About Epilepsy

Introduction to epilepsy research
By Dr. Orrin Devinsky

Research in epilepsy is focused on trying to understand the process that leads the brain to have seizures as well as trying to discover new and better ways to treat epilepsy. Our ability to define the different problems that can lead to epilepsy at genetic, molecular, and cellular levels will help us to target prevention and therapy. For example, recent research suggests that some forms of epilepsy result from disorders in ion channels; drugs that influence ion channels can help to control seizures. Other research has shown that excessive immunological responses (autoimmunity) can irritate brain cells and provoke seizures, and that seizure activity can lead to increased immunological activity.

Epilepsy is a disorder, not a disease. Anything that injures the brain or affects its functions has the potential to cause seizures. Epilepsy research is directed at trying to find common pathways that underlie epilepsy. Large multicenter studies that pool data from many sites may help us to collect a sufficiently powerful set of data to better understand the genetics of why epilepsy is difficult to control in some individuals while others have bad side effects to specific medications.

Increasing public awareness about epilepsy and advocating for patients and families remains critical for improving the quality of lives for people with epilepsy NOW. Our society often discriminates or creates obstacles for individuals with medical problems, especially those with disorders that are misunderstood. And epilepsy is the paradigm of a disorder in which lack of information and misinformation is common among the general population. Increasing awareness can make the school, work, and life with epilepsy much easier and much more productive.

*Orrin Devinsky is Professor of Neurology, Neurosurgery, and Psychiatry at NYU School of Medicine. He directs the NYU Comprehensive Epilepsy Center and the Saint Barnabas Institute of Neurology and Neurosurgery. He also currently directs the Phenome Core for the Epilepsy Phenome Genome Project. Orrin founded Finding A Cure Against Epilepsy and Seizures (FACES) and co-founded epilepsy.com and the Epilepsy Therapy Project. He currently serves as the President of the Epilepsy Research Foundation and has served on boards of the American Epilepsy Society and local and national Epilepsy Foundation. He has published widely in epilepsy and behavioral neurology, with more than 250 articles, 50 chapters and 20 books and monographs.

What is Epilepsy?

Epilepsy is a neurological disorder of the central nervous system, specifically of the brain . It is characterized by the tendency to have recurrent seizures.

A person would be diagnosed with epilepsy if they have at least two unprovoked (or reflex) seizures, or one unprovoked (or reflex) seizure and are very likely to have another, or diagnosed with an epilepsy syndrome.

The International League Against Epilepsy (ILAE) recently classified epilepsy as a disease, instead of a disorder, to better convey that epilepsy is a serious medical condition.

The brain is made up of billions of nerve cells or neurons that communicate through electrical and chemical signals. When there is a sudden excessive electrical discharge that disrupts the normal activity of the nerve cells, a seizure may result.

Seizures cause a change in function or behavior. A seizure may take many different forms including a blank stare, muscle spasms, uncontrolled movements, altered awareness, odd sensations, or a convulsion. The location in the brain of the abnormally discharging nerve cells determines the form the seizure will take. Seizures may occur rarely or as often as numerous times a day. If the condition is successfully controlled by medication, a person may be seizure free.

Epilepsy is one of the most common chronic neurological disorders. An estimated 50 million people worldwide have epilepsy. That means approximately one percent of the general population has epilepsy.

Epilepsy can be present at any age although its onset is most often in childhood or in the later years of life. Sometimes those who develop seizures during childhood outgrow their seizures. In the elderly, there is an increased incidence due to strokes and aging of the brain. In more than half of those with epilepsy, seizures can be well controlled with seizure medication.

EPILEPSY IS HIGHLY TREATABLE

70% of people with epilepsy can gain seizure freedom with medication alone.

30% of people have drug-resistant epilepsy. There are additional treatments for people with drug-resistant epilepsy that can improve seizure control or stop seizures altogether.

A person has drug-resistant epilepsy if they have not achieved seizure freedom with adequate trials of two antiseizure medications[3]. There are a variety of treatment options for drug-resistant seizures including surgery[4], medically-managed diet therapy, and nerve stimulation. Treatment options for drug-resistant epilepsy should be evaluated at a comprehensive epilepsy program.

[3] Kwan P et al. (2010) Definition of drug resistant epilepsy: consensus proposal by the ad hoc Task Force of the ILAE Commission on Therapeutic Strategies.Epilepsia51:1069-1077.http://onlinelibrary.wiley.com/doi/10.1111/j.1528-1167.2009.02397.x/full

[4] Wiebe S et al. (2001) A Randomized, Controlled Trial of Surgery for Temporal-Lobe Epilepsy.N Engl J Med345:311-381.http://www.nejm.org/doi/full/10.1056/NEJM200108023450501#t=article

 

What is a seizure?

A seizure is a brief, abnormal, excessive surge of electrical activity in the brain that produces a sometimes noticeable change in behaviour. There are many different types of seizures, which may reflect the area from which the seizure begins (seizure focus) and the pattern in which the abnormal electrical discharge spreads through the brain.

The person may experience body sensations such as “pins and needles”, smells, sounds, fear, depression, distortions of sensory stimuli, momentary jerks or head nods, staring with loss of awareness and convulsive movements.

Seizures usually last seconds to minutes, rarely longer. The period immediately after a seizure, called the “postictal period,” varies depending on the duration, intensity, and type of seizure. The most common symptoms that a person may experience immediately after a convulsive seizure are confusion, muscular ache, headache, and fatigue.

Some people experience what is called an aura.—an “early warning system” for seizures. An aura is a strange sensation or feeling that is in fact a simple partial seizure (see Seizure Types below). Auras may consist of dizziness, an unusual feeling in the stomach, buzzing in the ear, a powerful emotion, or just about any sensation at all. Many people don’t realize they have an aura until they review their symptoms with a physician.

After you have a seizure, try to remember if you noticed anything unusual at the beginning, (such as an unexplained feeling or sensation) and write it down. After a while, if you notice a pattern, then you may have found an early warning system for your seizures.

Identifying an aura can be helpful. You may be able to take quick precautions to ensure safety for when the seizure occurs. Also, the symptoms experienced during an aura may help your physician “localize” your seizures.

Classification and seizure types

A seizure is an electrical disturbance in the brain caused by brain cells firing in a highly rhythmic fashion. The kind of seizure a person has depends on which part and how much of the brain is affected by the electrical disturbance.

Different parts of the brain are specialized to do different things. There are parts of the brain that help us speak, understand those around us, and coordinate our movements. Our brains are involved in everything we experience, think, say, feel or do. Any one of these functions can be altered or disrupted during a seizure. A seizure may take many different forms, including a blank stare, uncontrolled movements, altered awareness, odd sensations, or convulsions.

Seizures are usually brief and can last anywhere from a few seconds to a few minutes. The brain is very good at stopping seizure activity. Immediately afterwards, a person may have no lingering effects or they could experience temporary effects, such as muscle weakness or confusion.

SEIZURE CATEGORIES

Seizures are divided into three main categories: Focal Onset , Generalized Onset , or Unknown onset . The category is determined by the location of the seizure activity within the brain at the beginning of the seizure.

Seizures may also be described as either motor or nonmotor, depending on whether or not muscle movement is involved.

The description of what happens during the seizure, along with any changes that happen before or after the seizure, are important features used by a healthcare provider to determine the seizure category and the seizure type. The duration of the seizure is another important feature. http://www.canadianepilepsyalliance.org/wp-content/uploads/2019/02/New-Epilepsy-Classification.pdf

 

 

FOCAL SEIZURES Focal seizures start in a particular site, or ‘focus’, within one brain hemisphere. The location of the seizure activity in the brain will determine what the seizure will look or feel like.

A focal seizure in the part of the brain responsible for hearing could cause a sudden but temporary distortion in sound or the person could hear a sound that isn’t there (i.e. an auditory hallucination). A focal seizure in the part of the brain responsible for controlling finger movements could cause a sudden twitching of one or more fingers on the opposite side of the body.

Focal seizures can vary a lot from one person to another because of the wide range of functions that our brains control. However, an individual with a single seizure focus usually has the same experience each time their seizure starts.

FOCAL AWARE SEIZURES

During this type of seizure, a person will be alert, aware of everything that is happening, and able to have a conversation with others. People often refer to this seizure as an aura if they experience things that are not visible to others such as an unusual feeling.

Focal aware seizures could also result in visible changes, for example twitching of certain muscles on one side of the body or an uncontrollable movement.

FOCAL IMPAIRED AWARENESS SEIZURES

This type of focal seizure causes a change in awareness or in thinking abilities. During a focal impaired awareness seizure, a person may have trouble communicating or understanding language. They might have a blank stare and could be unresponsive. Some people exhibit repetitive movements or automatic behaviours, such as chewing movements, rearranging objects or fiddling with clothing. Healthcare providers call these behaviours “automatisms”. Some people wander during a focal impaired awareness seizure.

Some individuals who exhibit unusual behaviours during a focal impaired awareness seizure could be mistaken for being under the influence of alcohol or drugs. People could also be mistakenly viewed as uncooperative if they do not respond to someone’s questions or instructions during the seizure.

The seizure activity may remain in the part of the brain where it began, or it may spread to other areas in the brain. Some focal seizures evolve to abilateral(both the left and right hemispheres)tonic-clonic seizure.

FOCAL TO BILATERAL TONIC-CLONIC SEIZURE

Focal to bilateral tonic-clonic seizures start in a limited area on one side of the brain and spread to involve both sides. This differs from a generalized onset tonic-clonic seizure, which starts on both sides of the brain.

Another difference is that Focal onset seizures have an abnormal region of the brain leading to the electrical storm of a seizure. Testing may not detect the place or cause of focus, while Generalized onset seizures are believed to result from neurochemical and/or genetic abnormalities widespread throughout brain, and no focal injured brain region is involved.

Bilateral tonic-clonic seizures: happen in more than 3 out of 10 people with focal epilepsy.
Sometimes the person will not recall the beginning of the seizure the seizure may spread quickly so the first part is hard to see. This part usually lasts seconds to less than a minute. The bilateral tonic-clonic part of these seizures usually lasts less than 2 or 3 minutes. After the seizure, consciousness returns slowly, and the person may be drowsy, confused, agitated, or depressed. Some people may need to rest for a few hours after a seizure, while others return to their pre- seizure state within minutes.
If the person does not return to their pre-seizure state, or if another seizure occurs before they return to their pre seizure state, this may be a sign of a seizure emergency called status epilepticus.
A person who has repeated or long tonic-clonic seizures (longer than 5 minutes) needs immediate medical help. Call 911. People who have had tonic-clonic seizures should talk to their health care team about first aid, when to go to the hospital, creating a seizure response plan, and whether rescue therapies are required.

When a focal impaired awareness seizure ends, the person may initially be confused and disoriented. This can make it difficult to tell exactly when the seizure (or ictal period) has ended and the post-ictal phase that follows the seizure has begun.

 

GENERALIZED SEIZURES

Generalized seizures quickly spread across the left and right hemispheres of the brain. Many, but not all, generalized seizures are associated with a loss of awareness.

Most generalized seizures cause changes in the body’s muscles, such as a stiffening of the muscles (tonic), a decrease in muscle tone (atonic), rhythmic jerking movements (clonic), or a sudden twitch or jolt-like movement (myoclonic). These various types of muscular changes are associated with different types of generalized seizures, as listed below, but could occur during focal seizures too.

There are six main types of generalized seizures: Tonic-Clonic, Absence, Clonic, Tonic, Atonic, and Myoclonic.

 
 
GENERALIZED OR UNKNOWN ONSET TONIC CLONIC

For most people, this is the type of seizure they think of when they think of epilepsy. During the seizure there are two phases, tonic (a stiffening of the muscles) and clonic (rhythmic jerking of the muscles). These phases can happen in any order, but most often the tonic phase is first, followed by the clonic phase.

Generalized or Unknown Onset Tonic-clonic seizures can occur if someone has generalized onset epilepsy and the seizure is a generalized seizure from the very start. A tonic-clonic seizure can also occur if someone has focal epilepsy if their focal seizure evolves to become a bilateral convulsive seizure. Generalized Or Unknown Onset Tonic-clonic seizures can also occur when people do not have epilepsy and can be brought on (or provoked) by various things such as fever, infection, low blood sugar, or alcohol withdrawal.

The typical length of a Generalized or Unknown Onset tonic-clonic seizure is from under a minute to a few minutes. Like other seizures, these seizures generally run their course and end naturally on their own. When the person regains consciousness, they will usually be confused and will gradually reorient themselves to where they are and what has happened. People are often tired and sore after a Generalized or Unknown Onset tonic-clonic seizure and may want to rest.

 

GENERALIZED ABSENCE SEIZURES

These seizures are very brief, about 9 seconds on average. The most striking feature is a blank or vacant look that could be misinterpreted as a brief episode of daydreaming. The blank look may be the only outward sign, although some people have other features that could include eye movements, blinking or automatic behaviours.

An generalized absence seizure would typically start abruptly and end abruptly. After the brief seizure, the person will generally carry on with whatever they had been doing before. These seizures can go unnoticed, or, if noticed, they may not be recognized as being a seizure.

CLONIC SEIZURES

These seizures cause rhythmic jerking movements. When the rhythmic jerking movements are the only feature, it is a clonic seizure. These types of movements occur more frequently in association with a phase of muscle stiffening (see generalized or unknown onset tonic-clonic seizures above). These seizures may also have a focal onset.

 
TONIC SEIZURES

These seizures cause the muscles to stiffen. If a person is standing, a sudden increase in muscle tone could cause them to fall. Some people call this a “drop attack”. Generalized tonic seizures could also cause a sudden stiffening (or contraction) of the muscles in both arms. These seizures usually last less than 20 seconds, but sometimes they could be up to about 60 seconds. These seizures may also have a focal onset.

 
FOCAL OR GENERALIZED ATONIC

These seizures cause a loss of muscle tone, which means the individual suddenly becomes limp. If a person is standing, the sudden loss of muscle tone will cause them to fall. Therefore, both generalized or unknown onset tonic seizures and focal or generalized atonic seizures can be associated with episodes that people may refer to as drop attacks. These seizures may also have a focal onset.

 

FOCAL OR GENERALIZED MYOCLONIC

These seizures are extremely brief, jolt-like movements that resemble a startle response. For example, an individual could have a sudden jerk of their upper arms or shoulders. Sometimes the muscle contractions are subtle and may not be visible to an observer. These seizures are usually less than a second in length. They may also have a focal onset.

 
WHAT ARE EPILEPSY SYNDROMES?

When a person’s seizure disorder has a characteristic group of features, it is called a syndrome. Syndromes have a cluster of symptoms or signs that define them. Some of the most common or well-defined epileptic syndromes are febrile seizures, infantile spasms, Lennox-Gastaut syndrome, Benign Rolandic epilepsy, juvenile myoclonic epilepsy, progressive myoclonic epilepsy, reflex epilepsies, temporal lobe epilepsy, and frontal lobe epilepsy.

WHAT IS STATUS EPILEPTICUS?

Seizures usually end naturally after a few seconds or minutes, but on rare occasions a seizure doesn’t stop. When a seizure goes on longer than 30 minutes, or repeats in a series, the person is in status epilepticus. This state of continuous seizure activity can happen with any type of seizure. Status epilepticus is considered a medical emergency. When a seizure is continuous for a period longer than 30 minutes, or repeats in a series without the individual regaining their normal level of consciousness during the 30-minute period, this is traditionally defined as a person in status epilepticus.

 

 

How is epilepsy diagnosed?

There are a number of resources a physician will use to determine the diagnosis of epilepsy. Medical history obtained from the patient is essential to the diagnosis. A careful description of the circumstances and events before, during and after the seizure provides critical clues in determining if the diagnosis is epilepsy. Reports from the patient and witnesses provide valuable information to the physician.

There are tests conducted which may help determine the diagnosis of epilepsy. Not all patients require all of these tests.

a) Electroencephalogram (EEG) is the most specific test for diagnosing epilepsy because it records electrical brain function (remember, epilepsy is a disorder of abnormal electrical function). By using small electrodes (flat metal disks) attached to the scalp with a sticky paste, the electrical activity produced by the brain is recorded. The test is painless and harmless and takes approximately one and a half hours from start to finish.

Sometimes the brain functions perfectly normally during an EEG. Therefore, patients with epilepsy do not necessarily always show an EEG abnormality with a single recording. The abnormal electrical discharges are more likely to be detected after multiple or prolonged recordings. Persons may sometimes be asked to stay awake all night before having an EEG because abnormal electrical activity may express itself during the EEG test after sleep deprivation. The EEG pattern recorded helps define the type of the seizures.

b) Video EEG Telemetry
A routine EEG (even with sleep deprivation) may not provide the information needed for diagnosis and treatment. It may be necessary to record the EEG during actual seizures. To undergo Video EEG Telemetry, a person must be admitted to hospital and be monitored, both by EEG and a video camera, twenty-four hours a day. Video EEG Telemetry is critical in the preoperative evaluation of persons being considered for epilepsy surgery.

c) Computerized Axial Topography (CT Scan) examines brain structure. During a CT Scan, a thin beam of X-rays is focused around the head. The X-ray tube moves around the site taking many pictures which are processed by a computer. A special “dye” may be injected to make the pictures clearer.

This test is performed to try and identify a cause for the epilepsy or seizures (stroke, tumor, etc).

d) Magnetic Resonance Imaging (MRI Scan) provides very precise and life-like pictures of brain structure, using a very large magnet, radio waves and computer. Like the CT scan, the MRI scan is also performed to try to find a cause for the diagnosis of epilepsy.

e) Neuropsychology
Memory problems and other cognitive difficulties are common in persons with seizures. The psychologist who performs the neuropsychological evaluation will assess your particular situation. This is done through an interview and some testing. The psychologist will ask about how epilepsy has affected your personal, social, academic, and vocational life. In addition, the psychologist will give you paper and pencil tests of memory, attention, thinking, reasoning motor skills, language, and spatial skills. The neuropsychological evaluation takes about five hours broken up into shorter sessions.

A neuropsychological evaluation can discover if speech functions are controlled by the left or right side of your brain. Secondly, the pattern of strengths and weaknesses you show on the test results tells the doctor what parts of the brain might be healthy or compromised. Thirdly, the neuropsychological evaluation can assist in the identification of epilepsy surgery candidates who might be at risk for serious memory or speech disorders.

f) Sodium-Amytal Testing
Prior to epilepsy surgery, a patient may undergo sodium-amytal testing in order to make sure that memory and speech functions are not located in the part of the brain that will be removed. The neuroradiologist injects a medication into the blood supply to the brain, putting half of the brain to sleep for approximately 10 minutes. During that time, the neuropsychologist questions the patient to reveal which functions are preserved in the “awake half” of the brain. The sodium-amytal test takes approximately one hour to complete.

How common is epilepsy?

Researchers tell us that between 0.5 and 1% of the population suffers from epilepsy – an estimated 50 million people worldwide. Most epilepsy begins at the extremes of age (childhood and old age) but new cases can develop at any age (depending on the cause).

Is epilepsy inherited?

Some types of epilepsy have an inherited pattern. Most commonly these are forms of the generalized epilepsies that begin in childhood or adolescence. Some people have certain inherited diseases (rare in occurrence) that have epilepsy as one feature of the illness. When epilepsy is the sole manifestation of the illness, there is a low probability of inheritance.

How is Epilepsy Treated?

Antiepileptic drugs are the principal therapy for treating epilepsy. These drugs do not cure epilepsy but attempt to control it by suppressing seizures. The ultimate goal of antiepileptic drug therapy is to establish perfect seizure control and minimal or no side effects from medication. Sometimes long-term seizure control may not be possible because of the underlying cause.

Drug therapy must be individualized. It is important for the patient to be an active participant in the discussion and treatment of his or her epilepsy. Open communication between the physician and patient about what to expect, what is experienced, what is tolerable, and the impact of both adverse medication effects and seizures on the quality of life is the best way to manage drug therapy. The person’s lifestyle and cost of the drug are additional factors which the physician must take into consideration when recommending a particular medication for seizure control.

When drug treatment of epilepsy is started, it may take several months of adjusting dosages and trying different drugs before optimal effects can be achieved.

How does antiepileptic medication work?

Antiepileptic drugs (AEDs) must be taken daily in order to maintain a steady level of drug in the bloodstream and brain to be effective in preventing seizures. Some drugs are more effective for certain types of seizures than others.

After a medication is swallowed it is absorbed into the blood and exerts its effect by eventually getting to the brain. Some drugs are broken down to other chemicals in the liver; some are excreted unchanged by the liver and kidney. The speed that this occurs varies from person to person, drug to drug, and by the presence of other medication. For these reasons, some medications may need to be taken more frequently in order to maintain a relatively constant level of medication in the bloodstream.

The level of some drugs in the blood may be measured in order to better adjust the dosage and study how the body absorbs and metabolizes a particular drug. When a medication is added or its dosage changed, it usually takes several days before the body establishes a new steady level of the drug.

Blood levels are not generally required once the patient has achieved optimal seizure control unless adverse side effects are evident. Some of the new medications do not require measurement of blood levels.

Here are some helpful tips on gaining the best possible seizure control:

  • Medication must be taken as prescribed and no changes should be made without consulting your doctor. One of the most common reasons for treatment failure is poor patient compliance (not taking medications as prescribed).
  • It may be helpful, as a reminder, to take your medication in association with routine daily activities (e.g. tooth brushing, meals, and bedtime).
  • If a dosage of medication is missed, it is recommended you make it up with your next dosage. To avoid missing a dosage you may wish to purchase a daily pill counter at your local pharmacy to carry with you at all times.
  • Check how many refills are left on your prescription bottle before your next visit to the physician or pharmacist.
  • Always refill prescriptions in time and have an “emergency” supply of medicine on and. Running out of medication or suddenly stopping medication may lead to repeated, closely-spaced seizures with serious consequences.
  • Before taking other medications, check with your doctor or pharmacist about interactions with antiepileptic drugs. For example, aspirin, certain antibiotics, and anti-inflammatory drugs may produce important drug interactions. Occasionally birth control pills are made less effective by some antiepileptic medications.
  • It is advisable to avoid excessive sleep deprivation and excessive alcohol and recreational drug use. Complete avoidance may be preferable.
  • When undergoing any dental or surgical procedure it is important that your doctor be consulted to determine how to arrange medication doses on the day of the surgery. Your surgeon and anesthetist should be informed of your epilepsy and medication.
  • When there is too much drug in the blood, symptoms of toxicity occur that are similar for most antiepileptic medications. The most common symptoms are dizziness, blurred vision, drowsiness and loss of balance. Other symptoms of medication excess can occur that are unique to a particular drug. Consult your doctor if you experience any of these symptoms. Some antiepileptic drugs require periodic blood tests to look for rare toxic effects on the blood and liver, especially when starting a new or different drug therapy.
  • Generic preparations may at times be substituted for brand name medications with your doctor’s approval. It is best to be consistent with taking either a generic brand or brand name rather than switching from one to the other. The body may handle different preparations of the same drug in a different manner.
  • When taking phenytoin (Dilantin), careful dental and gum care, as recommended by a dental hygienist or dentist, is necessary to avoid gum problems.
  • For persons taking antiepileptic drugs, family planning is an important issue. To ensure optimal outcomes for both mother and child, a physician must be consulted prior to conception. A special meeting time should be arranged so that the couple can discuss this very important issue with the doctor.
  • Some antiepileptic drugs have the potential to cause birth defects in a small percentage of births. All women with epilepsy who are of child bearing age should take Folic Acid (at least 5 milligrams each day). Drug therapy may need to be changed prior to and during pregnancy. It is advisable that the expectant mother maintain close contact with appropriate medical personnel during pregnancy.
  • Some antiepileptic drugs may affect bone health. Consult your doctor about the need for supplemental calcium and vitamin D.
  • It is important to keep a calendar record of any seizures which occur. The description, timing and any possible drug side effects should also be recorded. Each time you see your doctor, take your calendar record with you.
  • As a patient, it is important to realize that while your doctor can help with advice, your attitude toward your epilepsy may ultimately play an important role in seizure control.
What is Epilepsy Surgery?

Surgical therapy has been used for more than a century, but the past three decades have seen a dramatic rise in its use. Patients with partial epilepsy who have had minimal success with drug therapy for controlling seizures are usually candidates for a preoperative assessment for surgical therapy. The goal of surgery is to remove the region of the brain that triggers the seizures, without affecting vital functions such as language, memory, movements and sensation.

Surgery for epilepsy is usually done at highly specialized centres and requires a great deal of patient cooperation for the extensive pre-operative testing used to determine whether surgery would be of benefit. As with other surgical procedures, the benefits must always be carefully weighed against the risks.

Additional Treatment Options

Vagus Nerve Stimulation

Vagus Nerve Stimulation (VNS) is a surgical therapy that involves the implantation of a battery-powered device called a Vagus Nerve Stimulator under the skin in the chest. The device is similar to a heart pacemaker. A wire runs from the device to the vagus nerve in the neck. The VNS device stimulates the left vagus nerve which then sends an electrical signal to the brain. The signals help to prevent or interrupt the electrical disturbances in the brain that result in seizures.

A doctor programs the device to deliver periodic doses of stimulation, such as 30 seconds of stimulation followed by five minutes of no stimulation.

The individual or a caregiver can start or stop the stimulation by hand with the use of a special magnet. If a person experiences an aura or feels that a seizure is beginning, the magnet can be passed over the chest where the generator is located. This will activate extra stimulation to attempt to stop the seizure or reduce how long the seizure continues or its intensity.

Individuals using the device should ask the doctor how long the battery will last in order to allow for replacement when necessary. Replacement of the battery requires minor surgery.

VNS is not suitable for everyone with epilepsy. It is being used in patients who do not respond to medication and who are not suitable for epilepsy-related surgery.

The procedure has successfully reduced seizure frequency, intensity, and/or duration in some individuals when used with previous seizure medication.

There can be some adverse side effects including hoarseness, sore throat, shortness of breath, and coughing. Typically these side effects occur during stimulation. If the hoarseness is persistent or uncomfortable, the doctor should be notified.

Ketogenic Diet

A strict ketogenic diet high in fats and low in protein and carbo¬hydrates has been used in the treatment of difficult-to-control epilepsy in children. Occasionally it is used in the treatment of teenagers and adults. A chemical change is created in the body called ketosis resulting in the body breaking down fats instead of carbohydrates. This process inhibits seizures in some people.

The diet requires medical supervision. It does not provide all of the vitamins and minerals necessary for health so nutritional supplements are required to avoid deficiencies. Use of these supplements must be monitored by a doctor. Studies indicate that approximately one-third of children strictly adhering to the diet are seizure free or close to it, one-third experience a reduction in seizures, and one-third are unresponsive.

Complementary Therapies

There are many complementary therapies that some individuals have found helpful in seizure control. Although some of these methods may not have been scientifically proven, there are people with epilepsy who have found that they help in reducing seizures. A number of the methods were developed centuries ago before current treatments were available.

It is important to remember that all therapies should be discussed with a doctor. Complementary therapies are used to supplement and not to replace accepted treatments.

Advocates of a self-control approach in dealing with epilepsy believe that playing an active role will not only alleviate feelings of powerlessness but may also be effective in controlling seizures. Through persistence and careful observation, some individuals have developed the ability to use tools such as mental imagery, odors, or relaxation techniques to prevent or delay seizures.

Some individuals have found that yoga, massage therapy, or meditation is helpful.

Others advocate aromatherapy, herbal remedies, or vitamin therapy, while a number have had positive results from art, music, and pet therapy. Individuals have also found that techniques such as acupuncture and hypnosis are effective in seizure control.

Reflexology is a technique involving the application of pressure to points on the foot or hand that are believed to correspond to different parts of the body. For example, by massaging a certain part of the foot, a reflexologist tries to bring about a response in a part of the body. People have sometimes found this approach helpful.

Biofeedback uses EEG recordings to help a patient develop a level of brain activity believed to raise the seizure threshold. Supporters of this approach believe that one can learn to control brain waves and that once a successful approach has been learned, the person may eventually be able to exert control without the assistance of the EEG recordings.

What can I do to help improve my memory?

Many people with epilepsy complain of absentmindedness, forgetting names and things that went on in the past. This may be due to the underlying cause of the epilepsy, medication, or a combination of both. While there is no cure, there are ways to compensate for these difficulties.

First, try to be organized about what you want to remember. Keep a daily diary where you record important events. Write down when seizures occur, when medications are changed, when you have appointments, and even the names of new people you want to remember. Make the diary a big part of your life, checking it often (e.g. every morning) and writing in it every day.

Secondly, when you want to remember to do something, use a simple aid. For example, if your aunt’s birthday is next week, mark her name on that day in a calendar or diary. Put another note to yourself on the telephone, if you plan to call her that day. The notes and cues will prompt your memory.

When you want to remember a phone message, write down the important points in a diary or book (not on loose sheets of paper). Then place a colourful clip on the top of that page to remind you to pass on the message to your friend.

If you cannot remember a name or number you knew before, stay calm. Becoming upset only makes it harder to remember. Accept the fact that your memory is not perfect, and you need extra time to recall. When did you last see them? Who were they with? What were you doing? Often these clues gradually build up the memory trace, and make it easier to recall the name.

Finally, your memory will be better if you pay attention to one thing at a time. When you want to remember something you are reading, find a quiet spot with no interruptions. Concentrate on the material and ignore distracting thoughts or noises. Turn off the TV and radio if you have to study for a test. Learning means rehearsing the material several times. Discovering humorous or meaningful associations with the material makes a stronger memory trace.

Summary

  1. Use simple memory aids.
  2. Pay better attention.
  3. Stay calm and take the time to recall things carefully.
What restrictions does epilepsy impose on daily activities?

Depending on the seizure type and frequency, certain restrictions may apply. Each case must be judged individually. Consult your physician to determine what restrictions may apply to you. It is your responsibility to be straight-forward, honest, and apply common sense in any discussion regarding restrictions on activities such as driving, working at heights, or bathing and swimming alone.

First aid for Seizures

Generalized Tonic Clonic Seizure

In convulsive) seizures, the individual loses consciousness and falls. The body is initially rigid (tonic phase). In the clonic phase, the arms and legs jerk or twitch rhythmically. Consciousness is regained slowly.

  • -Stay calm.
  • -Do not offer food or drink until the person is fully alert.
  • -Turn the person on his or her side as the seizure ends to allow saliva or other fluids to drain away and keep airway clear.
  • -Do not put anything in the person’s mouth: it is not possible for someone to swallow their tongue.
  • -Do not hold the person down or restrain their movement.
  • -Remove objects that may cause harm - clear the area of sharp or dangerous objects.
  • -Time the seizure – Usually there is no need for a trip to the hospital, unless the seizure lasts longer than five minutes (not including the postictal phase), the person has more than one seizure in a row, or if a person is injured, pregnant, or has diabetes.
  • -Stay with the person until they are fully alert and thinking clearly. Reassure the person when consciousness returns.
  •  

Focal Seizures

For someone with disturbance of consciousness and undirected behaviour, such as mumbling or random movements including head turning or pulling at clothes:

  • -Speak calmly.
  • -Do not restrain, but gently guide the person away from danger.
  • -Stay with the person until he or she is fully alert.
  • -Please note, the seizure and post seizure confusion may last as long as 20 minutes.
  •  

Generalized Absence Seizure

For momentary lapses of attention (generalized Absence seizures) no first aid is needed; the seizures only last a few seconds. The individual may appear to be daydreaming. Because these seizures are so mild looking, they may go undiagnosed. If you suspect someone of having absence seizures, bring it to the attention of an appropriate person.

 

Acknowledgments

Our thanks to Deirdre Floyd, former President, Epilepsy Association of Nova Scotia and staff of the Epilepsy Program (Halifax Infirmary Site), Capital Health Halifax NS.

We would like to thank to the Canadian Epilepsy Alliance, Canadian League Against Epilepsy, Edmonton Epilepsy Association, and the International Bureau for Epilepsy for providing the revised content in the section called “About Epilepsy”.