Epilepsy - A Chronic Neurologic disorder

Epilepsy is a chronic (long-lasting) medical condition marked by recurrent epileptic seizures. An epileptic seizure is an event of altered brain function caused by abnormal or excessive electrical discharges from brain cells. Epilepsy is one of the most common neurologic disorders, affecting up to 1 percent of the population in the United States.

There are different types of seizures, different types of epilepsy syndromes, and different causes of epilepsy. For example, both brain tumors and stroke can cause seizures and lead to chronic epilepsy. Some of the causes can be diagnosed and treated with medicines, and some require surgery.

•  Causes of Epilepsy

About 65 percent of newly diagnosed epilepsy cases have no obvious cause. Of the remaining 35 percent, the more common reasons include stroke, congenital abnormalities (those we are born with), brain tumors, trauma, and infection. It is important to determine the cause to help guide treatment

• Diagnosis

The evaluation of patients with epilepsy is aimed at determining the type of seizures (epileptic versus non-epileptic) and their cause, since various seizure types respond best to specific treatments. The diagnosis is based on:

• The patient's medical history, including any family history of seizures, associated medical conditions, and current medicines. The doctor will ask you some important questions, including the following:
  • At what age did the seizures begin?
  • What circumstances surrounded your first seizure?
  • What factors seem to bring on the seizures?
  • What do you feel before, during, and after the seizures?
  • How long do the seizures last?
  • Have you been treated for epilepsy before?
  • What medicines were prescribed and in what dosages?
  • Was the treatment effective?
• Others who have often seen you before, during, and after seizures, such as family and close friends, should be present to provide details of your seizures if they involve loss of consciousness.
• A complete physical and neurological exam of muscle strength, reflexes, eyesight, hearing, and ability to detect various sensations is used so that your doctors can better understand the cause of your seizures. Additional testing often includes:
  • An electroencephalogram (EEG), which measures electrical activity in the brain
  • Imaging studies of the brain, such as magnetic resonance imaging (MRI)
  • Blood tests to measure red and white blood cell counts, blood sugar, blood electrolyte levels, and to evaluate liver and kidney function (Blood tests help rule out other illnesses.)
  • Other tests are used as needed, including magnetic resonance spectroscopy (MRS), positron emission tomography (PET), and single photon emission computed tomography (SPECT).

The most important part of the evaluation is the electroencephalogram (EEG) because it is the only test that directly detects electrical activity in the brain (seizures are defined by abnormal electrical activity in the brain). During an EEG, electrodes (small metal disks) are attached to specific locations on your head. The electrodes are also attached to a monitor to record the brain's electrical activity. The EEG is useful to confirm a diagnosis of epilepsy and to determine the type of epilepsy.
The routine EEG procedure takes about 90 minutes, but a routine EEG records only about 20 minutes of brain waves. Because this is such a short amount of time, the results of routine EEG studies are often normal, even in people known to have epilepsy. Therefore, prolonged EEG monitoring might be necessary.
Prolonged EEG-video monitoring is an even better diagnostic method. During this type of monitoring, an EEG monitors the brain's activity and cameras videotape body movements and behavior during a seizure. Prolonged monitoring often requires the patient to spend time in a special hospital facility for several days. Prolonged EEG-video monitoring is sometimes required to definitively diagnose epilepsy.

• Treatment

The majority of epileptic seizures are controlled with drug therapy, particularly anti-convulsant drugs. The type of treatment prescribed will depend on several factors, including the type of epilepsy (focal/partial versus generalized), the frequency and severity of the seizures, the person's age, overall health, and medical history. An accurate diagnosis of the type of epilepsy (not just the type of seizure, since most seizure types occur in different types of epilepsy) is critical to choosing the best treatment.
There are many drugs available to treat epilepsy, including:

• Phenytoin (Dilantin^® or Phenytek^®)
• Phenobarbital
• Carbamazepine (Tegretol^® or Carbatrol^®)
• Primidone (Mysoline^®)
• Ethosuximide (Zarontin^®)
• Valproic acid (Depakene^®)
• Divalproex (Depakote^®, Depakote ER^®)
• Diazepam (Valium^®) and related medications such as clonazepam (Klonopin^®), and clorazepate (Tranxene^®)
• Felbamate (Felbatol^®)
• Gabapentin (Neuronti-n^®)
• Lacosamide (Vimpat®)
• Lamotrigine (Lamictal^®)
• Tiagabine (Gabitril^®)
• Topiramate (Topamax^®)
• Levetiracetam (Keppra^®)
• Zonisamide (Zonegran^®)
• Pregabalin (Lyrica^®)
• Rufinamide (Banzel®)

In general, for a given type of epilepsy there are only minor differences among appropriate drugs. The choice is most often based on other factors specific to each patient, such as which side effects can be tolerated and which delivery method is acceptable.
Although the different types of epilepsy vary greatly, in general, medicines can control seizures in about 70 percent of epilepsy patients.
It might take several months before the best drug and dosage are determined for you. During this adjustment period, you might be monitored with frequent blood tests. It is very important to keep your follow-up appointments with your doctor and the laboratory to minimize your risk for serious side effects and to prevent complications.
When seizures continue despite treatment for epilepsy, it might be because the episodes thought to be seizures are non-epileptic. In such cases, you should get a second opinion from a specialist and undergo EEG-video monitoring so the diagnosis can be re-evaluated. In specialized centers, about 15 percent to 20 percent of patients referred for persistent, refractory or intractable seizures ultimately prove to have non-epileptic conditions instead.

• Side effects of epilepsy medicine

As is true of all drugs, the drugs used to treat epilepsy have side effects. The occurrence of side effects depends on

1. dose
2. type of medicine
3. length of treatment

The side effects worsen with higher doses but tend to be less severe with time as the body adjusts to the medicine. Anti-epileptic drugs are usually started at lower doses and increased gradually to make this adjustment easier.
Side effects of epilepsy drugs can include

• blurry or double vision, 
•  fatigue, sleepiness, unsteadiness,
• stomach upset, 
• skin rashes, 
• low blood cell counts, 
• liver problems, 
• swelling of the gums, 
• hair loss, 
• weight gain, and 
• tremor.

• Who treats epilepsy?

A neurologist, a doctor who specializes in diseases of the brain and nervous system, best determines the diagnosis of epilepsy. Some neurologists take advanced training and become epileptologists. These doctors specialize in the diagnosis and treatment of epilepsy. This involves determining the cause of the epilepsy and starting anti-convulsant medicine to prevent further seizures. Many internists and family practice doctors also treat epilepsy.

Read more about Epilepsy from Cleveland Clinic