Epilepsy can be a devastating diagnosis for patients and their families, but with the right treatment, epilepsy can be controlled. Neurologist Imad Najm, MD, answers the most common questions he gets from patients and their families.
Q: How is epilepsy defined and definitively diagnosed?
A: Epilepsy is a neurological disorder characterized by sudden, recurrent seizures. Once a seizure occurs at least twice, or if there is a known lesion on the brain, then epilepsy is suspected, but not definitively diagnosed.
Epilepsy is not truly confirmed until we get a recording of the brain waves during a seizure using an electroencephalogram (EEG), a test that detects electrical activity in your brain. When we suspect epilepsy in patients due to seizures but they don't respond to medication, we monitor them at the hospital for up to five days, attempting to capture a seizure with an EEG. The EEG will remain completely normal if it is a nonepileptic seizure.
Q: What causes epilepsy?
A: There are multiple potential causes for epilepsy, but I like to categorize them as one of three things: genetic, congenital or acquired.
First, genetic is when there’s a particular problem with one of the several genes that leads to epilepsy.
Second is congenital, which means we have a predisposition to getting the disease due to brain malformations that we are born with, also known as cortical dysplasia.
Third, there is acquired epilepsy, which is caused by something that happened to us after birth, such as an infection in the brain like encephalitis or meningitis, an abscess or tumor, or a traumatic brain injury from a car accident or other head wound.
Q: How is epilepsy treated?
A: The main treatment, which is successful in controlling seizures in up to 70% of patients, is an antiepileptic seizure medication. Brain surgery is a widely accepted second option for those patients whose seizures continue to happen after two or more antiepileptic medications have been tried, and the diagnosis is confirmed as epilepsy by an EEG. In that case, we’ll identify which area of the brain is causing the seizures using Magnetic Resonance Imaging (MRI), and find out if it’s safe for us to go in and remove that particular area.
While brain surgery sounds very high risk, epilepsy surgery is probably one of the safest that we do in neurology, with a risk of less than 1% for any complication. And 70 to 80% of patients who receive epilepsy surgery remain seizure-free.
Other less common and less effective treatments include responsive nerve stimulation and vagus nerve stimulation. These treatments are done by devices that stimulate nerves in the body or the brain itself. Ketogenic diets, which are extremely high-fat diets, are used rarely to treat children with highly severe cases of epilepsy, because ketones in the body can sometimes decrease the risk of seizures. It’s not used very often in older adults, primarily because that type of diet can have negative health effects on an adult’s body.
Q: What are the different types and levels of severity in epilepsy?
A: Epilepsy can be divided into focal epilepsy and generalized epilepsy.
Focal epilepsy is epilepsy that leads to seizures that are generated in a one area of the brain, usually the cortex or outer layer. Generalized epilepsy usually happens more often in children, and typically the start or the pacemaker of the seizure is deep inside the brain in an area called the thalamus.
Any type of epilepsy, whether it’s generalized or focal, could be mild, with rare seizures and usually no convulsions,; or it could be incredibly severe, to the point where a person has hundreds of seizures per day.
Q: What does a typical epileptic seizure look like?
A: There is no such thing as a “typical” seizure, though there are several different types. Absence seizures occur when a person is talking and then, all of a sudden, he or she stops and stares into space for 10 to 20 seconds; his or her body is not visibly affected. This type of seizure happens so quickly, it’s often hard for other people to tell something happened.
A seizure that starts in one part of the brain may begin with just shaking of one hand or one side of the body and progress to whole-body generalized convulsions. Seizures can also be atonic, where the patient loses muscle tone and may fall to the ground, or tonic, where the body goes rigid.
On the other end of the spectrum, there’s the type of seizure you see most often in movies: grand mal seizures. A grand mal seizure can make a person’s whole body convulse violently for 1 to 2 minutes. Picture someone running a full-length marathon at full speed in two minutes, rather than the typical three hours--that’s what a grand mal seizure feels like. You can imagine the severe body aches and fatigue.
Q: What safety precautions can individuals with epilepsy and their families take?
A: When patients and their families ask about some of the things they can do to protect themselves from harm during a seizure, I suggest they need to be able to answer at any time, in any situation, the following two questions:
- First, if I have a seizure now, would I harm myself?
- Second, if I have a seizure now, would I be a risk to other people?
If the answer to either of these questions is “yes,” that person should avoid being in this compromised position, whether that means avoiding driving, avoiding exercise, or not going to work that day. Some common warning signs of an oncoming seizure could be dizziness, change in vision, feelings of anxiousness, or nausea.
The bottom line
The good news is in most cases, seizures can be controlled. And by controlled, I mean no seizures. In most states and countries, a person with epilepsy is authorized to drive if they have had no seizures for at least six months. And that is something that is completely doable when patients are taking antiepileptic medication.
