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General information on seizures and epilepsy
Common types of epilepsyIf you have more than one event called a seizure without a separate treatable cause, then you have epilepsy. Many times seizures are solitary and either are treated briefly or not at all. Many illnesses or medicines can cause seizures and the treatment is to eliminate the cause. There are also non-epileptic events caused by emotional distress. Seizures and possibly epilepsy are initially based on the description of what happened. Seizures come in many types and the things that happen during them can vary. The most commonly thought of seizure comes with many names that have been used in the past. Grand mal, convulsion or fit have all been used for what we currently call a tonic-clonic seizure. The words tonic (meaning stiffness) and clonic (meaning shaking) describe the way these seizures appear. There is often an initial tightness that is seen with eyes that roll upward and a yell produced by the breathing muscle tightening and pushing air outward. Often, this yell is very disturbing to observers who assume it is pain-related, which it is not. A tonic-clonic seizure begins as slight, rhythmic shaking; towards the end, the shaking is slower and harder. When the tonic-clonic seizure ends, there is a relaxation of the muscles. This can produce a funny breathing sound, loss of urine or bowel control and a general limpness for minutes (that seem like hours). Fortunately, tonic-clonic seizures are uncommon and most respond to treatment. They can occur with other conditions besides epilepsy, such as high fever in children (febrile seizures), with alcohol (either when drinking a lot or immediately after stopping), in low and high blood sugar, with drugs like cocaine, or with low blood pressure (syncope). The most common seizure type in children is "absence." This seizure was historically part of what was called petit mal. It generally lasts 2-15 seconds and consists of a motionless stare with immediate recovery of awareness. Absence is seen in the school setting with a sudden decline in schoolwork and can be occurring hundreds of times daily. Absence is generally easy to induce with over-breathing and occurs in intellectually normal children. Childhood absence was considered "petite mal" or "a little bad" to French neurologists, as it generally goes away in the teens and doesn't permanently compromise the child's health. Partial seizures are common in children and the most common seizure in adults. Partial seizures are varied in their appearance because they represent the area of the brain they come from. The idea is that the seizure begins in a specific area and the function of that area is seen in the seizure. The simple partial seizure is the smallest version of this concept, beginning with a wide variety of symptoms. The seizure may start with jerking, tingling, indescribable feelings, stomach sensations, fear, unpleasant odors, visual images or sounds that begin and end quickly. Sometimes these warn of the onset of a lapse of awareness called a complex partial seizure. Loss of memory and staring are common, but many automatic behaviors can occur that make it appear that the person is aware of what is going on when he or she is not. These seizures can be missed and sometimes are only apparent after a tonic-clonic has followed one. Partial seizures vary depending on the extent of brain included with the seizure but have a starting point that can often be located. Many other seizure types, such as myoclonic, atonic and tonic also occur in combination with these other types. Diagnostic proceduresThe description of these seizures and the medical history of the patient are used to determine that seizures are a possibility. There is no test that is always abnormal in seizures. Several tests can be helpful. Seizures can come from an injury or abnormality in the brain so a picture of the brain is helpful. Computerized tomography (CT) is of limited use as it is not very sensitive in finding abnormalities. CT is often done to exclude significant problems first, but magnetic resonance imaging (MRI) sees the brain much better. Small tumors, abnormalities in the brain's shape or blood vessels, and scars from head injury are seen much better and make MRI mandatory where a seizure could be caused by these conditions. Electroencephalography (EEG), or brainwave recordings, tell us how the brain is working. There are normal EEG waves and others that suggest injury or the risk for seizures. There are different EEG abnormalities for different types of seizures. The problem with testing is that the majority of MRIs and EEGs are normal in people with seizures and epilepsy, so having normal test results is likely. Normal results can be upsetting, as many patients then want to know how we can be sure of the diagnosis. Normal results are positive, as the chance that the seizures are less troublesome and medications can be discontinued in the future is better. More testing will be done if the seizures are hard to stop but initially these might not be helpful. Visit Continuing Seizures for more information about diagnostic tests or visit Frequently Asked Questions about epilepsy monitoring. Medications for seizure controlThe treatment approach is to recognize and define seizures and then to eliminate them. Again, where epilepsy does not exist and the seizures are due to low blood sugar, for example, the treatment may be blood sugar control. Medications for epilepsy can stop seizures without side effects. Two or three medicines may need to be tried before the right one is found, but generally the most successful drugs are tried first. Two-thirds of patients will attain seizure freedom with only nuisance side effects. All seizures should be stopped, including the warning sensations that are called auras, whenever possible. Auras can be tolerated if they don't inhibit the person from daily responsibilities, but they may increase the chance of future seizures that are more serious. Picking the medication to treat the seizures is a matter of several issues. First, does it work? Most epilepsy medications stop seizures in 1/3 to 1/2 of patients as their first treatment. Safety or the risk of serious side effects is a consideration. Fortunately, most of the medications don't have serious risk issues. The effect on bone marrow, kidney, liver or brain can in a few drugs create concern. Again, these are infrequent, occurring in 1 of 10,000 or more patients. Probably the most important issue is side effects. It might be said that medications are helpful poisons and we separate them from other poisons because they produce more desirable effects than undesirable effects. Side effects, or the negative effects of the medication, are what keep patients from reaching the higher doses that produce seizure freedom. The side effects are very individual because of the person's perception of what is a concern. Each drug will have common side effects such as fatigue, tiredness, dizziness and unsteadiness. Each medication may also have some unique side effects and those effects are how patients determine what they would prefer to take. Weight gain or loss, behavior changes, gum swelling, rashes or thinking problems are some of the issues patients must deal with. The patient and physician must review the available medication choices and pick the one that is most suitable to the individual's lifestyle. The newer medications tend to have fewer of these side effects and can even have beneficial side effects. These might include weight loss or reduction in symptoms of illnesses such as migraine headaches or depression. The final issue that must be addressed is what may be called "ease-of-use." Ease-of-use is a combination of the qualities of the drug, its preparations and how it's given. Qualities such as the breakdown of the medicine, problems with combining it with other medicines, and its ability to be started quickly can effect the ease-of-use. Preparations such as the pill size, elixirs and intravenous forms all affect the ability to continue and give treatment easily. How often a drug must be taken each day can affect the success of a drug's treatment. Where epilepsy medications are concerned, effectiveness, safety, side effects and ease-of-use must be considered to make the best choice. How long does one treat seizures? Often it seems that no one mentions the end of therapy, but many people can eventually discontinue medications. Seizures that stop for a period of two years can be gone, in remission, and the medication may be stopped. This is the goal most patients desire and one of the reasons they should carefully take all medications as prescribed. The absence of obvious brain damage in the medical history, physical examination, MRI and EEG results help determine the likelihood that medications will be successful and may be one day discontinued. But all of these thoughts start with seizure freedom for at least two years. For information about other epilepsy treatments, see continuing seizures. Epilepsy in special populationsWomen are one group with some unique issues. Information is now appearing that suggests some epilepsy medications may thin bones, advancing osteoporosis, and may lead to reduced hormone levels contributing to a low birth rate in woman with seizures. Pregnancy and the effect of medications on the developing fetus is important to women who take medications for seizures. The negative effects of many drugs on the developing fetus mean some women consider not having children while on medications. Some seizure medications have reportedly caused malformations in children while the effects of other medications are unknown. The group of doctors treating pregnant women seem to agree that the best choice is to recommend good nutrition, good prenatal care, folate supplements and using epilepsy medications when they are clearly needed. Some physicians give pregnancy vitamins to all women capable of becoming pregnant so that these nutritional supplements are present at conception. When treating children with epilepsy, it is important to remember that they are not simply "small adults." They need special attention to the type of seizures they have and the medications that are best suited for them. Children's developing brains can be affected by some epilepsy medications, which is unique to a child. School performance is a measure of this effect as are a child's interaction with others and the development of his or her social skills. Children are affected in different ways by medication. Sedating medication in adults often leads to behavior outbursts in children. Phenobarbitol sometimes produces a "monster child" and such an effect must be monitored for from all medications. In addition, children often need higher doses of medications because their bodies eliminate the medicines faster. Maturing Americans, that ever-increasing number of people eligible for AARP, have important needs as well. Seizures and epilepsy are so frequently associated with the young that people fail to note that the highest frequency is in individuals over age 65. The frequency of stroke and the damage it creates is mostly responsible for this higher rate. Best estimates are that 2-3% of those over 65 have seizures. Older people's bodies eliminate medications slower than youngsters and must often have medication adjustments done more slowly using lower doses to avoid side effects. According to the State of Minnesota, older individuals take an average of eight medications each. Seizure medications were among those most frequently prescribed.
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