What are Epilepsy & Seizures?

What is epilepsy?

Epilepsy is diagnosed when a person has:

• At least two unprovoked seizures occurring more than 24 hours apart.
• One unprovoked seizure with a high risk of further seizures.  
• Diagnosis of an epilepsy syndrome.

What is a seizure?

A seizure is a sudden, uncontrolled electrical disturbance in the brain. It can cause changes in behavior, movements, feelings, and consciousness.

• Think of your brain as a complex electrical system. During a seizure, there’s a temporary “power surge” that disrupts normal brain function.
• Seizures can last from a few seconds to several minutes.
• Not all seizures are related to epilepsy. Some can be caused by other factors like high fever, low blood sugar, or alcohol withdrawal.

Who Does Epilepsy Affect?

Epilepsy doesn’t discriminate – it can affect people of all ages, races, and ethnicities. However, certain groups are more likely to develop epilepsy:

• Children, especially in their first year of life.
• Older adults, particularly those over 65.
• People with certain genetic conditions.
• Individuals who have had brain injuries or strokes.

Who is more likely to have epilepsy and seizures?

While anyone can develop epilepsy, some factors increase the risk:

• Family history of epilepsy.
• Brain injuries from accidents or stroke.
• Developmental disorders such as autism.
• Infections that affect the brain, like meningitis.
• Prenatal injury or lack of oxygen during birth.

How Common is Epilepsy?

According to the The American Journal of Medicine 2021 Epilepsy is the 4th most common neurological disorders globally:

• Approximately 65 million people worldwide have epilepsy.
• In the United States, about 3.4 million people have active epilepsy.
• Nearly 1 in 26 people will develop epilepsy at some point in their lifetime.

What Happens in Your Brain During Epilepsy?

To understand epilepsy, it’s helpful to know a bit about how the brain works:

• Your brain contains billions of neurons that communicate through electrical and chemical signals.
• In epilepsy, there’s an imbalance in these signals, leading to excessive and synchronized electrical activity.
• This abnormal activity can stay in one area of the brain (focal seizures) or spread to both sides (generalized seizures).

Seizure Triggers

Many people with epilepsy find that certain factors can trigger seizures:

• Lack of sleep or changes in sleep patterns
• Stress
• Alcohol or drug use
• Flickering lights or patterns
• Hormonal changes (e.g., during menstruation)
• Missing medication doses
• Certain medications or supplements

How to Identify Seizure Triggers

• Identifying your personal seizure triggers can help manage epilepsy:
• Keep a seizure diary: Note the circumstances around each seizure
• Look for patterns: Do seizures occur more often at certain times or after specific activities?
• Discuss with your doctor: They can help interpret your observations and suggest management strategies.

Types of Seizures

Seizures are generally classified into two main categories:

Focal Onset Seizures

Focal seizures, also known as partial seizures, start in one area of the brain.

Symptoms of Focal Seizures:

• Altered awareness or consciousness
• Involuntary movements like twitching or repetitive motions
• Changes in emotions or thoughts
• Sensory changes (unusual smells, tastes, or sensations)
• Autonomic symptoms (sweating, nausea, or changes in heart rate)

Focal seizures can be further classified as:

1. Focal Aware Seizures: The person remains conscious and aware during the seizure.

2. Focal Impaired Awareness Seizures: Consciousness is affected, and the person may appear confused or unresponsive.

Generalized Onset Seizures

Generalized seizures involve both sides of the brain from the start.

Types of generalized seizures include:

1. Absence Seizures: Brief lapses in awareness, often mistaken for daydreaming.

2. Tonic-Clonic Seizures: Involve loss of consciousness, muscle stiffening, and jerking movements.

3. Atonic Seizures: Sudden loss of muscle tone, often causing falls. 4. Myoclonic Seizures: Brief, shock-like jerks of muscles.

Types of Epilepsy

Epilepsy is not a single disorder but a group of related disorders. Some common types include:

Types of Childhood Epilepsy

• Benign Rolandic Epilepsy: Characterized by seizures affecting the face and sometimes spreading to the body.
• Childhood Absence Epilepsy: Frequent absence seizures that can impact learning.
• Juvenile Myoclonic Epilepsy: Involves myoclonic seizures, often starting in adolescence.

 Nonepileptic Seizures

It’s important to note that not all seizure-like events are epileptic:

• Psychogenic Nonepileptic Seizures (PNES): These events look like seizures but are not caused by abnormal brain electrical activity. They often have a psychological origin.
• Syncope: Fainting spells that can sometimes be mistaken for seizures.

Symptoms and Causes of epilepsy

What Are the Signs and Symptoms of Epileptic Seizures?

Seizure symptoms can vary widely depending on the type of seizure and the area of the brain affected. Common signs include:

• Temporary confusion
• Staring spell
• Uncontrollable jerking movements of the arms and legs
• Loss of consciousness or awareness
• Cognitive or emotional symptoms, such as fear and anxiety

It’s important to note that seizure symptoms can be subtle and may not always involve convulsions.

What Causes Epilepsy?

Epilepsy can have various causes, but in about half of all cases, no specific cause can be identified. Some known causes include:

• Brain injuries (from accidents, strokes, or oxygen deprivation)
• Brain tumors
• Infections affecting the brain (like meningitis or encephalitis)
• Developmental disorders (such as autism or Down syndrome)
• Prenatal injuries or birth complications.

Genetics and Acquired Causes of Epilepsy

Epilepsy can be:

1. Genetic:

• Some forms of epilepsy run in families
• Certain genes may make a person more susceptible to environmental triggers

2. Acquired:

• Resulting from brain damage or changes in brain structure
• Can occur at any age, but more common in older adults due to strokes or neurodegenerative diseases

Recent research has identified several genes associated with various forms of epilepsy. For instance, mutations in genes like SCN1A and KCNQ2 have been linked to specific epilepsy syndromes .

Psychosocial and Emotional Impact

Living with epilepsy can have significant psychological and social effects:

• Anxiety and depression are common among people with epilepsy
• Fear of having a seizure in public can lead to social isolation
• Cognitive issues, such as memory problems, can affect daily life and work
• Stigma and misconceptions about epilepsy can lead to discrimination

A study published in Epilepsy & Behavior found that up to 50% of people with epilepsy experience depression at some point in their lives .

Diagnosis and Tests

How is Epilepsy Diagnosed?

Diagnosing epilepsy involves several steps:

1. Detailed medical history

2. Neurological examination

3. Various diagnostic tests:

Medical History and Imaging Tests

• EEG (Electroencephalogram):
• Records brain’s electrical activity
•  Can show abnormal patterns even when not having a seizure
•   Sometimes, long-term EEG monitoring is needed
• MRI (Magnetic Resonance Imaging):
• Provides detailed images of brain structure
• Can identify structural abnormalities that might cause seizures
• PET (Positron Emission Tomography):
•   Shows brain activity and metabolism
•   Useful in localizing seizure focus for surgical planning
• SPECT (Single-Photon Emission Computed Tomography):
•   – Can be used to locate the area where seizures begin
• Blood Tests and Neurological Evaluations
• Blood tests:
•  Rule out other conditions that might cause seizure-like symptoms
•  Check for genetic markers associated with certain types of epilepsy
• Neurological exam:
•   Assesses brain function and motor abilities
•   Helps identify any neurological deficits

Differential Diagnosis and Epilepsy Syndromes

Doctors must rule out other conditions that can cause seizure-like symptoms, such as:

• Syncope (fainting)
• Migraines
• Sleep disorders
• Psychological conditions

Anti-epileptic drugs (AEDs) are the primary treatment for epilepsy:

• They work by altering brain chemistry to reduce seizure activity
• Examples include carbamazepine, valproic acid, and levetiracetam
• Finding the right medication and dosage often requires trial and error

A meta-analysis published in The Lancet Neurology found that newer AEDs generally have similar efficacy but may have different side effect profiles compared to older drugs .

Diet Therapy for Epilepsy

Certain diets can help control seizures in some people, especially children:

• Ketogenic Diet: High-fat, low-carbohydrate diet
• Modified Atkins Diet: Less restrictive version of the ketogenic diet
• Low Glycemic Index Diet: Focuses on foods that have a low glycemic index

A systematic review in Neurology found that the ketogenic diet can lead to a >50% reduction in seizures for about half of the children who try it [4].

Surgery and Devices for Epilepsy

When medications fail to control seizures, surgery may be an option:

• Resective Surgery: Removes the part of the brain causing seizures
• Laser Interstitial Thermal Therapy (LITT):
• Uses laser to destroy seizure-causing tissue
• Responsive Neurostimulation (RNS):
• Implanted device that detects and stops seizures.

 Vagus Nerve Stimulation

VNS involves implanting a device that sends electrical pulses to the vagus nerve:

• Can reduce seizure frequency and severity
• Often used when other treatments have failed
• May improve mood and quality of life.

First Aid for Seizures

Knowing how to respond to a seizure is crucial:

• Stay calm and time the seizure
• Protect the person from injury
• Do not restrain the person or put anything in their mouth
• Turn the person on their side after the seizure ends
• Stay with them until they are fully alert.

Neurostimulation Options

Besides VNS, other neurostimulation techniques include:

• Deep Brain Stimulation (DBS): Electrodes implanted in specific brain areas
• Transcranial Magnetic Stimulation (TMS): Non-invasive method using magnetic fields.

Alternative Medicines

Some people with epilepsy explore complementary therapies:

• Herbal remedies (e.g., CBD oil)
• Acupuncture
• Biofeedback

Prevention

Can Epilepsy Be Prevented?

While not all cases of epilepsy can be prevented, certain measures can reduce the risk:

• Wearing seatbelts and helmets to prevent head injuries
• Controlling high blood pressure and managing stroke risk
• Getting proper prenatal care to prevent complications during pregnancy and birth
• Avoiding illicit drugs and excessive alcohol consumption
• Maintaining a healthy lifestyle with regular exercise and proper sleep

Recent research suggests that some cases of epilepsy might be preventable. A study published in Neurology found that up to 25% of epilepsy cases might be prevented by addressing known risk factors .

Prognosis and Outlook

Is There a Cure for Epilepsy?

While there’s no universal cure for epilepsy, many people achieve seizure freedom:

• About 70% of people with epilepsy can become seizure-free with proper treatment
• Some children with epilepsy outgrow the condition
• In some cases, surgery can provide a long-term cure.

Will I Always Have Seizures?

The outlook varies depending on the individual and type of epilepsy:

• Many people achieve long-term seizure control with medication
• Some may have occasional breakthrough seizures
• A small percentage have drug-resistant epilepsy and continue to have frequent seizures.

How Long Will I Need Medications?

The duration of treatment varies:

• Some people need lifelong medication
• Others may be able to stop medication after being seizure-free for several years
• Any changes in medication should be done under close medical supervision

Life-threatening Complications

While most seizures are not life-threatening, there are some serious risks:

• Status Epilepticus: A prolonged seizure or series of seizures without full recovery in between, which can lead to brain damage or death if not treated promptly
• SUDEP (Sudden Unexpected Death in Epilepsy): A rare but devastating complication, more common in people with poorly controlled seizures

Living with Epilepsy

Managing Seizures and Medications

Living well with epilepsy involves:

• Taking medications as prescribed
• Identifying and avoiding seizure triggers
• Regular follow-ups with healthcare providers
• Keeping a seizure diary to track frequency and potential triggers

Mental Health and Stigma

People with epilepsy may face unique mental health challenges:

• Higher rates of anxiety and depression
• Potential cognitive effects of seizures or medications
• Stigma and misconceptions about epilepsy

Support groups and counseling can be beneficial in addressing these issues.

Driving, Employment, and Education Considerations

• Driving restrictions vary by location and seizure control
• Workplace accommodations may be necessary for some jobs
• Educational support might be needed for students with epilepsy.

Pregnancy, Parenthood, and Epilepsy

Women with epilepsy can have healthy pregnancies, but special considerations are needed:

• Pre-conception planning with healthcare providers
• Potential adjustment of medications during pregnancy
• Close monitoring throughout pregnancy and after birth

When to See a Doctor or Visit the Emergency Room

Seek immediate medical attention if:

• A seizure lasts longer than 5 minutes
• Consciousness doesn’t return after the seizure ends
• A second seizure follows quickly
• Injury occurs during the seizure
• The seizure occurs in water

Complications

Seizure Clusters

Some people experience seizure clusters – multiple seizures within a short period:

• Can be more dangerous than isolated seizures
• May require special rescue medications.

Post-Ictal State

The period following a seizure, known as the post-ictal state, can involve:

• Confusion
• Fatigue
• Headache
• Temporary weakness or paralysis (Todd’s paralysis)

Research and Future Directions

Seizure Prediction and Modeling

Exciting developments in seizure prediction include:

• Wearable devices that can detect patterns preceding seizures
• AI and machine learning models to predict seizure likelihood

A study in EBioMedicine demonstrated that a deep learning algorithm could predict seizures with high accuracy using EEG data .

Advances in Epilepsy Research

Ongoing research areas include:

• Gene therapy for specific types of epilepsy
• Optogenetics: using light to control neurons
• Improved brain imaging techniques

Potential Future Therapies

Promising future treatments may include:

• Personalized medicine based on genetic profiles
• Stem cell therapies to repair damaged brain tissue
• Advanced neurostimulation devices.

Social and Cultural Impact

Human Rights and Stigmatization

Epilepsy can lead to human rights issues:

• Discrimination in employment and education
• Social exclusion due to misunderstanding and fear
• Efforts by organizations like the WHO to combat stigma and promote awareness

Economics of Epilepsy Care

The economic impact of epilepsy is significant:

• Direct costs: medical care, medications
• Indirect costs: lost productivity, disability
• Societal costs: support services, research funding

A study in Epilepsia estimated the annual cost of epilepsy in the United States to be $15.5 billion .

References:

1. Giussani, G., et al. (2014). Epilepsy and its treatment in primary care: a systematic review. European Journal of Neurology.
2. Tsiouris, K. M., et al. (2018). A deep learning approach to real-time seizure detection using short-time Fourier transform of EEG signals. EBioMedicine.
3. Begley, C. E., et al. (2015). The cost of epilepsy in the United States: an estimate from population-based clinical and survey data. Epilepsia.
4.   Pal, D. K., et al. (2020). Genetic basis of epilepsy syndromes. Nature Reviews Neurology.
5. Kanner, A. M. (2003). Depression in epilepsy: prevalence, clinical semiology, pathogenic mechanisms, and treatment. Biological Psychiatry.
6. Marson, A. G., et al. (2007). The SANAD study of effectiveness of carbamazepine, gabapentin, lamotrigine, oxcarbazepine, or topiramate for treatment of partial epilepsy. The Lancet.
7. Levy, R. G., et al. (2012). Ketogenic diet and other dietary treatments for epilepsy. Cochrane Database of Systematic Reviews.