Epilepsy: How Is It Treated And Managed?

Recap: Seizure vs Epilepsy

In our previous article, we talked about the differences between seizures and epilepsy: a seizure being just a single event, while epilepsy involves recurrent unprovoked seizures. We also learnt that a person is diagnosed with epilepsy if they have had two unprovoked seizures (or one unprovoked seizure with the likelihood of more) that were not caused by some known and reversible medical condition e.g. high fever, alcohol withdrawal or extremely low blood sugar.

How is epilepsy being treated and managed? Read on to find out more.

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Treatment for epilepsy

The goal of treatment is to prevent seizures. Treatment choices include antiepileptic medications (AEDs), surgery for cases refractory to medical therapy as well as diet therapy. Epilepsy is considered to be resolved for those who have remained seizure-free for the last 10 years, with no seizure medicines for the last 5 years.

Medications (AEDs)

Antiepileptic drugs (AEDs) are the mainstay of epilepsy treatment. They prevent seizures by reducing excessive electrical activity in the brain. >20 different AEDs are available today, with differing benefits and side effects. The doctor will decide what to prescribe depending on many factors:

• Type of seizures e.g.
  • Valproate is the preferred choice as monotherapy for generalised tonic-clonic seizures
  • Carbamazepine and gabapentin may aggravate absence and myoclonic seizures
• Gender: Valproate should be avoided in females of childbearing age due to risk of birth defects.
• Age: In elderly, liver and kidney function are diminished, thus affecting clearance of certain AEDs like carbamazepine and pregabalin respectively, necessitating therapy modification. 
• Lifestyle: AEDs which affect concentration may be avoided in students; some studies suggest that levetiracetam and lamotrigine are least likely to interfere with cognitive processes 
• Concomitant medical conditions 
  • AEDs can affect the mood centers in the brain. Those more likely to raise the risk of depression include levetiracetam, topiramate, and should be avoided in those with existing depression
  • Topiramate and valproate are AEDs which are also effective for migraine prevention
  • Valproate may worsen tremors in Parkinson’s disease
• Interactions with other medicines
  • Some AEDs like carbamazepine can cause the liver to speed up the breakdown of other drugs e.g. warfarin, and render them less effective
  • Pregabalin is an AED with fewer drug interactions and may be suitable for those with multiple medications

Usually treatment starts with using a single AED (monotherapy) at a low dose, which is increased slowly, until your seizures are controlled. If your seizures are not controlled with this drug, a different AED is usually tried, either as a replacement or add-on. 

Most side effects of antiseizure drugs are relatively minor, such as fatigue, dizziness, and weight gain. Long-term side effects of some AEDs may include bone thinning, which may be prevented with appropriate supplementation. Rarely, severe and life-threatening reactions such as suicidal thoughts, allergic reactions or damage to the liver or bone marrow can occur. 

For certain AEDs e.g. phenytoin, regular blood tests are done to monitor effectiveness and safety. The amount of AED in the blood is compared to a reference range. The reference range is a range of concentrations of an AED within which most people will get a benefit from the drug. Below this range the drug is unlikely to work whereas above it, toxic effects are likely to occur. 

It is very important to continue taking antiseizure medication for as long as it is prescribed. Some people with epilepsy may be advised to discontinue their antiseizure drugs after being seizure-free for 4-5 years. Discontinuing medication should always be done under the advice and supervision of a physician.

Rescue Medications

If a person has frequent seizures despite the use of maintenance AEDs, the doctor might prescribe a rescue medication to abort a breakthrough seizure when it occurs. Usually, caregivers will be given detailed instructions about administration. As it is usually not possible to take a medication by mouth during a seizure, common rescue medications include rectal diazepam or intramuscular midazolam injection.

Surgery

When medical therapy fails to control seizures, surgery may be considered:

• Surgical resection
  • Suitable only for focal seizures, which originate in a small, well-defined area of the brain AND does not interfere with vital functions e.g. speech, cognition, movement, sensation
  • Also has risks of complications e.g. permanent cognitive and personality changes, physical disability
  • May still need to continue medication for some time post-op to prevent seizure recurrences
• Laser Ablation
  • Laser Interstitial Thermal Therapy (LITT)
  • Done without needing to open the skull, minimally invasive.
  • MRI is used to map out the exact area of the brain to operate on. 
  • Laser is then delivered to this area to eliminate the seizure focus. 
• Surgical implantation of devices e.g.
  • Vagus Nerve Stimulation (VNS) was FDA-approved for treatment of epilepsy in 1997.
    •  A stimulator is implanted under the skin at the left collar bone. This is connected to the left vagus nerve. 
    • The stimulator sends regular, mild electrical stimulations through this nerve to help calm down the irregular electrical brain activity that leads to seizures.
    • It is used ALONGSIDE AEDs to reduce frequency, length and severity of attacks. 
    • It may cause temporal discomfort in throat, hoarse voice and difficulty swallowing.
  • Responsive Nerve Stimulation (RNS) was FDA-approved for treatment of epilepsy in 2013.
    • The device is implanted in the skull. 
    • It can record seizure activity directly from the brain and delivers electrical stimulation to stop seizures. 

Diet for patients with epilepsy

A high-fat, very low carbohydrate ketogenic diet has been purported to treat medication-resistant epilepsies. Some studies have shown that 50% of people who try the ketogenic diet have a >50% improvement in seizure control and 10% experience seizure freedom. Culturally however, it may be challenging to adhere to in Asia where the diet is relatively low in fat and high in carbohydrates.

Prevention of epilepsy

To reduce the risk of seizures: 

• Take AEDs as prescribed
• Avoid over-consumption of alcohol
• Learn relaxation techniques to manage stress
• Get sufficient sleep
• Eat a healthy diet 
• Avoid bright, flashing lights and other visual stimuli e.g. video games
• Seek early treatment for illness and fever
• Keep a diary to record triggers and number of seizures; this will enable the physician to assess effectiveness of medication(s) and make appropriate adjustments.

To prevent complications of seizures (e.g. drowning, falls injuries):

• Avoid swimming alone 
• Take showers instead of bathing in a bathtub
• Avoid activities at heights without proper safety precautions
• Avoid cooking alone or with open fire

Conclusion

Epilepsy may be a chronic neurological disorder that can affect sufferers in many ways, but it can be kept under good control. First and foremost, epileptics should seek proper diagnosis and prompt treatment. With adherence to prescribed medications, as well as being well-informed about managing the condition, most epileptics can lead full, productive lives, relatively free of seizures.