Treating Epilepsy

Aim of epilepsy treatment is to stop or decrease seizure activity, with minimal drug side effects. Epilepsy is mainly treated with anti-seizure medications that successfully control seizures in up to 70% of people. Those who don’t gain seizure control through ASMs alone are sometimes offered surgery, diets or other therapies.Attending regular medical appointments and discussing concerns with proper counseling with the treating doctor is an important aspect of holistic epilepsy management.

 

Seizure Triggers

Events and circumstances that can bring on a seizure are called seizure triggers. It does not occur in all people with epilepsy. Avoidance of an identified trigger helps manage epilepsy better. Some common seizure triggers include missed medication, sleep deprivation, disturbed sleep, stress, anxiety, infection, puberty, menstruation, menopause, additional use of certain medications, bright, flashing or flickering lights and others.

 

Anti-Seizure Medications (ASMs)

ASMs are the first line treatment for epilepsy. About 70% of people respond well to ASMs and seizures get controlled. It needs to be remembered that ASMs do not cure epilepsy but help control or diminish seizure activity. There are many different types of ASMs available, and sometimes it takes time to determine the best one. If the use of one ASM (monotherapy) doesn’t provide optimal outcome, the doctor may prescribe an alternative ASM or a combination of different ones (polytherapy).ASM treatment is prescribed only after a definite diagnosis of epilepsy has been made. Occasionally it may commence after just one seizure, if the doctor believes the person to be at a high risk of further seizures.Choice of ASM is based on seizure type(s), age (some ASMs can only be taken by adults, whilst others are suitable for children and adults), gender (woman with epilepsy of childbearing age need special considerations), medicine tolerability, other health conditions and prior intake of other medicines.

 

Some ASMs can affect an unborn baby, so doctors may change medications in women planning to start a family. Although, sometimes a change in a woman’s ASMs is not possible, as the risk of seizure activity is too great. More than 95% of pregnant women living with epilepsy deliver a healthy baby.

 

It needs to be remembered that no seizures with ASMs does not mean one is ‘cured’. Sudden stopping of medicines by self can be harmful resulting in more severe and prolonged seizures and even death. Do not discontinue medicines without your doctor’s advice.

List of ASMs available in Pakistan

• Brivaracetam

• Carbamazepine

• Clobazam

• Clonazepam

• Diazepam

• Gabapentin

• Lacosamide

• Lamotrigine

• Levetiracetam

• Midazolam

• Oxcarbazepine

• Phenobarbitone

• Phenytoin

• Sodium valproate

• Topiramate

• Vigabatrin

• Zonisamide

ASM intake

To attain good seizure control, it is important that ASMs must be taken as prescribed by the doctor, in the right dose regularly and punctually. Taking ASMs at the same time every day helps maintain a steady level of drug in the body and good seizure control. If one happens to miss a dose unintentionally it is advised to take it as soon as one remembers.

 

ASM side-effects

Common

Drowsiness, irritability, mood change, weight gain or loss, dizziness, sleep disturbance, nausea, vomiting, blurred vision, hair loss, unwanted hair growth, swollen gums and tremors in fingers.

 

Serious

An allergic reaction (rash) to an ASM requires immediate stopping of the ASM and medical advice as this can turn very serious.

 

Cognition & learning

Sometimes ASMs can affect a person’s attention and concentration. Some ASMs might also affect a person’s motivation, energy levels, or mood. Sometimes these side effects go away with ASM dose adjustment. Do not self-adjust your dose. Immediately contact your doctor. For minimal side-effects the doctor starts medicines in a low dose and gradually increases. Likewise, ASMs are slowly tapered off when required.

 

ASM interactions

Drug interactions can happen between various ASMs, ASMs and other drugs or ASMs and alternative therapies like homeopathy, herbal treatment. To avoid this the treating doctor should be made aware of all medicines the person with epilepsy is taking.

 

ASM effect on daily activity

Some ASMs cause drowsiness, sleepiness and slowed reactionary response. The patient driving, using a machine, or any high-risk job must be counseled about this risk.

 

ASM & bones

Some ASMs can cause osteoporosis by decreasing bone strength and increasing the risk of bone fractures. Calcium and Vitamin D supplements help bone health. For details ask your doctor.

 

Epilepsy Surgery

Only a small number of those whose seizures cannot be controlled by medications are deemed suitable candidates for surgery. The desired goal of neurosurgery is to improve a person’s quality of life by reducing or eliminating seizures. It is only considered for people who have epilepsy with a focal cause, on adequate mapping, indicating the part of the brain where the seizures are arising and/or on neuroradiology , if surgical approach will help and is safe not leaving a permanent major neurological defect like loss of memory, speech and others.

Surgery can have positive results leading to reduced seizures and improved quality of life however, not without risks. Thorough pre- surgical assessment to weigh the risks vs. benefits is extremely important. Patient and family members must be clearly counseled about the risks, and chances of complete or partial control of seizures.

Tests required for pre-surgical assessment.

• A Proper Detailed History from patient and witness

• Clinical Examination

• Inter-ictal electroencephalogram (EEG)

• Prolonged Video EEG Monitoring

• Magnetic Resonance Imaging (MRI) Scan (high resolution)

• Single-Photon Emission Computed Tomography (SPECT) Scan

• Positron Emission Tomography (PET) Scan

• Depth or Grid Electrodes EEG or Stereoelectroencephalography (SEEG)

• Neuropsychiatric Evaluation

Risks of epilepsy surgery

Possible risks may include problems with memory, partial loss of sight, weakness on one side of the body, depression or other mood problems. Like any other surgery it also carries potential risks related to anesthesia or may result in unanticipated complications which arise during the procedure. The risks of unexpected complications are low, but still important to consider.Risks will vary from person to person, Surgery is never recommended when the risks are likely to outweigh the benefits.

 

Ketogenic Diet

The ketogenic diet is an established treatment option for children with difficult-to-control epilepsy. However, adults may also benefit from this dietary regime. It is a special high fat, low carbohydrate, controlled protein diet that has been used for a long time as treatment of epilepsy. The diet is a medical treatment and is usually only considered when at least two suitable medications have been tried and have not worked.

In some cases, a special diet is prescribed as an adjunct therapy for people living with uncontrolled epilepsy. This is not recommended for everyone and needs to be taken under supervision of a doctor and dietician. Diet does not replace medications, which must be continued as per the doctor’s advice.

 

Medicinal Cannabis

Medicinal Cannabis is recommended for more effective therapies in severe, uncontrolled epilepsies. However, its availability varies from country to country. In Pakistan it is yet not legally approved.

 

Visiting Your Doctor

The frequency of visits is usually determined by how one has responded to treatment and any related issues one may be experiencing. People living with uncontrolled epilepsy tend to see their doctor more frequently than those whose epilepsy is under control.

Living with epilepsy extends much beyond seizures and includes issues related to wellbeing, safety, lifestyle, stress, education, relationships and others. Depending on one’s ongoing life the doctor may suggest and other specialists become involved in one’s care, such as psychologists or social workers.

 

Requirements for an effective doctor review

Before visiting your doctor be prepared with the following as it helps you not to forget what you have asked and your doctor can quickly do your medical review and advice. This includes:

• Seizure diary – properly filled to monitor seizure activity, frequency, duration, triggers, and recovery.

• Home video of seizures on mobile (if new onset events or there is a distinct change in seizure pattern)

• Any ASMs side-effects.

• Coping with daily life issues (domestic, social, employment, education)

• Mood and emotions.

• Safety concerns like cooking, driving, travelling by public transport etc.

• Intended marriage.

• Planning pregnancy