What is epilepsy

Epilepsy is a central nervous system (neurological) disorder in which brain activity becomes abnormal, causing seizures or periods of unusual behavior, sensations, and sometimes loss of awareness. Seizures are bursts of electrical activity in the brain that temporarily affect how it works. Seizure can vary widely and cause a wide range of symptoms. Some people with epilepsy simply stare blankly for a few seconds during a seizure, while others repeatedly twitch their arms or legs. Having a single seizure doesn’t mean you have epilepsy. At least two unprovoked seizures are generally required for an epilepsy diagnosis.

Seizures can affect people in different ways, depending on which part of the brain is involved. Some seizures cause the body to jerk and shake (a “fit”), while others cause problems like loss of awareness or unusual sensations. They typically pass in a few seconds or minutes.

Seizures can occur when you’re awake or asleep. Sometimes they can be triggered by something, such as feeling very tired.

Epilepsy can be considered a spectrum disorder because of its different causes, different seizure types, its ability to vary in severity and impact from person to person, and its range of co-existing conditions. Some people may have convulsions (sudden onset of repetitive general contraction of muscles) and lose consciousness. Others may simply stop what they are doing, have a brief lapse of awareness, and stare into space for a short period. Some people have seizures very infrequently, while other people may experience hundreds of seizures each day. There also are many different types of epilepsy, resulting from a variety of causes. Recent adoption of the term “the epilepsies” underscores the diversity of types and causes.

In general, a person is not considered to have epilepsy until he or she has had two or more unprovoked seizures separated by at least 24 hours. In contrast, a provoked seizure is one caused by a known precipitating factor such as a high fever, nervous system infections, acute traumatic brain injury, or fluctuations in blood sugar or electrolyte levels.

Anyone can develop epilepsy. Epilepsy can start at any age, but usually starts either in childhood or in people over 60. It’s often lifelong, but can sometimes get slowly better over time. About 2.3 million adults and more than 450,000 children and adolescents in the United States currently live with epilepsy. Each year, an estimated 150,000 people are diagnosed with epilepsy. Epilepsy affects both males and females of all races, ethnic backgrounds, and ages. In the United States alone, the annual costs associated with the epilepsies are estimated to be $15.5 billion in direct medical expenses and lost or reduced earnings and productivity.

The majority of those diagnosed with epilepsy have seizures that can be controlled with drug therapies and surgery. However, as much as 30 to 40 percent of people with epilepsy continue to have seizures because available treatments do not completely control their seizures (called intractable or medication resistant epilepsy).

While many forms of epilepsy require lifelong treatment to control the seizures, for some people the seizures eventually go away. The odds of becoming seizure-free are not as good for adults or for children with severe epilepsy syndromes, but it is possible that seizures may decrease or even stop over time. This is more likely if the epilepsy starts in childhood, has been well-controlled by medication, or if the person has had surgery to remove the brain focus of the abnormal cell firing.

Many people with epilepsy lead productive lives, but some will be severely impacted by their epilepsy. Medical and research advances in the past two decades have led to a better understanding of the epilepsies and seizures. More than 20 different medications and a variety of dietary treatments and surgical techniques (including two devices) are now available and may provide good control of seizures. Devices can modulate brain activity to decrease seizure frequency. Advance neuroimaging can identify brain abnormalities that give rise to seizures which can be cured by neurosurgery. Even dietary changes can effectively treat certain types of epilepsy. Research on the underlying causes of the epilepsies, including identification of genes for some forms of epilepsy, has led to a greatly improved understanding of these disorders that may lead to more effective treatments or even to new ways of preventing epilepsy in the future.

Figure 1. Recovery position

Anyone can develop epilepsy. Epilepsy affects both males and females of all races, ethnic backgrounds and ages.

Treatment with medications or sometimes surgery can control seizures for the majority of people with epilepsy. Some people require lifelong treatment to control seizures, but for others, the seizures eventually go away. Some children with epilepsy may outgrow the condition with age.

When to see a doctor

Seek immediate medical help if any of the following occurs:

• The seizure lasts more than five minutes.
• Breathing or consciousness doesn’t return after the seizure stops.
• A second seizure follows immediately.
• You have a high fever.
• You’re experiencing heat exhaustion.
• You’re pregnant.
• You have diabetes.
• You’ve injured yourself during the seizure.

If you experience a seizure for the first time, seek medical advice.

Types of epilepsy

In March 2017 the International League Against Epilepsy ¹, a group of the world’s leading epilepsy professionals, introduced a new method to group seizures. This gives doctors a more accurate way to describe a person’s seizures, and helps them to prescribe the most appropriate treatments.

Seizures are divided into groups depending on:

• where they start in the brain (onset)
• whether or not a person’s awareness is affected
• whether or not seizures involve other symptoms, such as movement

Depending on where they start, seizures are described as being focal onset, generalized onset or unknown onset.

Levels of awareness

Seizures are also described depending on a person’s level of awareness during their seizures; this means whether or not they are aware of the seizure and what is happening around them. These seizures are known as focal aware seizures or focal impaired awareness seizures.

Focal onset seizures

Focal onset seizures start in, and affect, just one part of the brain, sometimes called the ‘focus’ of the seizures. It might affect a large part of one hemisphere or just a small area in one of the lobes.

These seizures fall into two categories:

1. Focal aware seizures
2. Focal impaired awareness seizures

Sometimes a focal onset seizure can spread to both sides of the brain (called a focal to bilateral tonic-clonic seizure). The focal onset seizure is then a warning, sometimes called an ‘aura’ that another seizure will happen.

Symptoms of focal seizures may be confused with other neurological disorders, such as migraine, narcolepsy or mental illness. A thorough examination and testing are needed to distinguish epilepsy from other disorders.

Focal aware seizures without loss of consciousness

Previously called simple partial seizures, in focal aware seizures the person is conscious (aware and alert), will usually know that something is happening and will remember the seizure afterwards. They may alter emotions or change the way things look, smell, feel, taste or sound. They may also result in involuntary jerking of a body part, such as an arm or leg, and spontaneous sensory symptoms such as tingling, dizziness and flashing lights.

Some people find their focal aware seizures hard to put into words. During the seizure they may feel ‘strange’ but not be able to describe the feeling afterwards. This may be upsetting or frustrating for them.

Focal seizures without loss of consciousness can cause:

• a general strange feeling that’s hard to describe
• a “rising” feeling in your tummy – like the sensation in your stomach when on a fairground ride
• a feeling that events have happened before (déjà vu)
• unusual smells or tastes
• tingling in your arms and legs
• an intense feeling of fear or joy
• stiffness or twitching in part of your body, such as an arm or hand

You remain awake and aware while this happens.

These seizures are sometimes known as “warnings” or “auras” because they can be a sign that another type of seizure is about to happen.

Focal seizures with impaired awareness

Once called complex partial seizures, these seizures involve a change or loss of consciousness or awareness.

Focal impaired awareness seizures affect a bigger part of one hemisphere (side) of the brain than focal aware seizures.

Your consciousness is affected and you may be confused. During a focal impaired awareness seizure, you may stare into space and not respond normally to your environment or perform repetitive movements, such as hand rubbing, chewing, swallowing or walking in circles. You might be able to hear others, but not fully understand what they’re saying or be able to respond to them. You may not react as you would normally. If people speak loudly to you, you may think others are being aggressive and so you may react aggressively towards other people. Focal impaired awareness seizures often happen in the temporal lobes but can happen in other parts of the brain.

After the seizure, you may be confused for a while, sometimes called ‘post-ictal’ (after-seizure) confusion. It may be hard to tell when the seizure has ended. You might feel tired, and want to rest. You may not remember the seizure afterwards.

During a focal seizures with impaired awareness, you lose your sense of awareness and make random body movements, such as:

• smacking your lips
• rubbing your hands
• making random noises
• moving your arms around
• repeatedly picking at clothes or fiddling with objects
• chewing or swallowing
• suddenly losing muscle tone and limbs going limp or floppy, or limbs suddenly becoming stiff;
• repetitive jerking movements that affect one or both sides of the body;
• making a loud cry or scream; or
• making strange postures or repetitive movements such as cycling or kicking.

Non-motor symptoms can include:

• changes or a ‘rising’ feeling in the stomach or déjà vu (feeling like you’ve ‘been here before’);
• getting an unusual smell or taste;
• a sudden intense feeling of fear or joy;
• a strange feeling like a ‘wave’ going through the head;
• stiffness or twitching in part of the body, (such as an arm or hand);
• a feeling of numbness or tingling;
• a sensation that an arm or leg feels bigger or smaller than it actually is; or
• visual disturbances such as colored or flashing lights or hallucinations (seeing something that isn’t actually there).

You won’t be able to respond to anyone else during the seizure and you won’t have any memory of it.

Sometimes focal seizures spread from one side (hemisphere) to both sides of the brain. This is called a focal to bilateral tonic-clonic seizure.

Focal to bilateral tonic-clonic seizure (previously called a secondarily generalised seizure)

When this happens the person becomes unconscious and will usually have a tonic clonic (‘convulsive’ or shaking) seizure. If this happens very quickly, they may not be aware that it started as a focal seizure.

Generalized seizures

Generalized onset seizures affect both sides of the brain at once and happen without warning.

The person will be unconscious (except in myoclonic seizures), even if just for a few seconds and afterwards will not remember what happened during the seizure.

Six types of generalized seizures exist.

Absence seizures

Absence seizures, previously known as “petit mal” seizures, are characterized by staring into space (lose awareness of your surroundings for a short time) or subtle body movements such as eye blinking or lip smacking. These seizures may occur in clusters and cause a brief loss of awareness. Absence seizures mainly affect children, but can happen at any age.

During an absence seizure, a person may:

• stare blankly into space
• look like they’re “daydreaming”
• flutter their eyes
• make slight jerking movements of their body or limbs

The seizures usually only last up to 15 seconds and you won’t be able to remember them. They can happen several times a day.

Tonic seizures

Tonic seizures cause all your muscles to suddenly become stiff, like the first stage of a tonic-clonic seizure. These seizures usually affect muscles in your back, arms and legs and may cause you to lose balance and fall to the ground.

Atonic seizures

Atonic seizures, also known as drop seizures, cause all your muscles to suddenly relax, so you may fall to the ground.

Atonic seizures tend to be very brief and you’ll usually be able to get up again straight away.

Clonic seizures

Clonic seizures are associated with repeated or rhythmic, jerking muscle movements. Clonic seizures cause the body to shake and jerk like a tonic-clonic seizure, but you don’t go stiff at the start.

These seizures usually affect the neck, face and arms. Clonic seizures typically last a few minutes and you might lose consciousness.

Myoclonic seizures

A myoclonic seizure is where some or all of your body suddenly twitches or jerks, like you’ve had an electric shock. They often happen soon after waking up.

Myoclonic seizures usually only last a fraction of a second, but several can sometimes occur in a short space of time. You normally remain awake during them.

Tonic-clonic seizures

Tonic-clonic seizures, previously known as “grand mal” seizures, are the most dramatic type of epileptic seizure and can cause an abrupt loss of consciousness, body stiffening and shaking, and sometimes loss of bladder control or biting your tongue — is what most people think of as a typical epileptic fit.

They happen in two stages – an initial “tonic” stage, shortly followed by a second “clonic” stage:

• Tonic stage – you lose consciousness, your body goes stiff, and you may fall to the floor
• Clonic stage – your limbs jerk about, you may lose control of your bladder or bowel, you may bite your tongue or the inside of your cheek, and you might have difficulty breathing

The seizure normally stops after a few minutes, but some last longer. Afterwards, you may have a headache or difficulty remembering what happened and feel tired or confused.

At the start of the seizure:

• the person becomes unconscious
• their body goes stiff and if they are standing up they usually fall backwards.
• they may cry out
• they may bite their tongue or cheek.

During the seizure:

• they jerk and shake as their muscles relax and tighten rhythmically
• their breathing might be affected and become difficult or sound noisy
• their skin may change color and become very pale or bluish
• they may wet themselves

After the seizure (once the jerking stops):

• their breathing and color return to normal
• they may feel tired, confused, have a headache or want to sleep.

Status epilepticus or intractable epilepsy

Status epilepticus is the name for any seizure that lasts a long time, or a series of seizures where the person doesn’t regain consciousness in between.

• It’s a medical emergency and needs to be treated as soon as possible.

You can be trained to treat it if you look after someone with epilepsy. If you haven’t had any training, call your local emergency number for an ambulance immediately if someone has a seizure that hasn’t stopped after five minutes.

What are the different kinds of epilepsy?

Just as there are many different kinds of seizures, there are many different kinds of epilepsy. Hundreds of different epilepsy syndromes – disorders characterized by a specific set of symptoms that include epilepsy as a prominent symptom – have been identified. Some of these syndromes appear to be either hereditary or caused by de novo mutations. For other syndromes, the cause is unknown. Epilepsy syndromes are frequently described by their symptoms or by where in the brain they originate.

Absence epilepsy

Absence epilepsy is characterized by repeated seizures that cause momentary lapses of consciousness. These seizures almost always begin in childhood or adolescence and tend to run in families, suggesting that they may be at least partially due to genetic factors. Individuals may show purposeless movements during their seizures, such as a jerking arm or rapidly blinking eyes, while others may have no noticeable symptoms except for brief times when they appear to be staring off into space. Immediately after a seizure, the person can resume whatever he or she was doing. However, these seizures may occur so frequently (in some cases up to 100 or more a day) that the person cannot concentrate in school or other situations. Childhood absence epilepsy usually stops when the child reaches puberty. Although most children with childhood absence epilepsy have a good prognosis, there may be long-lasting negative consequences and some children will continue to have absence seizures into adulthood and/or go on to develop other seizure types.

Neocortical epilepsy

Neocortical epilepsy is characterized by seizures that originate from the brain’s cortex, or outer layer. The seizures can be either focal or generalized. Symptoms may include unusual sensations, visual hallucinations, emotional changes, muscle contractions, convulsions, and a variety of other symptoms, depending on where in the brain the seizures originate.

There are many other types of epilepsy that begin in infancy or childhood. For example, infantile spasms are clusters of seizures that usually begin before the age of 6 months. During these seizures the infant may drop their head, jerk an arm, bend at the waist and/or cry out. Children with Lennox-Gastaut syndrome have several different types of seizures, including atonic seizures, which cause sudden falls and are also called drop attacks. Seizure onset is usually before age four years. This severe form of epilepsy can be very difficult to treat effectively. Rasmussen’s encephalitis is a progressive form of epilepsy in which half the brain shows chronic inflammation. Some childhood epilepsy syndromes, such as childhood absence epilepsy, tend to go into remission or stop entirely during adolescence, whereas other syndromes such as juvenile myoclonic epilepsy (which features jerk-like motions upon waking) and Lennox-Gastaut syndrome are usually present for life once they develop. Children with Dravet syndrome have seizures that start before age one and later in infancy develop into other seizure types.

Hypothalamic hamartoma

Hypothalamic hamartoma is a rare form of epilepsy that first occurs during childhood and is associated with malformations of the hypothalamus at the base of the brain. People with hypothalamic hamartoma have seizures that resemble laughing or crying. Such seizures frequently go unrecognized and are difficult to diagnose.

Frontal lobe epilepsy

Frontal lobe epilepsy is a common epilepsy syndrome that features brief focal seizures that may occur in clusters. It can affect the part of the brain that controls movement and involves seizures that can cause muscle weakness or abnormal, uncontrolled movement such as twisting, waving the arms or legs, eye deviation to one side, or grimacing, and are usually associates with some loss of awareness. Seizures usually occur when the person is asleep but also may occur while awake.

Temporal lobe epilepsy

Temporal lobe epilepsy begin in the temporal lobes of your brain, which process emotions and are important for short-term memory. Some symptoms of a temporal lobe seizure may be related to these functions, including having odd feelings — such as euphoria, deja vu or fear.

Temporal lobe epilepsy are sometimes called focal seizures with impaired awareness. Some people remain aware of what’s happening, but during more-intense seizures, you might look awake but be unresponsive. Your lips and hands may make purposeless, repetitive movements.

Temporal lobe seizures may stem from an anatomical defect or scar in your temporal lobe, but the cause is often unknown. Temporal lobe seizures are treated with medication. For some people who don’t respond to medication, surgery may be an option.

Symptoms of temporal lobe epilepsy

An unusual sensation (aura) may precede a temporal lobe seizure, acting as a warning. Not everyone who has temporal lobe seizures has auras, and not everyone who has auras remembers them.

The aura is actually the first part of a focal seizure before consciousness is impaired. Examples of auras include:

• A sudden sense of unprovoked fear or joy
• A deja vu experience — a feeling that what’s happening has happened before
• A sudden or strange odor or taste
• A rising sensation in the abdomen, similar to being on a roller coaster

Sometimes temporal lobe seizures impair your ability to respond to others. This type of temporal lobe seizure usually lasts 30 seconds to two minutes.

Characteristic signs and symptoms of temporal lobe epilepsy include:

• Loss of awareness of surroundings
• Staring
• Lip smacking
• Repeated swallowing or chewing
• Unusual finger movements, such as picking motions

After a temporal lobe seizure, you may have:

• A period of confusion and difficulty speaking
• Inability to recall what occurred during the seizure
• Unawareness of having had a seizure
• Extreme sleepiness

In extreme cases, what starts as a temporal lobe seizure evolves into a generalized tonic-clonic (grand mal) seizure — featuring convulsions and loss of consciousness.

What causes temporal lobe epilepsy

Often, the cause of temporal lobe seizures remains unknown. However, they can be a result of a number of factors, including:

• Traumatic brain injury
• Infections, such as encephalitis or meningitis, or a history of such infections
• A process that causes scarring (gliosis) in a part of the temporal lobe called the hippocampus
• Blood vessel malformations in the brain
• Stroke
• Brain tumors
• Genetic syndromes

During normal waking and sleeping, your brain cells produce varying electrical activity. If the electrical activity in many brain cells becomes abnormally synchronized, a convulsion or seizure may occur.

If this happens in just one area of the brain, the result is a focal seizure. A temporal lobe seizure is a focal seizure that originates in one of the temporal lobes.

Complications of temporal lobe epilepsy

Over time, repeated temporal lobe seizures can cause the part of the brain that’s responsible for learning and memory (hippocampus) to shrink. Brain cell loss in this area may cause memory problems.

Temporal lobe epilepsy diagnosis

After a seizure, your doctor will thoroughly review your symptoms and medical history. Your doctor may order several tests to determine the cause of your seizure and evaluate how likely it is that you’ll have another one.

Tests may include:

• Neurological exam. Your doctor may test your behavior, motor abilities and mental function to determine if you have a problem with your brain and nervous system.
• Blood tests. Your doctor may take a blood sample to check for signs of infections, genetic conditions, blood sugar levels or electrolyte imbalances.
• Electroencephalogram (EEG). Electrodes attached to your scalp record the electrical activity of your brain, which shows up as wavy lines on an EEG recording. The EEG may reveal a pattern that tells doctors whether a seizure is likely to occur again, or help rule out other conditions that mimic epilepsy.
• Computerized tomography (CT) scan. A CT scan uses X-rays to obtain cross-sectional images of your brain. CT scans can reveal abnormalities in your brain that might cause a seizure, such as tumors, bleeding and cysts.
• Magnetic resonance imaging (MRI). An MRI uses powerful magnets and radio waves to create a detailed view of your brain. Your doctor may be able to detect lesions or abnormalities in your brain that could lead to seizures.
• Positron emission tomography (PET). PET scans use a small amount of low-dose radioactive material that’s injected into a vein to help visualize active areas of the brain and detect abnormalities.
• Single-photon emission computerized tomography (SPECT). A SPECT test uses a small amount of low-dose radioactive material that’s injected into a vein to create a detailed, 3-D map of the blood flow activity in your brain that happens during a seizure. Doctors may also conduct a form of a SPECT test called subtraction ictal SPECT coregistered to magnetic resonance imaging (SISCOM), which may provide even more-detailed results.

Treatment of temporal lobe epilepsy

Not everyone who has one seizure will have another one. Because a seizure can be an isolated incident, your doctor may not decide to start treatment until you’ve had more than one.

The optimal goal in seizure treatment is to find the best possible therapy to stop seizures, with the fewest side effects.

Medications

Many medications are available to treat temporal lobe seizures. However, many people don’t achieve seizure control with medications alone, and side effects, including fatigue, weight gain and dizziness, are common.

Discuss possible side effects with your doctor when deciding about treatment options. Also ask what effect your seizure medications and other medications you take, such as oral contraceptives, may have on each other.

Surgical or other procedures

When anti-seizure medications aren’t effective, other treatments may be an option:

• Surgery. The goal of surgery is to stop seizures from happening. This is often done through a traditional surgery, where surgeons operate to remove the area of the brain where seizures begin. In certain people, surgeons may be able to use MRI-guided laser therapy as a less invasive way to destroy the area of damaged tissue that causes seizures.

Surgery works best for people who have seizures that always originate in the same place in their brains. Surgery generally isn’t an option if your seizures come from more than one area of the brain, your seizure focus can’t be identified or your seizures come from a region of the brain that performs vital functions.

• Vagus nerve stimulation. A device implanted underneath the skin of your chest stimulates the vagus nerve in your neck, sending signals to your brain that inhibit seizures. With vagus nerve stimulation, you may still need to take medication, but you may be able to lower the dose.
• Responsive neurostimulation. During responsive neurostimulation, a device implanted on the surface of your brain or within brain tissue can detect seizure activity and deliver an electrical stimulation to the detected area to stop the seizure.
• Dietary therapy. Following a diet that’s high in fat and low in carbohydrates, known as a ketogenic diet, can improve seizure control. Variations on a high-fat, low-carbohydrate diet, such as the low glycemic index and modified Atkins diets, may be less effective. However, they aren’t as restrictive as the ketogenic diet and might provide some benefit.

When are seizures not epilepsy?

While any seizure is cause for concern, having a seizure does not by itself mean a person has epilepsy. First seizures, febrile seizures, nonepileptic events, and eclampsia (a life-threatening condition that can occur in pregnant women) are examples of conditions involving seizures that may not be associated with epilepsy. Regardless of the type of seizure, it’s important to inform your doctor when one occurs.

First Seizures

Many people have a single seizure at some point in their lives, and it can be provoked or unprovoked, meaning that they can occur with or without any obvious triggering factor. Unless the person has suffered brain damage or there is a family history of epilepsy or other neurological abnormalities, the majority of single seizures usually are not followed by additional seizures. Medical disorders which can provoke a seizure include low blood sugar, very high blood sugar in diabetics, disturbances in salt levels in the blood (sodium, calcium, magnesium), eclampsia during or after pregnancy, impaired function of the kidneys, or impaired function of the liver. Sleep deprivation, missing meals, or stress may serve as seizure triggers in susceptible people.

Many people with a first seizure will never have a second seizure, and physicians often counsel against starting antiseizure drugs at this point. In some cases where additional epilepsy risk factors are present, drug treatment after the first seizure may help prevent future seizures. Evidence suggests that it may be beneficial to begin antiseizure medication once a person has had a second unprovoked seizure, as the chance of future seizures increases significantly after this occurs . A person with a pre-existing brain problem, for example, a prior stroke or traumatic brain injury, will have a higher risk of experiencing a second seizure. In general, the decision to start antiseizure medication is based on the doctor’s assessment of many factors that influence how likely it is that another seizure will occur in that person.

In one study that followed individuals for an average of 8 years, 33 percent of people had a second seizure within 4 years after an initial seizure. People who did not have a second seizure within that time remained seizure-free for the rest of the study. For people who did have a second seizure, the risk of a third seizure was about 73 percent by the end of 4 years. Among those with a third unprovoked seizure, the risk of a fourth was 76 percent.

Febrile Seizures

Febrile seizures are seizures that are triggered by a high temperature, often from an infection. Febrile seizures happen to around 5 out of every 100 children under the age of 6. Your child’s having a febrile seizure can be alarming, and the few minutes it lasts can seem like an eternity. They are usually linked to a childhood illness, such as tonsillitis. Febrile seizures are not epilepsy. But children who have had febrile seizures have a higher chance of developing epilepsy when they are older, than children in general.

Febrile seizures represent a unique response of a child’s brain to fever, usually the first day of a fever. Fortunately, they’re usually harmless and typically don’t indicate an ongoing problem. You can help by keeping your child safe during a febrile seizure and by comforting him or her afterward.

See your doctor to have your child evaluated as soon as possible after a febrile seizure.

It’s unusual for a child over the age of 6 to continue having febrile seizures. If they do, they might have a form of epilepsy, and your doctor may want to do some tests to look into this.

Antiseizure medications following a febrile seizure are generally not warranted unless certain other conditions are present: a family history of epilepsy, signs of nervous system impairment prior to the seizure, or a relatively prolonged or complicated seizure. The risk of subsequent non-febrile seizures is low unless one of these factors is present.

Results from a study funded by the National Institute of Neurological Disorders and Stroke suggested that certain findings using diagnostic imaging of the hippocampus may help identify which children with prolonged febrile seizures are subsequently at increased risk of developing epilepsy.

Researchers also have identified several different genes that influence the risks associated with febrile seizures in certain families. Studying these genes may lead to new understandings of how febrile seizures occur and perhaps point to ways of preventing them.

Symptoms of febrile seizure

Febrile seizure symptoms can range from mild — staring — to more severe shaking or tightening of the muscles.

A child having a febrile seizure may:

• Have a fever higher than 100.4 F (38.0 C)
• Lose consciousness
• Shake or jerk arms and legs

Febrile seizures are classified as simple or complex:

• Simple febrile seizures. This more common type lasts from a few seconds to 15 minutes. Simple febrile seizures do not recur within a 24-hour period and are generalized, not specific to one part of the body.
• Complex febrile seizures. This type lasts longer than 15 minutes, occurs more than once within 24 hours or is confined to one side of your child’s body.

Febrile seizures most often occur within 24 hours of the onset of a fever and can be the first sign that a child is ill.

Causes of Febrile seizures

A high body temperature causes most febrile seizures.

Infection

Usually the fevers that trigger febrile seizures are caused by a viral infection, less commonly by a bacterial infection. Viral infections such as the flu and roseola, which often are accompanied by high fever, appear to be most associated with febrile seizure.

Post-immunization seizures

The risk of febrile seizures may increase after some childhood immunizations, such as the diphtheria, tetanus and pertussis or measles-mumps-rubella vaccinations. A child can develop a low-grade fever after a vaccination. The fever, not the vaccination, causes the seizure.

Risk factors for Febrile seizures

Factors that increase the risk of having a febrile seizure include:

• Young age. Most febrile seizures occur in children between 6 months and 5 years of age. It’s unusual for children younger than 6 months to have a febrile seizure, and it’s rare for these seizures to occur after 3 years of age.
• Family history. Some children inherit a family’s tendency to have seizures with a fever. Additionally, researchers have linked several genes to a susceptibility to febrile seizures.

Complications of Febrile seizures

Most febrile seizures produce no lasting effects. Simple febrile seizures don’t cause brain damage, mental retardation or learning disabilities, and they don’t mean your child has a more serious underlying disorder.

Febrile seizures don’t indicate epilepsy, a tendency to have recurrent seizures caused by abnormal electrical signals in the brain.

Recurrent febrile seizures

The most common complication is the possibility of more febrile seizures. The risk of recurrence is higher if:

• Your child’s first seizure resulted from a low fever.
• The period between the start of the fever and the seizure was short.
• An immediate family member has a history of febrile seizures.
• Your child was younger than 15 months at the time of the first febrile seizure.

Prevention of Febrile seizures

Most febrile seizures occur in the first few hours of a fever, during the initial rise in body temperature.

Giving your child medications

Giving your child infants’ or children’s acetaminophen (Tylenol, others) or ibuprofen (Advil, Motrin, others) at the beginning of fever may make your child more comfortable, but it won’t prevent a seizure.

Use caution when giving aspirin to children or teenagers. Though aspirin is approved for use in children older than age 3, children and teenagers recovering from chickenpox or flu-like symptoms should never take aspirin. This is because aspirin has been linked to Reye’s syndrome, a rare but potentially life-threatening condition, in such children.

Prescription prevention medications

Rarely, prescription anticonvulsant medications are used to try to prevent febrile seizures. However, these medications can have serious side effects that may outweigh any possible benefit.

Oral diazepam (Valium), lorazepam intensol, clonazepam (Klonopin) or rectal diazepam (Diastat) may be prescribed for children who are prone to febrile seizures. These medications are typically used to treat seizures that last longer than 10 minutes or if the child has more than one seizure within 24 hours. They are not typically used to prevent febrile seizures.

Diagnosis of febrile seizures

Identifying the cause of your child’s fever is the first step after a febrile seizure.

Simple febrile seizures

To determine the cause of infection, your doctor may recommend:

• A blood test
• A urine test
• A spinal tap (lumbar puncture), to find out if your child has a central nervous system infection, such as meningitis

Complex febrile seizures

For complex febrile seizures, your doctor also may recommend an electroencephalogram (EEG), a test that measures brain activity.

If the seizure involved just one side of the child’s body, your doctor may also recommend an MRI to check your child’s brain.

Treatment of febrile seizures

Most febrile seizures stop on their own within a couple of minutes. If your child has a febrile seizure that lasts more than 10 minutes — or if your child has repeated seizures — call for emergency medical attention.

More-serious episodes

If the seizure lasts longer than 15 minutes, a doctor may order medication to stop the seizure.

If the seizure is prolonged or accompanied by a serious infection or if the source of the infection can’t be determined, then your doctor may want your child to stay in the hospital for further observation. But a hospital stay isn’t usually necessary for simple febrile seizures.

Lifestyle and home remedies

If your child has a febrile seizure, stay calm and follow these steps:

• Place your child on his or her side on a surface where he or she won’t fall.
• Stay close to watch and comfort your child.
• Remove hard or sharp objects near your child.
• Loosen tight or restrictive clothing.
• Don’t restrain your child or interfere with your child’s movements.
• Don’t put anything in your child’s mouth.
• Time the seizure.

If your child has another febrile seizure:

• Don’t restrain your child, but do place him or her on a safe surface, such as the floor.
• Place your child on his or her side, keeping the face to the side and the lower arm extended under the head, to prevent your child from inhaling vomit if vomiting occurs.
• If your child had anything in his or her mouth when the seizure began, remove it to prevent choking. Don’t put anything in your child’s mouth during a seizure.
• Seek emergency care for a seizure that lasts longer than 10 minutes.

Nonepileptic Events

An estimated 5 to 20 percent of people diagnosed with epilepsy actually have non-epileptic seizures (NES), which outwardly resemble epileptic seizures, but are not associated with seizure-like electrical discharge in the brain. Non-epileptic events may be referred to as psychogenic non-epileptic seizures or PNES, which do not respond to antiseizure drugs. Instead, psychogenic non-epileptic seizures are often treated by cognitive behavioral therapy to decrease stress and improve self-awareness.

A history of traumatic events is among the known risk factors for psychogenic non-epileptic seizures. People with psychogenic non-epileptic seizures should be evaluated for underlying psychiatric illness and treated appropriately. Two studies together showed a reduction in seizures and fewer coexisting symptoms following treatment with cognitive behavioral therapy. Some people with epilepsy have psychogenic seizures in addition to their epileptic seizures.

Other nonepileptic events may be caused by narcolepsy (sudden attacks of sleep), Tourette syndrome (repetitive involuntary movements called tics), cardiac arrhythmia (irregular heart beat), and other medical conditions with symptoms that resemble seizures. Because symptoms of these disorders can look very much like epileptic seizures, they are often mistaken for epilepsy.

Pregnancy and seizures

Women who’ve had previous seizures typically are able to have healthy pregnancies. Birth defects related to certain medications can sometimes occur.

• In particular, valproic acid (Depakene) — one possible medication for generalized seizures — has been associated with cognitive deficits and neural tube defects, such as spina bifida. The American Academy of Neurology recommends that women avoid using valproic acid during pregnancy because of risks to the baby.

Discuss these risks with your doctor. Because of the risk of birth defects, and because pregnancy can alter medication levels, preconception planning is particularly important for women who’ve had seizures.

In some cases, it may be appropriate to change the dose of seizure medication before or during pregnancy. Medications may be switched in rare cases.

Contraception and anti-seizure medications

It’s also important to know that some anti-seizure medications can alter the effectiveness of oral contraceptives — a form of birth control — and some oral contraceptives can speed up the absorption of seizure medications. If contraception is a high priority, check with your doctor to evaluate whether your medication interacts with your oral contraceptive, and if other forms of contraception need to be considered.

Childhood epilepsy syndromes

A syndrome is a group of signs or symptoms that happen together and help to identify a unique medical condition.

If your child is diagnosed with an epilepsy syndrome, it means that their epilepsy has some specific signs and symptoms. These include ²:

• the type of seizure or seizures they have
• the age when the seizures start
• a specific pattern on an electroencephalogram (EEG).

An EEG test is painless and it records patterns of electrical activity in the brain. Some epilepsy syndromes have a particular pattern so the test can be helpful in finding the correct diagnosis. An epilepsy syndrome can only be diagnosed by looking at all the signs and symptoms together.

If your child is diagnosed with an epilepsy syndrome it may help the pediatrician (doctor who specializes in treating children) to plan their care. For example, choosing treatment options or deciding whether further tests are needed.

Different types of childhood epilepsy syndrome

Syndromes can vary greatly. Some are called ‘benign’ which means children become seizure-free (have no seizures) once they reach a certain age. Other syndromes are ‘severe’ and children have seizures which are difficult to control. Anti-epileptic drugs may be tried alone or in combination with each other and some non-drug treatments may also be tried, for example the ketogenic diet. Many children with severe epilepsy syndromes have additional difficulties with learning and behavior and may need extra support.

Examples of childhood epilepsy syndromes

Benign rolandic epilepsy

This syndrome affects 15% of children with epilepsy and can start at any time between the ages of 3 and 10.

Children may have very few seizures and most become seizure-free by the age of 16. They may have simple focal seizures, (sometimes called simple partial seizures) often at night, which begin with a tingling feeling in the mouth, gurgling or grunting noises and dribbling. Speech can be temporarily affected and symptoms may develop into a generalised tonic clonic (convulsive) seizure.Anti-epileptic drugs may not be necessary but they can be helpful to control seizures.

Childhood absence epilepsy

This syndrome starts between the ages of 4 and 10 and can affect up to 12% of children with epilepsy under 16. Absence seizures happen frequently and are very brief, lasting only a few seconds. Because of this they often go unnoticed.

During a seizure a child will become unconscious. They may look blank or stare and their eyelids may flutter. They may not respond to what is happening around them or be aware of what they are doing. Seizures respond well to medication. If a child is seizure-free for two years medication is sometimes reduced gradually. Up to 90% of children with childhood absence epilepsy will grow out of seizures by the age of 12. Occasionally a child may also have other types of seizure.

Juvenile myoclonic epilepsy

This syndrome starts between the ages of 12 and 18. Many children have three different types of seizure:

• myoclonic seizures (brief muscle jerks) in the upper body
• tonic clonic seizures
• absence seizures.

These often happen shortly as, or shortly after, the child or young person wakes up. Medication can be successful in controlling seizures, which often continue into adulthood and may become less severe.

Tiredness, stress and alcohol can trigger seizures. Up to 40% of children or young people with juvenile myoclonic epilepsy have seizures that are triggered by flashing or flickering lights (photosensitive epilepsy).

Infantile spasms (or West syndrome)

This syndrome often begins in the first year of life and can affect children who have had a previous brain injury before the age of 6 months. It is identified by brief spasms or jerks which happen in ‘clusters’. Spasms can affect the whole body or just the arms and legs. Each cluster can include between 10 – 100 individual spasms, which often happen when the child is waking up. Ongoing studies are looking at using anti-epileptic drugs and steroids to treat this syndrome, although around 25% of children have spasms that do not respond well to medication. Many children develop problems with learning or behaviour. Some may go on to develop Lennox-Gastaut syndrome.

Lennox-Gastaut syndrome

This syndrome usually begins between the ages of 3 and 5, but can start as late as adolescence. Children may have several different types of seizure with this syndrome. These include tonic (where the muscles suddenly become stiff), atonic (where the muscles suddenly relax), myoclonic, tonic clonic and atypical absences. Atypical absences often last longer than normal absences and are different as a child may be responsive and aware of their surroundings.

Many children also develop learning difficulties as well as behaviour problems.

This syndrome can be very difficult to treat with anti-epileptic drugs, and most children need a combination of different drugs. Some non-drug treatments such as the ketogenic diet and vagus nerve stimulation therapy can also be helpful. Seizures often continue into adult life.

Epilepsy symptoms

The main symptom of epilepsy is repeated seizures. These are sudden bursts of electrical activity in the brain that temporarily affect how it works.

Seizures can affect people in different ways, depending on which part of the brain is involved.

Seizure signs and symptoms may include:

• uncontrollable jerking movements and shaking of the arms and legs – called a “fit”
• losing awareness and staring blankly into space (a staring spell)
• becoming stiff
• strange sensations – such as a “rising” feeling in the tummy, unusual smells or tastes, and a tingling feeling in your arms or legs
• collapsing
• temporary confusion
• loss of consciousness or awareness
• psychic symptoms such as fear, anxiety or deja vu

Sometimes you might pass out and not remember what happened.

Symptoms vary depending on the type of seizure. In most cases, a person with epilepsy will tend to have the same type of seizure each time, so the symptoms will be similar from episode to episode.

Doctors generally classify seizures as either focal or generalized, based on how the abnormal brain activity begins.

Epilepsy causes

The epilepsies have many possible causes, but for up to half of people with epilepsy a cause is not known. In other cases, the epilepsies are clearly linked to genetic factors, developmental brain abnormalities, infection, traumatic brain injury, stroke, brain tumors, or other identifiable problems. Anything that disturbs the normal pattern of neuronal activity – from illness to brain damage to abnormal brain development – can lead to seizures.

The epilepsies may develop because of an abnormality in brain wiring, an imbalance of nerve signaling in the brain (in which some cells either over-excite or over-inhibit other brain cells from sending messages), or some combination of these factors. In some pediatric conditions abnormal brain wiring causes other problems such as intellectual impairment.

In other persons, the brain’s attempts to repair itself after a head injury, stroke, or other problem may inadvertently generate abnormal nerve connections that lead to epilepsy. Brain malformations and abnormalities in brain wiring that occur during brain development also may disturb neuronal activity and lead to epilepsy.

Genetics

Genetic mutations may play a key role in the development of certain epilepsies. Many types of epilepsy affect multiple blood-related family members, pointing to a strong inherited genetic component. In other cases, gene mutations may occur spontaneously and contribute to development of epilepsy in people with no family history of the disorder (called “de novo” mutations). Overall, researchers estimate that hundreds of genes could play a role in the disorders.

Several types of epilepsy have been linked to mutations in genes that provide instructions for ion channels, the “gates” that control the flow of ions in and out of cells to help regulate neuronal signaling. For example, most infants with Dravet syndrome, a type of epilepsy associated with seizures that begin before the age of one year, carry a mutation in the SCN1A gene that causes seizures by affecting sodium ion channels.

Genetic mutations also have been linked to disorders known as the progressive myoclonic epilepsies, which are characterized by ultra-quick muscle contractions (myoclonus) and seizures over time. For example, Lafora disease, a severe, progressive form of myoclonic epilepsy that begins in childhood, has been linked to a gene that helps to break down carbohydrates in brain cells.

Mutations in genes that control neuronal migration – a critical step in brain development – can lead to areas of misplaced or abnormally formed neurons, called cortical dysplasia, in the brain that can cause these mis-wired neurons to misfire and lead to epilepsy.

Other genetic mutations may not cause epilepsy, but may influence the disorder in other ways. For example, one study showed that many people with certain forms of epilepsy have an abnormally active version of a gene that results in resistance to anti-seizure drugs. Genes also may control a person’s susceptibility to seizures, or seizure threshold, by affecting brain development.

Other Disorders

Epilepsies may develop as a result of brain damage associated with many types of conditions that disrupt normal brain activity. Seizures may stop once these conditions are treated and resolved. However, the chances of becoming seizure-free after the primary disorder is treated are uncertain and vary depending on the type of disorder, the brain region that is affected, and how much brain damage occurred prior to treatment. Examples of conditions that can lead to epilepsy include:

• Head trauma. Head trauma as a result of a car accident or other traumatic injury can cause epilepsy.
• Brain conditions. Brain conditions that cause damage to the brain, such as brain tumors or strokes, can cause epilepsy. Stroke is a leading cause of epilepsy in adults older than age 35.
• Infectious diseases. Infectious diseases, such as meningitis, AIDS and viral encephalitis, can cause epilepsy.
• Prenatal injury. Before birth, babies are sensitive to brain damage that could be caused by several factors, such as an infection in the mother, poor nutrition or oxygen deficiencies. This brain damage can result in epilepsy or cerebral palsy.
• Developmental disorders. Epilepsy can sometimes be associated with developmental disorders, such as autism and neurofibromatosis.
• Alcoholism or alcohol withdrawal
• Alzheimer’s disease
• Strokes, heart attacks, and other conditions that deprive the brain of oxygen (a significant portion of new-onset epilepsy in elderly people is due to stroke or other cerebrovascular disease)
• Abnormal blood vessel formation (arteriovenous malformations) or bleeding in the brain (hemorrhage)
• Inflammation of the brain
• Infections such as meningitis, HIV, and viral encephalitis

Cerebral palsy or other developmental neurological abnormalities may also be associated with epilepsy. About 20 percent of seizures in children can be attributed to developmental neurological conditions. Epilepsies often co-occur in people with abnormalities of brain development or other neurodevelopmental disorders. Seizures are more common, for example, among individuals with autism spectrum disorder or intellectual impairment. In one study, fully a third of children with autism spectrum disorder had treatment-resistant epilepsy.

Risk factors for Epilepsy

Certain factors may increase your risk of epilepsy:

• Age. The onset of epilepsy is most common in children and older adults, but the condition can occur at any age.
• Family history. If you have a family history of epilepsy, you may be at an increased risk of developing a seizure disorder.
• Head injuries. Head injuries are responsible for some cases of epilepsy. You can reduce your risk by wearing a seat belt while riding in a car and by wearing a helmet while bicycling, skiing, riding a motorcycle or engaging in other activities with a high risk of head injury.
• Stroke and other vascular diseases. Stroke and other blood vessel (vascular) diseases can lead to brain damage that may trigger epilepsy. You can take a number of steps to reduce your risk of these diseases, including limiting your intake of alcohol and avoiding cigarettes, eating a healthy diet, and exercising regularly.
• Dementia. Dementia can increase the risk of epilepsy in older adults.
• Brain infections. Infections such as meningitis, which causes inflammation in your brain or spinal cord, can increase your risk.
• Seizures in childhood. High fevers in childhood can sometimes be associated with seizures. Children who have seizures due to high fevers generally won’t develop epilepsy. The risk of epilepsy increases if a child has a long seizure, another nervous system condition or a family history of epilepsy.

Seizure triggers

For many people with epilepsy, seizures seem to happen randomly.

Seizure triggers do not cause epilepsy but can provoke first seizures in those who are susceptible or can cause seizures in people with epilepsy who otherwise experience good seizure control with their medication. Seizure triggers include alcohol consumption or alcohol withdrawal, dehydration or missing meals, stress, and hormonal changes associated with the menstrual cycle. In surveys of people with epilepsy, stress is the most commonly reported seizure trigger. Exposure to toxins or poisons such as lead or carbon monoxide, street drugs, or even excessively large doses of antidepressants or other prescribed medications also can trigger seizures.

Sleep deprivation is a powerful trigger of seizures. Sleep disorders are common among people with the epilepsies and appropriate treatment of co-existing sleep disorders can often lead to improved control of seizures. Certain types of seizures tend to occur during sleep, while others are more common during times of wakefulness, suggesting to physicians how to best adjust a person’s medication.

For some people, visual stimulation can trigger seizures in a condition known as photosensitive epilepsy. Stimulation can include such things as flashing lights or moving patterns.

Common seizure triggers ³:

• Stress
• Not sleeping well
• Waking up
• Drinking alcohol
• Some medications and illegal drugs
• In women, monthly periods
• Flashing or flickering lights lights (this is an uncommon trigger)
• Not taking epilepsy medicine as prescribed
• Feeling tired
• Missing meals
• Having an illness which causes a high temperature

Keeping a diary of when you have seizures and what happened before them can help you identify and avoid some possible triggers.

Complications of epilepsy

Although most people with epilepsy lead full, active lives, there is an increased risk of death or serious disability associated with epilepsy. There may be an increased risk of suicidal thoughts or actions related to some anti-seizure medications that are also used to treat mania and bipolar disorder.

Having a seizure at certain times can lead to circumstances that are dangerous to yourself or others.

• Falling. If you fall during a seizure, you can injure your head or break a bone.
• Drowning. If you have epilepsy, you’re 15 to 19 times more likely to drown while swimming or bathing than the rest of the population because of the possibility of having a seizure while in the water.
• Car accidents. A seizure that causes either loss of awareness or control can be dangerous if you’re driving a car or operating other equipment.

Many states have driver’s license restrictions related to a driver’s ability to control seizures and impose a minimum amount of time that a driver be seizure-free, ranging from months to years, before being allowed to drive.

• Pregnancy complications. Seizures during pregnancy pose dangers to both mother and baby, and certain anti-epileptic medications increase the risk of birth defects. If you have epilepsy and you’re considering becoming pregnant, talk to your doctor as you plan your pregnancy.

Most women with epilepsy can become pregnant and have healthy babies. You’ll need to be carefully monitored throughout pregnancy, and medications may need to be adjusted. It’s very important that you work with your doctor to plan your pregnancy.

• Emotional health issues. People with epilepsy are more likely to have psychological problems, especially depression, anxiety and suicidal thoughts and behaviors. Problems may be a result of difficulties dealing with the condition itself as well as medication side effects.

Other life-threatening complications of epilepsy are uncommon, but may happen, such as:

• Status epilepticus. This condition occurs if you’re in a state of continuous seizure activity lasting more than five minutes or if you have frequent recurrent seizures without regaining full consciousness in between them. Status epilepticus can be convulsive (in which outward signs of a seizure are observed) or nonconvulsive (which has no outward signs and is diagnosed by an abnormal EEG). Nonconvulsive status epilepticus may appear as a sustained episode of confusion, agitation, loss of consciousness, or even coma. People with status epilepticus have an increased risk of permanent brain damage and death. One study showed that 80 percent of people in status epilepticus who received medication within 30 minutes of seizure onset eventually stopped having seizures, whereas only 40 percent recovered if 2 hours had passed before they received medication. The mortality rate can be as high as 20 percent if treatment is not initiated immediately.

• Sudden unexpected death in epilepsy (SUDEP). People with epilepsy also have a small risk of sudden unexpected death. The cause is unknown, but some research shows it may occur due to heart or respiratory conditions. People with frequent tonic-clonic seizures or people whose seizures aren’t controlled by medications may be at higher risk of SUDEP. Some studies suggest that each year approximately one case of SUDEP occurs for every 1,000 people with the epilepsies. For some, this risk can be higher, depending on several factors. People with more difficult to control seizures tend to have a higher incidence of SUDEP. Overall, about 1 percent of people with epilepsy die of SUDEP. SUDEP can occur at any age. Researchers are still unsure why SUDEP occurs, although some research points to abnormal heart and respiratory function due to gene abnormalities (ones which cause epilepsy and also affect heart function). People with epilepsy may be able to reduce the risk of SUDEP by carefully taking all antiseizure medication as prescribed. Not taking the prescribed dosage of medication on a regular basis may increase the risk of SUDEP in individuals with epilepsy, especially those who are taking more than one medication for their epilepsy.

Can the epilepsies be prevented?

At this time there are no medications or other therapies that have been shown to prevent epilepsy. In some cases, the risk factors that lead to epilepsy can be modified. Good prenatal care, including treatment of high blood pressure and infections during pregnancy, may prevent brain injury in the developing fetus that may lead to epilepsy and other neurological problems later. Treating cardiovascular disease, high blood pressure, and other disorders that can affect the brain during adulthood and aging also may prevent some cases of epilepsy. Prevention or early treatment of infections such as meningitis in high-risk populations may also prevent cases of epilepsy. Also, the wearing of seatbelts and bicycle helmets, and correctly securing children in car seats, may avert some cases of epilepsy associated with head trauma.

Diagnosis of epilepsy

To diagnose your condition, your doctor will review your symptoms and medical history. Your doctor may order several tests to diagnose epilepsy and determine the cause of seizures. Your evaluation may include:

• A neurological exam. Your doctor may test your behavior, motor abilities, mental function and other areas to diagnose your condition and determine the type of epilepsy you may have.
• Blood tests. Blood samples may be taken to screen for metabolic or genetic disorders that may be associated with the seizures. They also may be used to check for underlying health conditions such as infections, lead poisoning, anemia, and diabetes that may be causing or triggering the seizures. In the emergency department it is standard procedure to screen for exposure to recreational drugs in anyone with a first seizure.

Your doctor may also suggest tests to detect brain abnormalities, such as:

• Electroencephalogram (EEG). This is the most common test used to diagnose epilepsy. In this test, doctors attach electrodes to your scalp with a paste-like substance. The electrodes record the electrical activity of your brain.

If you have epilepsy, it’s common to have changes in your normal pattern of brain waves, even when you’re not having a seizure. Your doctor may monitor you on video while conducting an EEG while you’re awake or asleep, to record any seizures you experience. Recording the seizures may help the doctor determine what kind of seizures you’re having or rule out other conditions.

Your doctor may give you instructions to do something that will cause seizures, such as getting little sleep prior to the test.

• High-density EEG. In a variation of an EEG test, your doctor may recommend high-density EEG, which spaces electrodes more closely than conventional EEG — about a half a centimeter apart. High-density EEG may help your doctor more precisely determine which areas of your brain are affected by seizures.
• Computerized tomography (CT) scan. A CT scan uses X-rays to obtain cross-sectional images of your brain. CT scans can reveal abnormalities in your brain that might be causing your seizures, such as tumors, bleeding and cysts.
• Magnetic resonance imaging (MRI). An MRI uses powerful magnets and radio waves to create a detailed view of your brain. Your doctor may be able to detect lesions or abnormalities in your brain that could be causing your seizures.
• Functional MRI (fMRI). A functional MRI measures the changes in blood flow that occur when specific parts of your brain are working. Doctors may use an fMRI before surgery to identify the exact locations of critical functions, such as speech and movement, so that surgeons can avoid injuring those places while operating.
• Positron emission tomography (PET). PET scans use a small amount of low-dose radioactive material that’s injected into a vein to help visualize active areas of the brain and detect abnormalities.
• Single-photon emission computerized tomography (SPECT). This type of test is used primarily if you’ve had an MRI and EEG that didn’t pinpoint the location in your brain where the seizures are originating. A SPECT test uses a small amount of low-dose radioactive material that’s injected into a vein to create a detailed, 3-D map of the blood flow activity in your brain during seizures. Doctors also may conduct a form of a SPECT test called subtraction ictal SPECT coregistered to MRI (SISCOM), which may provide even more-detailed results.
• Neuropsychological tests. In these tests, doctors assess your thinking, memory and speech skills. The test results help doctors determine which areas of your brain are affected.

Along with your test results, your doctor may use a combination of analysis techniques to help pinpoint where in the brain seizures start:

• Statistical parametric mapping (SPM). SPM is a method of comparing areas of the brain that have increased metabolism during seizures to normal brains, which can give doctors an idea of where seizures begin.
• Curry analysis. Curry analysis is a technique that takes EEG data and projects it onto an MRI of the brain to show doctors where seizures are occurring.
• Magnetoencephalography (MEG). MEG measures the magnetic fields produced by brain activity to identify potential areas of seizure onset.

Accurate diagnosis of your seizure type and where seizures begin gives you the best chance for finding an effective treatment.

Epilepsy treatment

Doctors generally begin by treating epilepsy with medication. If medications don’t treat the condition, doctors may propose surgery or another type of treatment.

Epilepsy Medication

Most people with epilepsy can become seizure-free by taking one anti-seizure medication, which is also called anti-epileptic medication. Others may be able to decrease the frequency and intensity of their seizures by taking a combination of medications.

Many children with epilepsy who aren’t experiencing epilepsy symptoms can eventually discontinue medications and live a seizure-free life. Many adults can discontinue medications after two or more years without seizures. Your doctor will advise you about the appropriate time to stop taking medications.

Finding the right medication and dosage can be complex. Your doctor will consider your condition, frequency of seizures, your age and other factors when choosing which medication to prescribe. Your doctor will also review any other medications you may be taking, to ensure the anti-epileptic medications won’t interact with them.

Your doctor likely will first prescribe a single medication at a relatively low dosage and may increase the dosage gradually until your seizures are well-controlled.

For many people with epilepsy, seizures can be controlled with monotherapy at the optimal dosage. Combining medications may amplify side effects such as fatigue and dizziness, so doctors usually prescribe just one drug whenever possible. Combinations of drugs, however, are still sometimes necessary for some forms of epilepsy that do not respond to monotherapy.

When starting any new antiseizure medication, a low dosage will usually be prescribed initially followed by incrementally higher dosages, sometimes with blood-level monitoring, to determine when the optimal dosage has been reached. It may take time for the dosage to achieve optimal seizure control while minimizing side effects. The latter are usually worse when first starting a new medicine.

Seizure medications include:

Anti-seizure medications may have some side effects. Mild side effects include:

• Fatigue
• Dizziness
• Weight gain
• Loss of bone density
• Skin rashes
• Loss of coordination
• Speech problems
• Memory and thinking problems

More-severe but rare side effects include:

• Depression
• Suicidal thoughts and behaviors
• Severe rash
• Inflammation of certain organs, such as your liver

To achieve the best seizure control possible with medication, follow these steps:

• Take medications exactly as prescribed.
• Always call your doctor before switching to a generic version of your medication or taking other prescription medications, over-the-counter drugs or herbal remedies.
• Never stop taking your medication without talking to your doctor.
• Notify your doctor immediately if you notice new or increased feelings of depression, suicidal thoughts, or unusual changes in your mood or behaviors.
• Tell your doctor if you have migraines. Doctors may prescribe one of the anti-epileptic medications that can prevent your migraines and treat epilepsy.

At least half the people newly diagnosed with epilepsy will become seizure-free with their first medication. If anti-epileptic medications don’t provide satisfactory results, your doctor may suggest surgery or other therapies. You’ll have regular follow-up appointments with your doctor to evaluate your condition and medications.

Some people with epilepsy may be advised to discontinue their antiseizure drugs after 2-3 years have passed without a seizure. Others may be advised to wait for 4 to 5 years. Discontinuing medication should always be done with supervision of a health care professional. It is very important to continue taking antiseizure medication for as long as it is prescribed. Discontinuing medication too early is one of the major reasons people who have been seizure-free start having new seizures and can lead to status epilepticus. Some evidence also suggests that uncontrolled seizures may trigger changes in the brain that will make it more difficult to treat the seizures in the future.

The chance that a person will eventually be able to discontinue medication varies depending on the person’s age and his or her type of epilepsy. More than half of children who go into remission with medication can eventually stop their medication without having new seizures. One study showed that 68 percent of adults who had been seizure-free for 2 years before stopping medication were able to do so without having more seizures and 75 percent could successfully discontinue medication if they had been seizure-free for 3 years. However, the odds of successfully stopping medication are not as good for people with a family history of epilepsy, those who need multiple medications, those with focal seizures, and those who continue to have abnormal EEG results while on medication.

There are specific syndromes in which certain antiseizure medications should not be used because they may make the seizures worse. For example, carbamazepine can worsen epilepsy in children diagnosed with Dravet syndrome.

Epilepsy surgery

When medications fail to provide adequate control over seizures, surgery may be an option. With epilepsy surgery, a surgeon removes the area of your brain that’s causing seizures.

Doctors usually perform surgery when tests show that:

• Your seizures originate in a small, well-defined area of your brain
• The area in your brain to be operated on doesn’t interfere with vital functions such as speech, language, motor function, vision or hearing

Although many people continue to need some medication to help prevent seizures after successful surgery, you may be able to take fewer drugs and reduce your dosages.

In a small number of cases, surgery for epilepsy can cause complications such as permanently altering your thinking (cognitive) abilities or personality changes as well as physical disability, even in people who are excellent candidates for it. Talk to your surgeon about his or her experience, success rates, and complication rates with the procedure you’re considering.

Nonetheless, when medications fail, several studies have shown that surgery is much more likely to make someone seizure-free compared to attempts to use other medications. Anyone thinking about surgery for epilepsy should be assessed at an epilepsy center experienced in surgical techniques and should discuss with the epilepsy specialists the balance between the risks of surgery and desire to become seizure-free.

Even when surgery completely ends a person’s seizures, it is important to continue taking antiseizure medication for some time. Doctors generally recommend continuing medication for at least two years after a successful operation to avoid recurrence of seizures.

Surgical procedures for treating epilepsy disorders include:

• Surgery to remove a seizure focus involves removing the defined area of the brain where seizures originate. It is the most common type of surgery for epilepsy, which doctors may refer to as a lobectomy or lesionectomy, and is appropriate only for focal seizures that originate in just one area of the brain. In general, people have a better chance of becoming seizure-free after surgery if they have a small, well-defined seizure focus. The most common type of lobectomy is a temporal lobe resection, which is performed for people with medial temporal lobe epilepsy. In such individuals one hippocampus (there are two, one on each side of the brain) is seen to be shrunken and scarred on an MRI scan.
• Multiple subpial transection may be performed when seizures originate in part of the brain that cannot be removed. It involves making a series of cuts that are designed to prevent seizures from spreading into other parts of the brain while leaving the person’s normal abilities intact.
• Corpus callosotomy or severing the network of neural connections between the right and left halves (hemispheres) of the brain, is done primarily in children with severe seizures that start in one half of the brain and spread to the other side. Corpus callosotomy can end drop attacks and other generalized seizures. However, the procedure does not stop seizures in the side of the brain where they originate, and these focal seizures may even worsen after surgery.
• Hemispherectomy and hemispherotomy involve removing half of the brain’s cortex, or outer layer. These procedures are used predominantly in children who have seizures that do not respond to medication because of damage that involves only half the brain, as occurs with conditions such as Rasmussen’s encephalitis. While this type of surgery is very excessive and is performed only when other therapies have failed, with intense rehabilitation, children can recover many abilities.

Epilepsy Therapies

Electrical stimulation of the brain remains a therapeutic strategy of interest for people with medication-resistant forms of epilepsy who are not candidates for surgery.

• Vagus nerve stimulation. The vagus nerve stimulation device for the treatment of epilepsy was approved by the U.S. Food and Drug Administration (FDA) in 1997. The vagus nerve stimulator is surgically implanted under the skin of the chest, similar to a heart pacemaker and is attached to the vagus nerve in the lower neck. The device delivers short bursts of electrical energy to the brain via the vagus nerve. It’s not clear how this inhibits seizures, but the device can usually reduce seizures by 20 to 40 percent. Individuals usually cannot stop taking epilepsy medication because of the stimulator, but they often experience fewer seizures and they may be able to reduce the dosage of their medication. You may experience side effects from vagus nerve stimulation, such as throat pain, hoarse voice, shortness of breath or coughing.
• Responsive stimulation involves the use of an implanted device that analyzes brain activity patterns to detect a forthcoming seizure. Once detected, the device administers an intervention, such as electrical stimulation or a fast-acting drug to prevent the seizure from occurring. These devices also are known as closed-loop systems. NeuroPace, one of the first responsive stimulation, closed-loop devices, received premarket approval by the FDA in late 2013 and is available for adults with refractory epilepsy (hard to treat epilepsy that does not respond well to trials of at least two medicines).
• Ketogenic diet. Some children with epilepsy have been able to reduce their seizures by following a strict diet that’s high in fats and low in carbohydrates.

In this diet, called a ketogenic diet, the body breaks down fats instead of carbohydrates for energy. After a few years, some children may be able to stop the ketogenic diet — under close supervision of their doctors — and remain seizure-free.

Consult a doctor if you or your child is considering a ketogenic diet. It’s important to make sure that your child doesn’t become malnourished when following the diet.

Side effects of a ketogenic diet may include dehydration, constipation, slowed growth because of nutritional deficiencies and a buildup of uric acid in the blood, which can cause kidney stones. These side effects are uncommon if the diet is properly and medically supervised.

Following a ketogenic diet can be a challenge. Low-glycemic index and modified Atkins diets offer less restrictive alternatives that may still provide some benefit for seizure control.

Potential future treatments

Researchers are studying many potential new treatments for epilepsy, including:

• Deep brain stimulation. In deep brain stimulation, surgeons implant electrodes into a specific part of your brain, typically your thalamus. The electrodes are connected to a generator implanted in your chest or the skull that sends electrical pulses to your brain and may reduce your seizures. Stimulation of an area called the anterior thalamic nucleus has been particularly helpful in providing at least partial relief from seizures in people who had medication-resistant forms of the disorder.
• Continuous stimulation of the seizure onset zone (subthreshold stimulation). Subthreshold stimulation — continuous stimulation to an area of your brain below a level that’s physically noticeable — appears to improve seizure outcomes and quality of life for some people with seizures. This treatment approach may work in people who have seizures that start in an area of the brain that can’t be removed because it would affect speech and motor functions (eloquent area). Or it might benefit people whose seizure characteristics mean their chances of successful treatment with responsive neurostimulation are low.
• Minimally invasive surgery. New minimally invasive surgical techniques, such as MRI-guided laser ablation, show promise at reducing seizures with fewer risks than traditional open brain surgery for epilepsy.
• Stereotactic laser ablation or radiosurgery. For some types of epilepsy, stereotactic laser ablation or stereotactic radiosurgery may provide effective treatment for people in which an open procedure may be too risky. In these procedures, doctors direct radiation at the specific area in the brain causing seizures, to destroy that tissue in an effort to better control the seizures.
• External nerve stimulation device. Similar to vagus nerve stimulation, this device would stimulate specific nerves to reduce frequency of seizures. But unlike vagus nerve stimulation, this device would be worn externally so that no surgery to implant the device is needed.
• A report on trigeminal nerve stimulation (using electrical signals to stimulate parts of the trigeminal nerve and affected brain regions) showed efficacy rates similar to those for vagal nerve stimulation, with responder rates hovering around 50 percent. (A responder is defined as someone having greater than a 50 percent reduction in seizure frequency.) Freedom from seizures, although reported, remains rare for both methods. At the time of this writing, a trigeminal nerve stimulation device was available for use in Europe, but it had not yet been approved in the United States.
• Transcutaneous magnetic stimulation involves a device being placed outside the head to produce a magnetic field to induce an electrical current in nearby areas of the brain. It has been shown to reduce cortical activity associated with specific epilepsy syndromes.

Lifestyle and home remedies

Understanding your condition can help you take better control of it:

• Take your medication correctly. Don’t adjust your dosage before talking to your doctor. If you feel your medication should be changed, discuss it with your doctor.
• Get enough sleep. Lack of sleep can trigger seizures. Be sure to get adequate rest every night.
• Wear a medical alert bracelet. This will help emergency personnel know how to treat you correctly.
• Exercise. Exercising may help keep you physically healthy and reduce depression. Make sure to drink enough water, and rest if you get tired during exercise.

In addition, make healthy life choices, such as managing stress, limiting alcoholic beverages and avoiding cigarettes.

Ketogenic Diet

Dietary approaches and other treatments may be more appropriate depending on the age of the individual and the type of epilepsy. A high-fat, very low carbohydrate ketogenic diet is often used to treat medication-resistant epilepsies. The diet induces a state known as ketosis, which means that the body shifts to breaking down fats instead of carbohydrates to survive. A ketogenic diet effectively reduces seizures for some people, especially children with certain forms of epilepsy. Studies have shown that more than 50 percent of people who try the ketogenic diet have a greater than 50 percent improvement in seizure control and 10 percent experience seizure freedom. Some children are able to discontinue the ketogenic diet after several years and remain seizure-free, but this is done with strict supervision and monitoring by a physician.

The ketogenic diet is not easy to maintain, as it requires strict adherence to a limited range of foods. Possible side effects include impaired growth due to nutritional deficiency and a buildup of uric acid in the blood, which can lead to kidney stones.

Researchers are looking at modified versions of and alternatives to the ketogenic diet. For example, studies show promising results for a modified Atkins diet and for a low-glycemic-index treatment, both of which are less restrictive and easier to follow than the ketogenic diet, but well-controlled randomized controlled trials have yet to assess these approaches.

Driving and Recreation

Most states and the District of Columbia will not issue a driver’s license to someone with epilepsy unless the person can document that she/he has been seizure-free for a specific amount of time (the waiting period varies from a few months to several years). Some states make exceptions for this policy when seizures don’t impair consciousness, occur only during sleep, or have long auras or other warning signs that allow the person to avoid driving when a seizure is likely to occur. Studies show that the risk of having a seizure-related accident decreases as the length of time since the last seizure increases. Commercial drivers’ licenses have additional restrictions. In addition, people with epilepsy should take extra care if a job involves operation of machinery or vehicles.

The risk of seizures also limits people’s recreational choices. Individuals may need to take precautions with activities such as climbing, sailing, swimming, or working on ladders. Studies have not shown any increase in seizures due to sports, although these studies have not focused on any activity in particular. There is some evidence that regular exercise may improve seizure control in some people, but this should be done under a doctor’s supervision. The benefits of sports participation may outweigh the risks and coaches or other leaders can take appropriate safety precautions. Steps should be taken to avoid dehydration, overexertion, and hypoglycemia, as these problems can increase the risk of seizures.

Pregnancy and Motherhood

Women with epilepsy are often concerned about whether they can become pregnant and have a healthy child. Epilepsy itself does not interfere with the ability to become pregnant. With the right planning, supplemental vitamin use, and medication adjustments prior to pregnancy, the odds of a woman with epilepsy having a healthy pregnancy and a healthy child are similar to a woman without a chronic medical condition.

Children of parents with epilepsy have about 5 percent risk of developing the condition at some point during life, in comparison to about a 1 percent risk in a child in the general population. However, the risk of developing epilepsy increases if a parent has a clearly hereditary form of the disorder. Parents who are worried that their epilepsy may be hereditary may wish to consult a genetic counselor to determine their risk of passing on the disorder.

Other potential risks to the developing child of a woman with epilepsy or on antiseizure medication include increased risk for major congenital malformations (also known as birth defects) and adverse effects on the developing brain. The types of birth defects that have been most commonly reported with antiseizure medications include cleft lip or cleft palate, heart problems, abnormal spinal cord development (spina bifida), urogenital defects, and limb-skeletal defects. Some antiseizure medications, particularly valproate, are known to increase the risk of having a child with birth defects and/or neurodevelopmental problems, including learning disabilities, general intellectual disabilities, and autism spectrum disorder. It is important that a woman work with a team of providers that includes her neurologist and her obstetrician to learn about any special risks associated with her epilepsy and the medications she may be taking.

Although planned pregnancies are essential to ensuring a healthy pregnancy, effective birth control is also essential. Some antiseizure medications that induce the liver’s metabolic capacity can interfere with the effectiveness of hormonal contraceptives (e.g., birth control pills, vaginal ring). Women who are on these enzyme-inducing antiseizure medications and using hormonal contraceptives may need to switch to a different kind of birth control that is more effective (such as different intrauterine devices, progestin implants, or long-lasting injections).

Prior to a planned pregnancy, a woman with epilepsy should meet with her health care team to reassess the current need for antiseizure medications and to determine a) the optimal medication to balance seizure control and avoid birth defects and b) the lowest dose for going into a planned pregnancy. Any transitions to either a new medication or dosage should be phased in prior to the pregnancy, if possible. If a woman’s seizures are controlled for the 9 months prior to pregnancy, she is more likely to continue to have seizure control during pregnancy. For all women with epilepsy during pregnancy, approximately 15-25 percent will have seizure worsening, but another 15-25 percent will have seizure improvement. As a woman’s body changes during pregnancy, the dose of seizure medication may heed to be increased. For most medicines, monthly monitoring of blood levels of the antiseizure medicines can help to assure continued seizure control. Many of the birth defects seen with antiseizure medications occur in the first six weeks of pregnancy, often before a woman is aware she is pregnant. In addition, up to 50 percent of pregnancies in the U.S. are unplanned. For these reasons, the discussion about the medications should occur early between the health care professional and any woman with epilepsy who is in her childbearing years.

For all women thinking of becoming pregnant, using supplemental folic acid beginning prior to conception and continuing the supplement during pregnancy is an important way to lower the risk for birth defects and developmental delays. Prenatal multivitamins should also be used prior to the beginning of pregnancy. Pregnant women with epilepsy should get plenty of sleep and avoid other triggers or missed medications to avoid worsening of seizures.

Most pregnant women with epilepsy can deliver with the same choices as women without any medical complications. During the labor and delivery, it is important that the woman be allowed to take her same formulations and doses of antiseizure drugs at her usual times; it is often helpful for her to bring her medications from home. If a seizure does occur during labor and delivery, intravenous short-acting medications can be given if necessary. It is unusual for the newborns of women with epilepsy to experience symptoms of withdrawal from the mother’s antiseizure medication (unless she is on phenobarbital or a standing dose of benzodiazepines), but the symptoms resolve quickly and there are usually no serious or long-term effects.

The use of antiseizure medications is considered safe for women who choose to breastfeed their child. On very rare occasions, the baby may become excessively drowsy or feed poorly, and these problems should be closely monitored. However, experts believe the benefits of breastfeeding outweigh the risks except in rare circumstances. One large study showed that the children who were breastfed by mothers with epilepsy on antiseizure medications performed better on learning and developmental scales than the babies who were not breastfed. It is common for the antiseizure medication dosing to be adjusted again in the postpartum setting, especially if the dose was altered during pregnancy.

With the appropriate selection of safe antiseizure medicines during pregnancy, use of supplemental folic acid, and ideally, with pre-pregnancy planning, most women with epilepsy can have a healthy pregnancy with good outcomes for themselves and their developing child.

Coping and support

Uncontrolled seizures and their effects on your life may at times feel overwhelming or lead to depression. It’s important not to let epilepsy hold you back. You can still live an active, full life. To help cope:

• Educate yourself and your friends and family about epilepsy so that they understand the condition.
• Try to ignore negative reactions from people. It helps to learn about epilepsy so that you know the facts as opposed to misconceptions about the disease. And try to keep your sense of humor.
• Live as independently as possible. Continue to work, if possible. If you can’t drive because of your seizures, investigate public transportation options near you. If you aren’t allowed to drive, you might consider moving to a city with good public transportation options.
• Find a doctor you like and with whom you feel comfortable.
• Try not to constantly worry about having a seizure.
• Find an epilepsy support group to meet people who understand what you’re going through.

If your seizures are so severe that you can’t work outside your home, there are still ways to feel productive and connected to people. You may consider working from home.

Let people you work and live with know the correct way to handle a seizure in case they are with you when you have one.

You may offer them suggestions, such as:

• Carefully roll the person onto one side.
• Place something soft under his or her head.
• Loosen tight neckwear.
• Don’t try to put your fingers or anything else in the person’s mouth. No one has ever “swallowed” his or her tongue during a seizure — it’s physically impossible.
• Don’t try to restrain someone having a seizure.
• If the person is moving, clear away dangerous objects.
• Stay with the person until medical personnel arrive.
• Observe the person closely so that you can provide details on what happened.
• Time the seizures.
• Be calm during the seizures.

1. International League Against Epilepsy. https://www.ilae.org/[↩]
2. Childhood epilepsy syndromes. https://www.epilepsysociety.org.uk/childhood-epilepsy-syndromes[↩]
3. Some common seizure triggers. https://www.epilepsy.org.uk/info/triggers[↩]