Epilepsy: causes, treatment, prognosis and everyday life
Epilepsy is an increased willingness to spontaneously excite neurons in the brain, causing seizures and other epileptic symptoms. Outsiders often experience an epileptic seizure very dramatically, expressing themselves through an open, twisted, fixed or empty gaze, while the body can be additionally shaken by cramps. A typical seizure event usually ends after less than two minutes on its own.
Seizure is not the same as epilepsy
Epilepsy can occur at any age. Ten out of every 100 people experience an epileptic seizure once in their lives. In one of these 10 people is then diagnosed and treated epilepsy. These figures show that not every seizure can be equated with the diagnosis of epilepsy.
The causes of epilepsy are very diverse and are classified according to whether the disease is idiopathic or symptomatic. Symptomatic epilepsy is an expression of other conditions (such as inflammation or brain tumor) and is treated by addressing the cause of the seizure event. In idiopathic epilepsies, on the other hand, there is usually an innate readiness for an increased readiness to excite the nerve cells. Therapy is in this case with antiepileptic drugs.
Nerve cells in the brain play crazy
An epileptic seizure is triggered by excessive and involuntary excitation of neurons in the brain, in which a group of neurons discharge simultaneously and violently. Depending on where in the brain this happens, different types of seizures can be distinguished:
Focal seizures are limited to a region of the brain. On the other hand, generalized seizures affect both halves of the brain, either directly from the onset of seizure (primarily generalized seizures) or through focal seizures that leave their region of origin and spread across the rest of the brain (secondary generalized seizures).
According to this classification, the symptoms of epilepsy also occur: While focal seizures often occur only in one region of the body (for example in the form of facial cramps or visual hallucinations), generalized seizures often manifest themselves throughout the body.
For diagnosis and therapy, it is very important to know what form of epilepsy it is. Because there are a variety of drugs that can be used to seizure prophylaxis. With the right medication, on average 50-80% of all treated people can be seized.
Epilepsy describes a state of the brain characterized by a constant readiness for epileptic seizures. An epileptic seizure is a sudden and temporary malfunction of the central nervous system (CNS), which results in a simultaneous and high-frequency discharge of nerve cells of the cerebral cortex. These discharges lead to the typical uncontrollable seizures that can occur throughout the body.
The diagnosis of epilepsy can be made when an epileptic seizure has occurred and further examinations of the brain (for example in EEG or MRI) have revealed an increased epileptogenicity (seizure readiness).
It could be everyone
Epilepsy occurs at a rate of about 1% in the total world population. Unlike common diseases such as diabetes mellitus type 2, there are no regional differences in the frequency of occurrence. Every human being has a 10% chance of having an epileptic seizure once in a lifetime. Not always afterwards the diagnosis epilepsy is made.
There are a variety of factors that can cause or trigger an epileptic seizure. Generally, a distinction is made between symptomatic and idiopathic causes.
Symptomatic: clear cause behind the seizure
Symptomatic forms are characterized by seizures expressing another underlying disease. The cause of epilepsy is therefore tangible.
- brain tumors
- Brain trauma or bleeding
- brain metastases
- Vascular malformations
- severe alcohol abuse
Idiopathic: seizure out of the blue
The idiopathic forms, however, occur without tangible cause. The origin of epilepsy can not be deduced either from imaging or from certain blood parameters. A genetic component is likely to be involved in the pathogenesis.
Furthermore, there are so-called trigger factors that can trigger an acute seizure even in healthy people.
- Alcohol withdrawal (most common cause of seizure in adulthood)
- drug withdrawal
- Intoxications with drugs
- high fever (most common cause of a seizure in childhood is the febrile convulsion)
- Hypoglycemia (especially after overdose of blood sugar lowering drugs in diabetics)
- sleep deprivation
- physical exhaustion
Further questions can be found here:
Causes and Harbingers of Epilepsy
Classification § Symptoms
Epilepsies are subdivided according to the place of origin in the brain into the two major groups focal and primarily generalized seizures. This classification is important because it is crucial for the choice of drug therapy.
1. Focal seizures
A focal seizure is characterized in that it takes place only at a defined region in the brain. Since each region of the brain is responsible for the function of a particular body region, the seizure occurs only in one place and not the entire body. Examples of partial seizures include facial cramps or hallucinations. An experienced examiner can already deduce the affected brain region based on the symptoms.
Focal seizures are further classified in:
- single-focal seizures that occur without loss of consciousness
- complex-focal seizures that occur with loss of consciousness
- Secondary Generalization Focal Seizures: These are seizure events that begin at a circumscribed brain region but then spread to both cerebral hemispheres. The clinical picture changes in the course of the seizure. While initially only one body region is affected, the symptoms soon spread to the entire body.
2. Primary generalized seizures
A primary generalized seizure is characterized by the fact that it affects both halves of the brain's brain from the beginning and can be seen clinically all over the body. Where the attack starts exactly is unclear. The primary generalized seizures can also be further subdivided depending on their severity:
- Clonic seizures are characterized by a rhythmic twitching of the muscles. This results in violent, confused and uncontrollable movements of the whole body.
- Tonic seizures are characterized by tensing of the muscles. The body seems cramped and rigid.
- Atonic seizures are characterized by a complete loss of body tension, the muscles are limp and motionless.
- Absences are also counted among the primary generalized seizures. During an absence, there is a short pause in consciousness without cramping or muscle tension. A classic absence manifests itself in a sudden pause in activity, a fixed gaze and a non-responsiveness. After the absence, the interrupted activities are continued as if nothing had happened.
Learn more about the symptoms here:
Important questions about the epileptic seizure
Not every epileptic seizure shows just one of the seizure patterns mentioned. On the contrary, the most common form of seizure is the so-called tonic-clonic seizure, which often follows a classical course and goes through several phases of different manifestations. A tonic-clonic seizure (also called grand mal seizure) always involves a loss of consciousness:
- An anura can come before the seizure. This lasts for seconds to minutes and describes a nonspecific feeling that occurs before the seizure or announces this.
- Tonic phase: The tonic phase is the beginning of the grand mal seizure. This results in a sudden and violent increase in tone of all muscles, lasting only seconds. Often, the tonic phase is accompanied by a cry (so-called initial scream) and a bite in the lateral tongue region (so-called lateral tongue bite). The arms are stretched upwards, the legs slightly bent, the pupils appear wide and do not respond to light. In many cases, it also comes to a stop of the breath.
- Clonic phase: Following the increase in tone, a rhythmic twitching of the entire musculature ensues, which gradually turns into an irregular, coarse twitch and finally ends in a relaxation of the entire body. The clonic phase can last for minutes to hours.
- postictal phase: the last phase is the so-called postictal phase, which lasts for a few minutes to hours and can be regarded as a kind of state of exhaustion.It comes to a deep sleep (terminal sleep) and often to a short-lasting disorientation.
The classic phase progression of the tonic-clonic seizure may be accompanied by other symptoms such as urine and faeces discharge or an increased, foamy salivation in front of the mouth.
After each seizure, it must first be clarified whether it was actually an epileptic seizure or whether other causes of spasm or unconsciousness come into question.
Take a close look at the seizure
To analyze the seizure picture, your doctor must first get some information about the seizure. This often requires the information of third parties, because you may not even be able to reconstruct what exactly happened. To speak for an epileptic seizure:
- Hints for the presence of an aura
- Duration of seizure <2 minutes
- The eyes are open in the attack, but empty, rigid or twisted.
- There is evidence of a fall without defense reaction (wound on the head).
- Urine or stool exit
- Amnesia and disorientation after seizure
- a headache
Examinations of the brain
Following an attack, further brain examinations should be undertaken. Magnetic resonance imaging (MRI) can reveal structural changes in the brain (such as a nervous disorder) that can be the cause of the seizure. Studies on cerebral hemorrhages or calcifications are best accomplished by computed tomography (CT). Imaging of the brain is important in order to differentiate symptomatic from idiopathic epilepsy and treat it in a targeted manner.
With the electroencephalogram (EEG), brain waves or discharges of the nerve cells can be directly derived. This method allows the physician to differentiate healthy brain activities from those of an epileptic. However, the EEG may look completely normal between seizures, making it difficult to confirm the diagnosis. Special examinations in the EEG can therefore also take place over 24 hours, under pajamas or with video surveillance.
Hints in the blood
Thorough clarification of the seizure also includes taking a blood sample and examining the blood for specific parameters. Especially blood sugar, electrolytes and thyroid levels should be collected.
Further diagnostics, such as brain water analysis or a psycho-psychiatric history, are not always necessary, but may be relevant to exclude certain differential diagnoses.
Questions and answers about diagnostics
The therapy of epilepsy is very complex. In addition to general measures aimed at a regular, unagitated rhythm of life for the stabilization of nerve cell activity, various drugs for seizure prophylaxis are used. It is not easy to find the right preparation, because in addition to the seizure form, attention must be paid to comorbidities, side effects and the age of the person affected.
A surgical intervention for the treatment of epilepsy is nowadays only used in very severe cases or when a medical treatment of the disease has failed.
1. General measures
If symptomatic epilepsy is present, the only method of treatment is the elimination of the causative agents. In all idiopathic forms of epilepsy care should be taken during the seizure-free interval to avoid triggers that may provoke a seizure:
- Avoid alcohol, nicotine and other drugs.
- Try to maintain a regular sleep-wake cycle.
- Avoid flickering light (for example in the nightclub).
- Avoid too much mental or physical stress.
- Eat on a regular basis to avoid hypoglycaemia.
- Do you do sports regulary.
2. Drug seizure prophylaxis
Drug therapy is recommended after a seizure, if additionally an increased seizure readiness in the EEG or specific changes in the MRT could be proven. If there were two seizures within half a year, a drug therapy is indicated even without further findings.
Medicines calm the nerve cells
Medications used to treat epilepsy are called anticonvulsants. In principle, they increase the seizure threshold in the brain and thus prevent an uncontrolled discharge of the neurons. The type of seizure plays a role in the selection of the appropriate preparation.
First-line medications for partial onset seizures are:
- Lamotrigine (Elmendos®, Lamictal®) and
- Levetiracetam (Keppra®)
Lamotrigine and levetiracetam can be used for continuous therapy in partial onset seizures and are characterized by good efficacy with relatively minor side effects. Lamotrigine must be slowly crept in, otherwise there is a risk of dangerous skin and mucous membrane reactions. One advantage is that it is hardly liver and kidney toxic and can therefore be used in many comorbidities.Levetiracetam is also well tolerated, but occasionally leads to dizziness and tiredness, which can significantly limit the quality of life.
The agony of choice
If neither Lamotrigine nor levetiracetam can be used, other preparations can be used. The list of second-choice funds is long.
- Carbamazepine (Carbaflux®, Carbagamma®, Finlepsin®, Tegretal®Timonil®)
- Gabapentin (Gababurg®, Gabagamma®, GabaLich®, Gabax®, Neurotin®)
- Valproate (Convulex®, Convulsofin®, Ergenyl®, Leptilan®, Orfiril®, Valproate®)
- Oxcarbazepine (Apydan Extend®, Timox®, Trileptal®)
- Pregabalin (Lyrica®)
Valproate: when the whole brain is affected
Primary generalized seizures are treated primarily with valproate. Valproate is a relatively old preparation that, unlike lamotrigine and levetiracetam, has more side effects and drug interactions. Valproate is also suitable for the long-term treatment of epilepsy. The disadvantage is that it is highly hepatotoxic, which makes regular controls of liver enzymes necessary. Furthermore, it should under no circumstances be given during pregnancy as it can damage the fetus.
In case of treatment failure or contraindications to valproate, lamotrigine or topiramate (Topomax®) are used.
Duration of treatment with each other
How long a therapy should be continued depends on various factors. Basically, the individual is weighed out and discussed about the end of treatment if there were no seizures for 2 to 5 years and the EEG is unremarkable.
In some cases, the administration of medication can be completely dispensed with. Prerequisites for this are:
- less than 2 seizures a year
- an inconspicuous EEG under provocation (for example, by flickering light)
- a normal psychic finding
- no indication of a predisposition to epilepsy
3. Interventional therapy methods
An operative intervention to treat epilepsy is not primarily targeted. However, it is an alternative when medical methods have failed. In the process, structural changes or the epileptogenic origin in the brain are surgically removed.
With this therapy method, however, there is the danger of turning off or changing certain brain functions. Furthermore, the remaining scar can create a new epileptic focus. It is therefore difficult to assess the complications or consequences of such an intervention, which is why the indication for an operation is held back.
Alternatives to surgery
Stimulation methods are an alternative to surgical procedures. Similar to a pacemaker, deep stimulation of the brain causes electrical stimulation via a so-called brain pacemaker in the CNS. The results of this therapy are very good, but the procedure involves a relatively high risk and is therefore rarely performed.
A similar, but less invasive therapy principle is the vagus nerve stimulation. The Nervus Vagus, the tenth of a total of 12 cranial nerves, is electrically stimulated in the neck area. These stimuli are transported via the nerves retrograde into the brain and reduce the seizure frequency by inhibiting brain activity via an as yet unclear mechanism.
4. Help in the attack
In the event you happen to be experiencing an epileptic seizure in another person, there are certain immediate actions that you can and should take to protect the affected person. A seizure usually ends after a few minutes by itself. Take this time!
- Keep calm!
- Set aside any objects that could hit or injure the person concerned.
- Guarantee a protected storage of the body (for example head pad).
- Do not insert objects in the mouth to prevent a tongue bite! This concept is long considered obsolete.
- Loosen tight clothing and remove the glasses if necessary.
- Call the ambulance.
- Watch the seizure and the duration. This information may later be very important to the attending physician.
- Talk to the person after the attack reassuring and friendly. Give him space and time to rest.
More on this topic can be found here:
Frequently asked questions about the treatment of epilepsy
In the context of epilepsy, it can come to the so-called status epilepticus, which represents an acute emergency and should always be clarified in-patient. There are three different situations that define status epilepticus:
- a tonic-clonic seizure lasting more than five minutes
- a focal seizure lasting more than 20 to 30 minutes or an absence
- recurrent seizures between which complete normalization of the condition does not occur
If one of these cases occurs, an emergency doctor must be contacted immediately.Because the status epilepticus can only be broken by medication with the administration of benzodiazepines. This is of great importance because increasing muscle tone can cause a dangerous increase in body temperature as well as cardiovascular failure.
The risk of suffering a second after a tonic-clonic seizure is untreated at 40%, while the recurrence risk after two tonic-clinical attacks already climbs to 80-95%. This makes it clear why a therapy usually makes sense and should always be sought in a timely manner.
Under optimal therapy, these numbers are reversed: seizure freedom can be achieved in idiopathic epilepsy in 80-90% of cases.
Healing is not always possible
The healing of a disease is the ultimate goal of medical practice. In epilepsy, a distinction must be made between seizure freedom and healing. Freedom from seizures occurs when there has been no seizure during therapy for two years, while a cure is only achieved when seizures no longer occur without medication.
By a gradual reduction of the drugs after years of seizure freedom, a cure of epilepsy can indeed be brought about. However, this does not always succeed. Especially with many forms of epilepsy, which begin only in adulthood, a lifelong medication is necessary.
Consequences in everyday life
An epilepsy can have consequences for everyday social life as well as in life planning and sometimes raises big questions: Is pregnancy still possible? Is it still allowed to travel by car?
Pregnancy & Lactation
A pregnancy despite epilepsy is usually nothing in the way. There are only a few women who are advised against pregnancy. However, as many medications can cause malformations in the unborn child, it is recommended to adjust to the right therapy before pregnancy.
The drug of choice is then the drug Lamotrigine, which is usually taken in lower doses. You should discuss with your neurologist early on your desire for a child, so that if necessary, a conversion of the drugs can be made.
If the pregnancy runs smoothly, nothing stands in the way of a natural birth. The question of breastfeeding can usually be answered easily: Most drugs reach the breast milk in such low concentrations that breastfeeding is usually not a problem. Lamotrigine is also the preferred remedy for lactation.
Make sure you get enough sleep after giving birth. Accept help from friends and family! Because too much sleep deprivation can make epilepsy noticeable, and sleep deprivation is inevitable in the weeks and months after birth.
After an epileptic seizure you have to give up driving for a while. Exactly how long in an individual case depends on the type and cause of the seizure and also on whether you drive a car or a truck:
- After a first unprovoked attack without increased seizure readiness (on MRI or EEG), you have to give up your car driving permit for six months and your truck driving license for two years.
- After a first provoked (for example by sleep deprivation or hypoglycaemia) with increased seizure readiness on MRI or EEG, they are allowed to drive again after three months and trucks again after six months.
- In the case of a diagnosed epilepsy (a seizure and additionally a proven increased seizure readiness) you get the driving license for cars back after one year, while for trucks a final withdrawal of the driving license takes place.
The prerequisite for all of these cases is that you do not have another seizure in the meantime. If you are free of seizures and plan long-distance travel by car, set up enough breaks to sleep and eat. Truck drivers should definitely think about changing jobs.
And here are some tips for you:
Self-help and dealing with epilepsy
Author: Lisa Wunsch
P. Berlit et al .: Clinical Neurology, Springer Verlag, 2012.U.G.
Frank: Neurology and Psychiatry, Urban & Fischer Verlag, 2010.
German Society of Neurology: Epileptic seizure and epilepsy in adulthood, http://www.awmf.org/uploads/tx_szleitlinien/030-041l_S1_Erster_epileptischer_Anfall_und_Epilepsien_im_Erwachsenenalter_2013-08_abgelaufen.pdf, last accessed on 14.03.2017.
German Society of Neurology: Status epilepticus in adulthood, http://www.awmf.org/uploads/tx_szleitlinien/030-079l_S1_Status_epilepticus_im_Erwachsenenalter_2012-verlängert.pdf, last accessed on 14.03.2017.
B. Schmitz: Epilepsy and the desire to have children, Eurap brochure, 2008.
R. L. Bromley: The prevalence of neurodevelopmental disorders in children prenatally exposed to antiepileptic drugs, Journal of Neurology, June 2013.
Comment: The most important questions and answers about epilepsy
Epilepsy is more widespread than suspected. In Germany, at least 0.5% of the population is affected, so among 1,000 people, there are on average at least five epileptics. Epileptic seizures are even more common. Every tenth has an increased spasm readiness. An estimated 4-5% of all people experience this at least once in their lives.For example, fever convulsions in children are typical. However, unlike active epilepsy, these occasional cramps only occur in special circumstances and not afterwards.
Numerous forms of epilepsy
In principle, epilepsy can begin at any age. Most often she does that in childhood. A second peak of disease is found beyond the age of 60 years.
The disease is based on over-excitability in the brain. There is an imbalance of certain neurotransmitters (especially glutamate and GABA) in their effect on communicating nerve cells. Depending on the affected area resulting from sensory or movement disorders. The abnormal excitations (excitations) occur predominantly only in isolated brain areas.
In contrast to this focal form, generalized epilepsy leads to large-scale spread of excitement over both hemispheres of the brain. There are simple-focal seizures with no and complex-focal seizures with impaired consciousness. The generalized form distinguishes tonic-clonic (grand times) from myoclonic-atonic seizures as well as absence, short disturbances of consciousness, without major motor cramping symptoms (petit mal). The different forms can merge into each other, without previously knowing exactly how and why this is going on.
Definition and diagnosis of epilepsy
Not every seizure immediately means you're suffering from epilepsy. By definition, this is only the case if at least two unrequested attacks occur within a year. For the diagnostic assessment of epilepsy, if available, a detailed account of the seizure by a present observer is valuable.
The most important diagnostic measure is the derivation and recording of the (stimulated) brain waves in the EEG (electroencephalogram). While this exam is cumbersome, it's not painful. Frequently, a CT (computed tomogram) from the head and / or an MRI (magnetic resonance imaging, also known as nuclear spin) are made from the head and blood tests are performed for diagnostic purposes. Occasionally, the nerve fluid (CSF) is examined.
Wide range of medicines
Epilepsy is mainly treated with medication. There is a wide range of classic (older) and newer antiepileptic drugs available. Medically, they are sometimes referred to as anticonvulsants.
The choice of medication depends on the form and cause of epilepsy. The goal is always seizure freedom by suppressing epileptic seizures. Anti-epileptic drugs reduce over-excitability in the brain by increasing the stimulus threshold for the formation and transmission of impulses and by strengthening the body's own inhibitory mechanisms. This is done by influencing the neurotransmitter metabolism, especially by blocking sodium or Calcium ion channels or certain receptors on the nerve cells.
Goal: seizure freedom with as few side effects as possible
All these medicines have their advantages and disadvantages. Some of them can be used alone in monotherapy, others only as an adjunctive therapy. Often several drugs are combined. The main goal of the desired seizure freedom succeeds in most cases.
A further challenge, however, are the sometimes considerable side effects that can affect the positive effect. To keep them as low as possible, the selected drugs often have to be adjusted in their dosage repeatedly or even changed.
High drop rates in tablet intake are a major problem from a medical point of view, especially in neurological treatment. In medical jargon, this is called non-compliance. It is estimated to be responsible for half of acute hospital admissions to epilepsy.
Weaning attempts only under medical supervision advisable
Although the drugs can not cure the cramping. Nevertheless, they do not necessarily have to be taken for life. Often a tapering of the medication after three to five seizure-free years is tried. For this purpose, the dose is first reduced in order to then settle the tablets completely. However, this entails considerable risks and should therefore be carried out under medical supervision.
Non-drug treatment procedures
If, despite the best possible choice of the available drugs and several attempts no satisfactory treatment success (more) can be achieved, may also be a surgical procedure in question. The prerequisite is that it is a focal epilepsy, for which a well-defined brain structure can be held responsible. After accurate localization and functional examination, the tissue in question is removed and future seizures are prevented if successful.
Another possibility is the electrical stimulation of the vagus nerve, whose calming effect can reduce the seizure frequency. For this, a small device is implanted on the chest wall.
Beyond medication and surgery, the ketogenic diet has long been successful, although its exact mechanism of action is still unknown.The diet is switched to a very high fat, low carbohydrate and moderate protein content. On a biochemical level, this creates a metabolic situation that is similar to fasting.
Biofeedback and behavioral therapy have also been helpful in some epileptics to reduce or even prevent seizures.
Course hardly predictable
The therapeutic offer is unfortunately not completely satisfactory. TheaThere is no promising method of treatment. With a success rate of 60% (focal epilepsy) to 80% (grand mal epilepsy) in the prevention of epileptic seizures, the drugs have so far proven best overall.
In view of the countless variants of epilepsy, it is also very difficult to predict the further course of the disease. Especially since the possible reasons are varied and mostly unknown. It is best if it is symptomatic or secondary epilepsy. Then another underlying condition is responsible for the cramps and if this can be cured, the seizures disappear. But even in epilepsy with unclear cause, a self-healing is possible in principle and already occurred
First aid for epileptic seizure
What is important for all those people who have never had to deal with an epileptic seizure is to know: usually the seizure ends after a short time by itself. First aid means in this case, the risk of injury to the person concerned as low as possible , Therefore, do not let him out of your sight, but do not hold him (except in case of a fit while bathing, where the head must be kept afloat). Remove or adjust dangerous objects and cover sharp edges.
The emergency physician must be called if the convulsion lasts longer than 10 minutes or if the victim does not come to consciousness between two seizures. Then the risk of oxygen deficiency in the brain is high. Even if the cramping person is seriously injured or you are not at all sure that it is a symptom of (known) epilepsy, you should seek emergency medical help.
Author: Dr. Hubertus Glaser