for example, anything over 10-15 minutes).

Some people with epilepsy have to remain on medication for their entire lives to control their seizures. Sometimes though, if a person with epilepsy goes a certain amount of time (usually 2 years) without having seizures, he or she can be weaned off of the anti-convulsant medication and often will live seizure-free for the remainder of her or his life.


AGES WHEN EPILEPSIES FIRST OCCUR


CAUSES OF EPILEPSY

In about half of all cases of epilepsy, there is no one cause that can be found. These are referred to as idiopathic - of unknown cause. Among the rest, epilepsy may be caused by any one of a number of things that make a difference in the way the brain works. For example, a head injury or lack of oxygen may damage the electrical system in the brain and cause a person to have epilepsy. Heredity can also be a factor in determining the cause of one's epilepsy, but in all cases, only about 8% are genetically based. Over 50% of all cases of epilepsy are idiopathic that is- no one knows why the epilepsy developed. Even with all of the technological advances in medicine, much is still unknown about the causes of epilepsy.

Much is unknown also about the specific causes of an actual seizure. What happens to the brain during a seizure is known though. The brain is the control center for the body. Normal electrical signals between cells make the brain and body work correctly. The cells work like on/off switches, turning electrical charges on and off automatically. Sometimes it is as if some cells get stuck in the +on+ position. This affects other cells and spreads to other parts or through all of the brain. For a person having the seizure, her or his usual awareness of the world is changed or his or her body might move automatically. Most seizures usually last a short time (a matter of seconds or two to three minutes), and then end naturally as special chemicals in the brain bring cell activity back to normal.


CAUSES OF SEIZURES

Different triggers for seizures exist for people with epilepsy. Sometimes stress or lack of sleep can bring on a seizure. A common cause of a seizure is a missed dose of medication. Some over-the-counter drugs can also cause seizures because of the interaction they might have with a person's anti-seizure medication. Use of certain illicit drugs like cocaine and amphetamines can also cause seizures. For some people with epilepsy, looking at strobe lights or a fan moving at a certain speed can trigger a seizure.

For many women, their seizures are related to their menstrual cycle in some way. The reason for the increased possibility of having a seizure during one's period is probably related to the hormonal changes that occur during menses; however, not enough research has been done in this area to know for sure. Many women say that their seizures occur only during their pre-menstrual or menstrual cycles.

Medical studies that have researched the causes of seizures have not been very successful in identifying all of the possible causes of seizures. However, many people with epilepsy know the feelings they get prior to a seizure and often try to pinpoint the specific causes of one of their seizures. For example, some know that if they have two or three nights without much sleep, they will usually have a seizure.

Obviously, some people with epilepsy can avoid certain activities or situations if they are aware that their seizures might be triggered by those stimuli; nevertheless, sometimes seizures result from natural cycles of the body and are unavoidable.


TYPES OF SEIZURES

Generalized seizures - involve electrical activity in both sides of the brain. This activity begins at the same time in both of the brain's hemispheres. Only the most common types of generalized seizures are defined here. The terms "grand mal" and "petit mal" have become outdated as more knowledge about the many different kinds of seizures has become available; also, those terms have negative connotations within American society. To classify seizures into only two categories has become inaccurate and outdated.

Tonic-Clonic Seizures (formerly known grand mal seizures) - Sometimes there is no aura accompanying this kind of seizure. It is a general convulsion of the whole body; during a tonic-clonic seizure, the person loses consciousness. The muscles in the body become rigid (tonic) and then begin to contract (clonic) in a jerking motion. These seizures usually last from 1 to 3 minutes, but can last much longer.

After a tonic-clonic seizure, the person often has a headache, is disoriented, and/or becomes sleepy. Sometimes excessive saliva is produced during the seizure, which people once thought meant that the person was 'foaming at the mouth.' The person having the seizure also often bites his or her tongue or cheek. Contrary to common myth, it is physically impossible that a person having a tonic-clonic seizure might swallow their tongue and choke.

Myoclonic Seizures- In this kind of seizure, the person usually experiences brief twitches on both sides of the body at the same time but they can occur on just one side of the body or the other. These involuntary movements are usually localized in the muscles of the neck, shoulders, upper arms, and upper legs; but often other parts of the body are also affected. Myoclonic seizures are often difficult to control with medication.

In juvenile myoclonic epilepsy, myoclonic seizures may be accompanied by absence or tonic/clonic seizures. This type of seizure usually begins between 10 and 20 years of age. In juvenile myoclonic epilepsy, seizures can be better controlled by medication. These seizures also affect the upper body area and often occur in the early morning. In juvenile myoclonic epilepsy, medication often has to be continued throughout the person's life, but control of seizures can be relatively thorough with a life-long regimen.

Clonic Seizures- These seizures involve jerking motions on both sides of the body without the tonic (stiffening) aspect. Also, after a person has a clonic seizure, she or he usually does not experience the period of confusion and tiredness that is associated with tonic-clonic seizures. 

Tonic Seizures- These seizures usually last about twenty seconds and involve an abrupt stiffening of the muscles in the body. Often, they occur while the person is sleeping.

Absence Seizures- (formerly called petit mal) These seizures are often mistaken for daydreaming or staring spells. There is no aura associated with absence seizures. These are often experienced in childhood and are often outgrown. Absence seizures usually last less than 10 seconds, but they can be longer. Simple absence seizures are just staring spells. Usually though, most absence seizures are complex: this means that in addition to the staring spell, the person might blink her or his eyes rapidly, rub his or her hands together, or move her or his mouth in a chewing motion.

Atonic Seizures- These usually last for very short periods of time and are associated with a sudden loss of muscle strength. This can cause the person to fall down; for his or her head to nod; for her or him to drop something, etc.. The danger involved with atonic seizures is that they occur suddenly and usually without warning; therefore, the person could fall down and injure themselves.

Partial Seizures-(formerly and often incorrectly referred to as petit-mal seizures) There are two main types of partial seizures : simple partial and complex partial.

Simple Partial Seizures Motor Seizures- These involve some kind of change in muscle activity, but unlike generalized seizures, this change is usually localized in one area of the body. Examples include twitching facial muscles or a jerking movement in a finger or an arm. Sometimes motor seizures can spread to the whole body and become generalized seizures or the seizure activity may stay localized in one area of the body.

Sensory Seizures- These seizures cause a person to have changes in sensation. Examples include distortions of actual sensations; smelling or hearing something that isn't there; hallucinations; and/or a feeling of numbness in a certain part of the body.

Autonomic Seizures- This kind of seizure causes changes in the autonomic nervous system - the part of the nervous system that controls involuntary body functions. Many of the features often experienced during an autonomic seizure (i.e., sweating, rise in heart rate, etc.) could be confused with a panic attack.

Psychic Seizures- Affecting the parts of the brain that interpret feelings and the experiencing of events, psychic seizures can have effects including garbled speech, difficulty in reading or speaking, or altered perceptions of time and memory. One type of psychic seizure causes sudden intense changes in a person's emotional state. Other types of psychic seizures cause feelings of deja vu, depersonalization (a feeling that one isn't one's self) or a feeling that one is in a dream. There are too many characteristics of psychic seizures to include them all, but an idea of what one might experience during a psychic seizure is explained above.

Complex Partial Seizures (also known as temporal lobe or psychomotor seizures) - During complex partial seizures, the person's consciousness becomes impaired, but she or he does not lose consciousness. Usually, the person stares and will not respond to commands or questions (if they do respond, the response is often inappropriate or incomplete). Other characteristics include involuntary movements such as chewing motions; lip smacking; tapping fingers; or grabbing motions. Rarer characteristics include running, screaming, and sometimes bizarre movements or actions.

Sometimes these behaviors are mistaken for inattentiveness or rudeness; with the more unusual behaviors associated with complex partial seizures, people might think that the person having the seizure has gone crazy. In this sort of situation, it becomes easy to understand how public lack of knowledge could negatively impact upon a person with epilepsy.

Complex partial seizures are usually preceded by some kind of aura. Often, after the seizure, the person is unaware that they have just had a seizure.


WHAT IS AN AURA?

An aura can be almost any kind of sensation experienced by a person before they have a seizure. Not every person with epilepsy has an aura before a seizure, but many do. It might be a feeling of fear or sickness, a strange smell or taste, irregular breathing, distorted sight, a hallucination (visual, audio, or kinesthetic), or just about any kind of abnormal feeling or sensation. Every person with epilepsy who does have an aura before his or her seizure has an aura that is unique to her or him, although some people may describe their auras in a similar manner. Sometimes auras are partial seizures which then develop into generalized seizures.


DIAGNOSING EPILEPSY

The most common tool for diagnosing epilepsy is an electroencephalogram (EEG). Electrodes are attached to the person's scalp and are connected to the EEG machine. The machine records the electrical activity in the brain. Often during the EEG, the person is asked to hyperventilate or open and close his or her eyes at certain intervals during which a strobe light is turned on and off. These activities are meant to increase chances of finding abnormalities in the EEG. Usually, an EEG lasts about 30 minutes, but sometimes a neurologist might want brain activity to be monitored for longer periods of time - up to 24 hours. In those cases, the person is connected to a kind of "mini" EEG machine that can be carried around easily.

A video EEG monitors people with both a video camera and an EEG simultaneously. Video EEGs are usually done during a hospital stay, but can be done on an outpatient basis. This kind of EEG allows the neurologist to see the kind of behavior that might accompany a person's seizure.
Another tool for diagnosis is a computed tomography scan (CT scan). CT scans use radiation (in very small, relatively safe amounts) to produce an image of the brain. This image can allow a neurologist to find any abnormalities in the brain that might be causing the epilepsy.
The newest method of creating an image of the brain is called magnetic resonance imaging (MRI). MRI provides a more detailed scan of the brain than a CT scan and can allow a neurologist to detect small scars or tumors that might be missed by a CT scan. Even though an MRI is completely safe (it doesn't use any radiation), some people experience claustrophobia due to the design of the machine.

Even with all of this technology, in more than 50% of the cases of epilepsy, a specific cause of the onset of a seizure disorder is never found. In other words, many people with epilepsy will never have an answer for the question, "Why do I have recurrent seizures?" This can often be frustrating for people with epilepsy who might wonder "What did I do to deserve this?" Eventually though, most people with epilepsy learn to live with their disorder and accept it as a part of their everyday life.


TREATMENTS FOR EPILEPSY

Epilepsy is not a disorder that can be "cured"; it can only be treated. But, it can often be treated successfully and many people with epilepsy can have many years go by without having a seizure.
The most common treatment for epilepsy is drug therapy. Until recently, very few anti-convulsant drugs were available. In the past few years, a number of new drugs have come onto the market which offer people with epilepsy more choices to find the medication that provides them with the best seizure control and the fewest side effects. Side effects of seizure medication differ from person to person, but usually a person's neurologist should be able to find a drug that allows one to experience the fewest side effects with good seizure control.
In cases where drug therapy is ineffective, other options do exist the most common of which are surgery and the ketogenic diet. Other alternative therapies are available, but most have not been well research as to their effectiveness in controlling seizures.


 Most Common Anti-Convulsant Drugs

BRAND NAME  GENERIC NAME  TYPES OF SEIZURES  POSSIBLE SIDE EFFECT
Dilantin phenytoin partial seizures, tonic-clonic seizures body hair increase, gum overgrowth, tremors, anemia, loss of coordination, double vision, nausea/vomiting, confusion, slurred speech
Tegretol carbamazepine partial seizures, tonic- clonic seizures drowsiness, dizziness, blurred vision, double vision, lethargy, nausea/vomiting
Depakote divalproex sodium absence seizures, tonic-clonic seizures, myoclonic seizures, partial seizures nausea/vomiting, indigestion, sedation, hair loss, tremors, weight gain
No common brand name phenobarbital partial seizures, tonic-clonic seizures drowsiness, lethargy, hyperactivity
Felbatol felbamate partial seizures, tonic-clonic seizures, atonic seizures, tonic seizures nausea, decreased appetite, weight loss, insomnia, severe anemia or liver problems
Neurontin gabapentin partial seizures, tonic-clonic seizures tiredness, dizziness, unsteadiness, weight gain
Lamictal lamotrigine partial seizures, tonic-clonic seizures, maybe absence and atonic seizures also double vision, dizziness, unsteadiness, headache, tiredness, rash. Although there are many other medications used to treat seizure disorders, we have only included the most commonly prescribed ones.

 

Surgical Treatments

There are two main kinds of surgery used to treat epilepsy.
In one kind of surgery, called a lobectomy, a section or lobe of the brain is removed. This is the most common type of epilepsy surgery. Most common is a temporal lobectomy in which all or part of the temporal lobe of the brain is removed. Usually, a temporal lobectomy is used to control complex partial seizures that are not controlled well with drug therapies. Before the surgery, the surgeon will assess whether or not removing these parts of the brain will affect the person's behavior.

The second major type of surgery to connote epilepsy is called a corpus callostomy. In this operation, no brain tissue is removed; instead, the nerve fibers that connect one side of the brain to the other are cut. This surgery is most often used to control generalized seizures in people who have not responded to drug therapies.

Surgery for seizures is only used as a therapy when all other options have failed. Prospects for surgery differ from person to person, but often, surgery can be successful when other remedies fail to work.

 

Ketogenic Diet

Most often used with young children, the ketogenic diet is a strict regimen that includes very few proteins or carbohydrates; instead, the diet is almost all fats. Intake of mostly fats causes a metabolic change in the body called ketosis. Once this state is attained, seizures are often controlled. The ketogenic diet is most effective with tonic, atonic, and myoclonic seizures, but all seizures can be controlled to some degree with this regimen. Because any variation in the diet could potentially cause a seizure, it must be carefully monitored by the person with epilepsy or the parent of a child with epilepsy.



BASIC FIRST AID FOR SEIZURES

For All Types of Seizures:


Additional Instructions for Tonic-Clonic Seizures:

 

Additional Instructions for Non-Convulsive Seizures:


A FEW FINAL WORDS...

Rarely do we experience such dramatic symptoms as with certain types of seizures. Throughout history, a substantial amount of superstition, misunderstanding, and unfounded fear have arisen around epilepsy and the people who have it. Even today, people with epilepsy are faced with many obstacles to their daily activities which are related more to the misconceptions of the general public than to their usually well-controlled disorder.

People with epilepsy are often restricted by state and other agencies which have specific requirements for drivers' licenses and other positions involving public safety. With growing public education, some of these regulations are appropriate to the disorder. However, many of these restrictions are outdated and need to be revised based on the present level of seizure control available through drug therapy.

Modern care offers excellent hope for the diagnosis, treatment, and understanding of epilepsy for almost all patients. If the public perception of the disease were as enlightened as the medical approach, most patients would have little to worry about other than taking their medications as prescribed.
If more people understood the truth about epilepsy, rather than believing the myths and old wives' tales, people with epilepsy would not be afraid to be open about their disorder and public perception could begin to change.


 REFERENCES
Devinsky, Orrin MD. A Guide to Understanding and Living with Epilepsy. F.A.Davis Company. Philadelphia, PA. 1994.

Various Pamphlets distributed by the Epilepsy Foundation of America, 4351 Garden City Drive, Landover, MD, 20785-9976

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