Treatment of epilepsy
Many seizures are the direct result of an underlying brain or bodily disorder. In such a case, treatment of the underlying condition will often be sufficient to prevent seizures from recurring, and the seizures themselves will need no specific management.
In general, seizures that have only occurred once are not treated unless they recur. Once seizures are recurrent, specific anti-epileptic medication will generally be needed. Some epileptics will only have seizures in certain settings, or find that their seizures are reliably provoked by specific triggers. Alcohol use and sleep deprivation are frequently responsible.
There has recently been an explosion of new drugs for treating epilepsy.
Choosing the best agent
Examples of widely-used established medications are Carbamazepine, Phenytoin, Phenobarbital, and Valproic acid. Examples of newer medications are Levetiracetam, Lamotrigine, Topiramate and Gabapentin.
All anti-epileptic drugs have side effects, and currently, no particular drug is clearly more effective than another.
Choosing the best agent is a complex task best done by a neurologist with a special interest in epilepsy. The choice will rest on the type of seizure, as well as the efficacy of the medication and how well it is tolerated by the individual patient.
Most patients are rendered seizure-free with the use of a single medication, or, if necessary, medications in various combinations.
Follow-up should occur at least annually. Monitoring drug levels in the blood is important for continued control of seizures and reduction of side-effects, but is often unnecessary, especially with newer agents.
Illness, pregnancy, sleep deprivation, skipping medication doses and using drugs, alcohol or certain medications may cause seizures in someone with previously well-controlled epilepsy. People with epilepsy should wear Medic-Alert bracelets, and family members should be instructed in how to assist during a seizure.
The last decade has seen the development of effective surgery for certain kinds of seizures. In general, surgery is reserved for patients with a seizure focus that can be precisely identified, and for those who have failed drug therapy.
Workup for surgery is complex, but when successful, it may render patients seizure-free without having to use medications.
Emergency first-aid treatment for a convulsive seizure
- Protect the person from injury. Clear the area of furniture or other objects that may cause injury. Cradle the head with a pillow if it is on a hard surface, but don't restrain the person's movements.
- Turn the person onto one side with the head down. This allows drainage of saliva and prevents inhalation of vomit.
- The vast majority of seizures will end spontaneously after a minute or two, and no specific treatment is necessary. When seizures continue, or consciousness is not regained between seizures, status epilepticus is diagnosed and requires urgent management that may be started by the emergency medical service, but is best performed in a hospital.
Although epilepsy tends to be a lifelong condition, effective management is available for most, allowing a seizure-free, productive life. Most occupations and recreational activities are open to people with controlled epilepsy, and most countries allow driving after a seizure-free period of 12 months.
Complications of seizures can occur in many forms. Although seizures themselves tend to be self-limiting, the consequences of abruptly losing contact with the environment can be dangerous. These include: accidents while driving, bathing, swimming or using machinery; injuries sustained from falling or trauma to flailing limbs; and aspiration of vomit, leading to choking or aspiration pneumonia.
Even when seizures do not directly threaten life or limb, the condition can be damaging.
If absence seizures are not recognised in children, these brief interruptions of attention throughout the day can lead to learning disability.
Older children and adults may find the prospect of seizures so socially embarrassing or frightening that they withdraw from the world. Explanation of the condition, the broader education of the public, and contact with other people affected by seizures can do much to alleviate this.
Lastly, all anti-epileptic drugs have side-effects, and this often governs the choice of agent in an individual patient. Most of these side-effects are reversible and simply represent individual intolerance to a particular medication or excessively high dose.
Rarely, side-effects can be unpredictable and serious. Pregnant women need especially careful choice of medication, and younger women who may fall pregnant need effective contraceptive advice. All women who are considering falling pregnant should take supplements of folic acid.
Professor Jonathan Carr, FCP (SA) Neurology, PhD. Head Division of Neurology, Tygerberg Hospital and University of Stellenbosch, Cape Town. February 2015.