A. General Considerations

Epilepsy is a neurological disorder caused by unusual nerve cell activity in the brain.

Epilepsy is a brain disorder that causes repeated seizures. Seizures cause brief changes in how a person behaves, thinks, or feels. Uncontrolled seizures can interfere with life and lead to early death.

Epilepsy is a chronic noncommunicable disease of the brain that affects people of all ages.

Around 50 million people worldwide have epilepsy, making it one of the most common neurological diseases globally.

Nearly 80% of people with epilepsy live in low- and middle-income countries.

It is estimated that up to 70% of people living with epilepsy could live seizure- free if properly diagnosed and treated.

The risk of premature death in people with epilepsy is up to three times higher than for the general population.

Three quarters of people with epilepsy living in low-income countries do not get the treatment they need.

One seizure does not signify epilepsy (up to 10% of people worldwide have one seizure during their lifetime). Epilepsy is defined as having two or more unprovoked seizures. Epilepsy is one of the world’s oldest recognized conditions, with written records dating back to 4000 BCE. Fear, misunderstanding, discrimination and social stigma have surrounded epilepsy for centuries. This stigma continues in many countries today and can impact on the quality of life for people with the disease and their families.

What is a seizure?

A seizure is a short episode of symptoms caused by a burst of abnormal electrical activity in the brain. Typically, a seizure lasts from a few seconds to a few minutes. (Older word for seizures include convulsions)

The brain contains millions of nerve cells (neurons). Normally, the nerve cells are constantly sending tiny electrical messages down nerves to all parts of the body. Different parts of the brain control different parts and functions of the body. Therefore, the symptoms that occur during a seizure depend on where the abnormal burst of electrical activity occurs. Symptoms that may occur during a seizure can affect your muscles, sensations, behaviour, emotions, consciousness or a combination of these.

What is epilepsy?

If you have epilepsy, it means that you have had repeated seizures. If you have a single seizure, it does not necessarily mean that you have epilepsy. About 1 person in 20 has a seizure at some time in their life. It may be the only one that occurs. The definition of epilepsy is more than one seizure. The frequency of seizures in people with epilepsy varies. In some cases there may be years between seizures. At the other extreme, in some cases the seizures occur every day. For others, the frequency of seizures is somewhere in between these extremes.

Epilepsy can affect anyone at any age.

Epileptic seizures arise from within the brain. A seizure can also be caused by external factors which may affect the brain. For example, a high temperature (fever) may cause a febrile convulsion. Other causes of seizures include lack of oxygen, a low blood sugar level, poisons and a lot of alcohol. Seizures caused by these external factors are not classed as epilepsy.

B. TYPES OF EPILEPSY AND SEIZURES

A seizure is a short episode of symptoms caused by a burst of abnormal electrical activity in the brain. Typically, a seizure lasts from a few seconds to a few minutes.

If you have epilepsy, it means that you have had repeated seizures. If you have a single seizure, it does not necessarily mean that you have epilepsy. About 1 in 20 people have a seizure at some time in their lives. It may be the only one that occurs. The definition of epilepsy is more than one seizure.

Seizures are divided into two main types – generalised and focal (used to be called partial). (There are also other uncommon types of seizure.) The patient with epilepsy usually have recurrences of the same type of seizure. However, some people have different types of seizures at different times.

B.1. Generalised seizures

These occur if the abnormal electrical activity affects all or most of the brain. The symptoms tend to be general and involve much of your body. There are various types of generalised seizure:

• A tonic-clonic seizure is the most common type of generalised seizure. With this type of seizure the whole body stiffens, it is associated with loss of consciousness, and the body shakes (convulses) due to uncontrollable muscle contractions.
• Absence seizure is another type of generalised seizure. With this type of seizure the patient have a brief loss of consciousness or awareness. There is no convulsion, the patient do not fall over and it usually lasts only seconds. Absence seizures mainly occur in children.
• A myoclonic seizure is caused by a sudden contraction of the muscles, which causes a jerk. These can affect the whole body but often occur in just one or both arms.
• A tonic seizure causes a brief loss of consciousness and the patient may become stiff and fall to the ground.
• An atonic seizure causes the patient to become limp and to collapse, often with only a brief loss of consciousness.

B.2. Focal seizures

In focal seizures the burst of electrical activity starts in, and stays in, one part of the brain. Therefore, the patient will have localised (focal) symptoms. Different parts of the brain control different functions and so symptoms depend on which part of the brain is affected.

Sometimes a focal seizure develops into a generalised seizure. This is called a secondary generalised seizure.

Even if a seizure is diagnosed, it may be the only one you ever have. For this reason epilepsy is not usually diagnosed after a single seizure. The definition of epilepsy is recurrent seizures.

C. SEIZURE SYMPTOMS

Seizure types — One of the most common seizure types is a convulsion. This may be called a “tonic-clonic,” “generalized tonic clonic,” or “grand mal” seizure. In this type of seizure, a person may stiffen and have jerking muscle movements; during the muscle-jerking, the person may bite their tongue, causing bleeding or frothing at the mouth.

Other seizure types are less dramatic. Shaking movements may be isolated to one arm or part of the face. Alternatively, the person may suddenly stop responding and stare for a few seconds, sometimes with chewing motions or smacking the lips.

Seizures may also cause “sensations” that the person feels but are not visible to others. As an example, one type of seizure can cause stomach discomfort, fear, or an unpleasant smell. Such subjective feelings are commonly referred to as auras. A person usually experiences the same symptoms with each seizure aura. Sometimes, a seizure aura can occur before a convulsive seizure.

Seizure triggers — A minority of people have seizure triggers, such as strong emotions, intense exercise, loud music, or flashing lights. When these triggers are at play, they usually immediately precede the seizure.

Although they are more difficult to link to a seizure, other factors can also increase the likelihood that a seizure will happen. As an example, fever, menstrual periods, a lack of sleep, and stress can all increase the risk of seizures in some people.

Missing doses of seizure medicine prescribed to a known patient makes him/her likely to have more seizures and is a common cause of breakthrough seizures and emergencies.

For many seizure types, the patient may be unaware during the seizure. When he/she is told about his/her behavior during the seizure, he/she may not believe it because he/she have no memory of the event.

The period following a seizure is called the postictal state (after a seizure). During this time, the patient may be confused and tired, and may develop a throbbing headache. This period usually lasts several minutes, although it can last for hours or even days.

In some people, the postictal period comes with certain symptoms. For example, the patient may experience mild to severe weakness in a hand, arm, or leg. Other people have difficulty speaking or experience temporary (partial) vision loss or other types of sensory loss. These can be important clues about the type of seizure and the part of the brain that was affected during the seizure.

D. SEIZURE CAUSES

Not all the seizures are caused by epilepsy. There are three main categories of seizure causes:

• Epileptic seizures – People with epilepsy have a type of brain dysfunction that intermittently causes episodes of abnormal electrical activity. This can be caused by any type of brain injury, such as trauma, stroke, brain infection, or a brain tumor. In some individuals, epilepsy is an inherited condition. In many cases, the cause of epileptic seizures is not clear.

• Provoked seizures – A similar type of abnormal electrical activity in the brain can be caused by certain drugs, alcohol withdrawal, and other imbalances, such as a low blood sugar. Seizures that are caused by problems like these are called “provoked” seizures, and they do not usually occur again once the problem is remedied. People with provoked seizures are not said to have epilepsy.

• Nonepileptic seizures – Nonepileptic seizures look like seizures, but are not caused by abnormal brain activity. These seizures may be due to fainting spell, a muscle disorder, or a psychological condition.

E. SEIZURE DIAGNOSIS

If you have a seizure and have never had one before, your doctor will want to get as much information about the seizure as possible. He or she will want to know a detailed description of the episode, including whether you lost consciousness, stared blankly, or twitched and jerked violently. The more information your doctor has about your seizure, the better able he or she will be to make the right diagnosis.

If a witness to the seizure is available and can come to the appointment or be contacted later, this can be very helpful to the physician.

In some cases, an underlying brain condition or brain damage causes epilepsy. Some conditions are present at birth. Some conditions develop later in life. There are many such conditions – for example:

• A patch of scar tissue in a part of the brain.
• A head injury.
• A stroke.

Some genetic syndromes.

• Growths or tumours of the brain.
• Previous infections of the brain, such as meningitis and encephalitis.

The condition may irritate the surrounding brain cells and trigger seizures.

Some underlying conditions may cause no other problems apart from seizures. In other cases, the underlying condition may cause other problems or disabilities in addition to the seizures.

Tests and procedures — depending on the circumstances of the seizure, age, and patient’s individual situation, the doctor may order one or more tests, including:

• Blood tests may be done to check for problems (such as low or high blood sugar) that may have caused your seizure, and to check for markers in the blood that could point to the type of seizure you had.

• Lumbar puncture may be done after a seizure to check for signs of infection. This is usually done in an emergency room, if the individual does not seem to be recovering normally from the seizure, or if the person has a fever or other signs of brain infection.

• Electroencephalography (EEG) may be done to check for abnormal electrical activity in the brain. The test is painless. Some types of seizure produce typical EEG patterns. However, a normal recording does not rule out epilepsy, and not all EEG abnormalities are related to epilepsy.

• Brain imaging studies (brain scan), such as MRI or CT scans, may be done to check for tumors, strokes, or other structural problems in the brain. However, these tests are often normal in people with epilepsy.

Although helpful, tests are not foolproof. It is possible to have epilepsy with normal test results. Also, if an abnormality is found on a brain scan, it does not prove that it causes seizures. However, tests may help to decide if the event was a seizure or caused by something else.

Sometimes no firm cause can be found to explain the event. Other conditions can look like seizures – for example, faints, panic attacks, collapses due to heart problems, breath-holding attacks in children.

A doctor may advise to wait and see if it happens again if there is doubt about the diagnosis.

F. Treatment for Seizures and Epilepsy.

Getting good medical care for epilepsy and seizures is a team effort, and the patient is the most important member of the team. The doctor and all other health care providers involved needs accurate information which are critical – it helps them sort out if the patient have seizures and/or what type of epilepsy the patient has. It also helps them choose which medicine may be best for the patient’s condition.

Epilepsy is often “invisible” to doctors, since seizures don’t usually happen during an office visit. That means your doctor is relying on patient’s description of how seizures are like, how often they happen, and how they affect his/her life.

Keepping a seizure diary to track any seizures or other symptoms is important to provide accurate and detailed information. Other important information which will help the doctor to take the best decisions is the list of all the medicines used by the patient – including any vitamins or herbal remedies – and the frequency or the amount of the medicines taken.

The appropriate treatment of the seizure will depend upon the type of seizure and whether the seizure was caused by epilepsy or another factor.

As an example, if the seizure was caused by an infection affecting the brain, treatment of the infection should prevent from having more seizures. Likewise, if the seizure was caused by a psychological problem, such as anxiety, treatment of the psychological problem may remedy the seizures.

The management of patients with epilepsy is focused on three main goals: controlling seizures, avoiding or minimizing treatment side effects, and maintaining or restoring quality of life.

Seizure medications — In case of epilepsy or if the seizure was caused by a stroke, tumor, or some type of permanent brain injury, the patient may need to take one or more antiseizure medications, sometimes referred to as anticonvulsant or antiepileptic medications.

Treatment can help most people with epilepsy have fewer seizures or stop having seizures completely.

Treatments include:

• medicines called anti-epileptic drugs – these are the main treatment
• surgery to remove a small part of the brain that’s causing the seizures
• a procedure to put a small electrical device inside the body that can help control seizures
• a special diet (ketogenic diet) that can help control seizures

Some people need treatment for life. But you might be able to stop treatment if your seizures disappear over time. Other people may not need any treatment if he/she knows seizure triggers and he/she is able to avoid them.

Anti-epileptic drugs (AEDs)

AEDs are the most commonly used treatment for epilepsy. They help control seizures in around 7 out of 10 of people. AEDs work by changing the levels of chemicals in your brain. They do not cure epilepsy, but can stop seizures happening.

AEDs are available in a number of different forms, including tablets, capsules, liquids and syrups. The patient usually needs to take the medicine every day. Any sudden interruption in taking AEDs can cause a seizure.

G. Living with epilepsy

Epilepsy is usually a lifelong condition, but most people with it are able to have normal lives if their seizures are well controlled.

Most children with epilepsy are able to go to a mainstream school, take part in most activities and sports, and get a job when they’re older.

But the patient may have to think about his epilepsy before performing things such as driving, certain jobs, swimming, using contraception and planning a pregnancy.

As epilepsy can affect people in different ways, everyone’s experience of living with the condition is different. But there are some general points that can help.

Controlling the seizures – seizures can be dangerous, so it’s important to try to keep them as well controlled as possible by:

• Taking the medicines as prescribed (without interruptions). If any unpleasant side effects may cause patient to skip a dose or stop taking the prescribed medication, this should be done only after getting medical advice, as it could cause a seizure.
• Identification and avoidance of seizure triggers.
• Regular reviews of epilepsy evolution and treatment by the GP or neurologist.
• Using safety measures at home, sport and leisure, work to avoid accidental injuries during a potential seizure.

H. Complications – Sudden unexpected death in epilepsy (SUDEP)

Sometimes a person with epilepsy dies during or after a seizure for no obvious reason. This is known as sudden unexpected death in epilepsy (SUDEP).

SUDEP is rare, but it’s important to be aware of the danger because it may sometimes be preventable.

The main thing you can do to reduce your risk is to make sure your epilepsy is well controlled. You can do this by taking your medicine as recommended and avoiding seizure triggers when possible.

If:

• You had a seizure, and you need medical advice,

or

• You have epilepsy and you are worried that your condition is poorly controlled

Contact a medical consultation or advice from a neurology specialist/epilepsy center: