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Medication for Epilepsy

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Epilepsy cannot be ‘Cured’ with medication. However, various medicines can control the seizures by stabilising the electrical activity of the brain. The success in controlling seizures by medication varies depending on the type of epilepsy. If there is no underlying cause for your seizures – Idiopathic epilepsy, you have a good chance that medication can fully control your seizures. Seizures caused by a core brain problem may be more difficult to control.

Your physician will take into account various conditions, such as your age, type of epilepsy, other medicines you may be taking, possible side–effects, if you are pregnant, etc while choosing your medication. There are some popular medicines for each type of epilepsy and if one does not suit you, another may be better.

Doctors usually start at the lowest possible dose to control seizures. The dose is usually increased if you have further seizures. Medicines are available as tablets, soluble tablets, capsules, or liquids.

Side–effects of Epilepsy Medications
Most medicines have probable side–effects, not everyone is effected. The listed of side–effects are found in the which comes in the medicine box. You should read this even though it may appear alarming. Many of the side–effects listed, are rare. When you start medication, don’t forget to ask your doctor about any problems that may arise for that particular medicine. Do not stop taking a medicine suddenly, if you notice a side–effect, but consult your doctor for advice. One of the common side–effect is sleepiness but eases or goes once the body gets used to the medicine. Side–effects which are rare, but you still need to be aware of are rashes or bruising whilst taking certain medicines.

Re–occurring Seizures
In some cases, seizures are not controlled immediately in spite of taking medicine. This could be because the dosage or timing of the medication needs re–assessing. A common cause of seizures is taking medication incorrectly. If you have taken a medicine correctly up to its maximum allowed dose, but it has not worked well, you may be advised to switch to a different medicine. If that does not work alone, taking two medicines together may be advised. It is quite uncommon that seizures are not controlled with two medicines.

Importance of correct medication
It is important to take your medicine as prescribed. Try to get into a daily routine. Forgetting an occasional dose is not a problem for some people, but for others would lead to breakthrough seizures. One of the reasons why seizures recur is due to not taking medication properly.

Duration of Epilepsy Medication
The chance of seizures recurring is higher for some types of epilepsy than others, only your doctor will be able to advise you, so follow his instructions religiously. You may be able to stop medication if your seizures have been well controlled for two or more years. Since there are many different types of epilepsy, some of which are age dependent may not need medication for long, but there are others that will need medication for life. Your life circumstances may influence the decision about stopping medication. If a decision is made to stop medication, it is best done gradually, reducing the dose over a period of several weeks or months. Follow the advice given by a doctor.

How effective is Medication used for Epilepsy?
The success in controlling seizures by medication varies depending on the type of epilepsy. For example, if no underlying cause can be found for your seizures you have a good chance that medication can fully control your seizures. Seizures caused by some underlying brain problems may be more difficult to control.

The following figures are based on studies of people with epilepsy which looked back over a five year period. These figures are based on grouping people with all types of epilepsy together which gives an overall picture.
  1. About 5 in 10 people with epilepsy will have no seizures at all over a five year period. Many of these people will be taking medication to control seizures. Some will have stopped treatment having had two or more years without a seizure whilst taking medication.
  2. About 3 in 10 people with epilepsy will have some seizures in this five year period, but far fewer than if they had not taken medication.
  3. In total, with medication about 8 in 10 people with epilepsy are well controlled with either no, or few, seizures.
  4. The remaining 2 in 10 people experience seizures, despite medication.
Which Medicine is the most Suitable?
A doctor will take into account various things when choosing a medicine to prescribe. These include: your type of epilepsy, age, other medicines that you take, possible side–effects, pregnancy, etc. There are popular medicines for each type of epilepsy. However, if one medicine does not suit, another may be better.

A low dose is usually started. The aim is to control seizures at the lowest dose possible. If you have further seizures, the dose is usually increased. There is a maximum dose allowed for each medicine. In about 7 in 10 cases, one medicine can control all, or most, seizures. Medicines may come as tablets, soluble tablets, capsules, or liquids to suit all ages.

What if Seizures still occur?
In some seizures are not controlled despite taking one medicine. This may be because the dosage or timing of the medication needs re–assessing. A common reason why seizures continue to occur is because medication is not taken correctly. If in doubt, your doctor or pharmacist can offer advice.

If you have taken a medicine correctly up to its maximum allowed dose, but it has not worked well, you may be advised to try a different medicine. If that does not work alone, taking two medicines together may be advised. However, in about 2 in 10 cases, seizures are not well controlled even with two medicines.

When is Medication Started?
The decision when to start medication may be difficult. A first seizure may not mean that you have ongoing epilepsy. A second seizure may never happen, or occur years after the first. For many people, it is difficult to predict if seizures will recur. Another factor to consider is how severe seizures are. If the first seizure was severe, you may opt to start medication immediately. In contrast, some people have seizures with relatively mild symptoms. Even if the seizures occur quite often, they might not cause much problem, and some people in this situation opt not to take any medication.

The decision to start medication should be made by weighing up all the pros and cons of starting, or not starting, treatment. A popular option is to ‘wait and see’ after a first seizure. If you have a second seizure within a few months, more are likely. Medication is commonly started after a second seizure that occurs within 12 months of the first. However, there are no definite rules and the decision to start medication should be made after a full discussion with your doctor.

What about side–effects?
All medicines have possible side–effects that affect some people. All known possible side–effects are listed in the leaflet which comes in the medicine packet. If you read this it may appear alarming. However, in practice, most people have few or no side–effects, or just minor ones. Many side–effects listed are rare. Each medicine has it’s own set of possible side–effects. Therefore, if you are troubled with a side–effect, a change of medication may resolve the problem.

When you start a medicine, ask your doctor about any problems which may arise for your particular medicine. Two groups of problems may be mentioned.
  1. Side–effects which are relatively common, but are not usually serious. For example, sleepiness is a common side–effect of some medicines. This tends to be worse when first started. This problem often eases or goes once the body gets used to the medicine. Other minor side–effects may settle down after a few weeks of treatment. If you become unsteady, it may indicate the dose is too high.
  2. Side–effects which are serious, but rare. Your doctor may advise what to look out for. For example, it is important to report any rashes or bruising whilst taking some types of medicine.
Do not stop taking a medicine suddenly. If you notice a side–effect, ask your doctor for advice.

Taking your Medication Correctly
It is important to take your medicine as prescribed. Try to get into a daily routine. Forgetting an occasional dose is not a problem for some people, but for others would lead to breakthrough seizures. One of the reasons why seizures recur is due to not taking medication properly. A pharmacist is a good source of advice if you have any queries about medication.

Some medicines taken for other conditions may interfere with medication for epilepsy. If you are prescribed or buy another medicine, always remind your doctor or pharmacist that you take medication for epilepsy. Even things such as indigestion medicines may interact with your epilepsy medication, which may increase your chance of having a seizure.

Some epilepsy treatments interfere with the contraceptive pill. You may need a higher dose pill for effective contraception. Your Family Planning doctor will be able to advise you about this.

What about Epilepsy Medication and Pregnancy?
Being pregnant does not usually make epilepsy any better or worse. However, there is a small chance that the unborn child may be affected by some medicines used to treat epilepsy. Before becoming pregnant it is best to seek advice from a doctor, epilepsy nurse, or counsellor. The potential risks can be discussed.

One important point is that you should take extra folic acid before becoming pregnant, and throughout the pregnancy. This may reduce the chance of certain abnormalities occurring.

If you have an unplanned pregnancy, do not stop epilepsy medication which may risk a seizure occurring. See a doctor as soon as possible.

How long do I need to take Medication for?
You may wish to consider stopping medication if you have not had any seizures for two or more years. It is important to discuss this with a doctor. The chance of seizures recurring is higher for some types of epilepsy than others. Overall, if you have not had any seizures for 2–3 years and you then stop medication:
  • About 6 in 10 people will remain free of seizures two years after stopping medication. If seizures do not return within two years after stopping medication, the long–term outlook is good. However, there is still a small chance of a recurrence in the future.
  • About 4 in 10 people will have a recurrence within two years. There are many different types of epilepsy, some of which are age dependent, but some that will need medication for life. Your epilepsy specialist should be able to offer you more advice about the long–term outlook for your particular type of epilepsy.
Your life circumstances may influence the decision about stopping medication. If a decision is made to stop medication, it is best done gradually, reducing the dose over a period of several weeks or months. Follow the advice given by a doctor.

Are there any other Treatments for Epilepsy?
Surgery to remove a cause of seizures in the brain is an option in a small number of cases. It may be considered when medication fails to prevent seizures. It is only possible for certain causes in certain areas of the brain. Therefore, only a small number of people are suitable for surgery. Also, there is risk involved in brain surgery. However, techniques continue to improve and surgery may become an option for more and more people in the future.

The ketogenic diet, a diet that needs to be supervised by an experienced dietician, is useful for some children and adults with particular types of epilepsy.

Vagal nerve stimulation is another treatment that is occasionally used in some cases. Complementary therapies such as aromatherapy may help with relaxation and relieve stress, but have no proven effect on preventing seizures.

Counseling – Some people with epilepsy become anxious or depressed about their condition. A doctor may be able to arrange counseling with the aim of overcoming such feelings. Genetic counseling may be appropriate if the type of epilepsy is thought to have a hereditary pattern. It may be an option to consider before starting a family.

Electroencephalogram (EEG)

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Electroencephalogram (EEG) is done to increase the certainty of the diagnosis made and to ascertain the type of seizure. It helps to determine proper medication and prognosis. However, EEG is not required in all cases and management of epilepsy in a given case can be done without the help of EEG if not available. Normal EEG does not rule out epilepsy.

Management
It consists of the following important steps:
  • Treatment of the cause if detected by investigations.
  • Avoidance of known provoking factors.
  • Drug therapy.
  • Balanced adjustment of daily routine and social acceptance.
The General practitioner or family doctor and family members play a key role to help the patient achieve this.

Commonly used antiepileptic drugs:
  • Phenobarbitone
  • Phenytoin
  • Carbamazepine
  • Sodium Valproate
These drugs suppress the neuronal hyperexcitability responsible for seizures and gradually may cool down the potentially hyperexcitable epileptic focus so that over the years after the last attack, they could be withdrawn gradually. In few cases recurrence of seizures is still a possibility, so a plan for withdrawal of drugs should be done strictly under medical supervision.

Response to the single drug or combination of the drugs is variable and depends on:
  • The gap between the first seizure and initiation of the proper treatment.
  • Proper drugs in proper doses.
  • Regularity and proper compliance of all the instructions.
  • Type of seizures and causes of the seizures.
The treatment of every epilepsy patient is highly individualized and strictly under medical supervision. The choice of the drug, the dosage, total duration of treatment after the last attack and mode of withdrawal of drugs are highly individualized. As the cost of drugs like Carbamazepine and Sodium Valproate is high and since the duration of the treatment is in years, economic constraints become an important factor for the choice of drug.

A record of attacks and drug therapy must be maintained. It is important to follow the doctor’s instructions on periodic follow up examinations. This helps the physicians to monitor the patient’s progress and detect any side effects of the drugs that may develop. Common side effects are nausea, vomiting, skin rash, gum hypertrophy, unsteadiness, double vision, drowsiness, weight loss or weight gain. These must be reported to the doctor. There is a general belief that these antiepileptic drugs dull the intelligence due to long-term use and often this is the major reason to discontinue treatment. The drugs do have mild effect on cognitive function but the advantages outweigh the side effects.

In selected cases it may be necessary to estimate the concentration of the drug in serum so that the optimal efficacy of the drug is combined with minimum side effects. This is known as serum level estimation or therapeutic drug monitoring.

In chronic patients total seizure control may not be possible and in such cases one may have investigate if surgery is a suitable option or strike a balance between seizures and the side effects of drugs.

Restrictions
Persons with epilepsy can do every thing except:
  • Drive a vehicle.
  • Work with open machines or fire.
  • Swim alone (once fits are properly controlled swimming can be done under supervision).
There are more cans than cant’s, so do not give up
History tells us…
Many great men like Julius Caesar, Napoleon Bonaparte, Vincent Van Gogh and Alfred Noble had epilepsy. Epilepsy is no bar to achieve greatness in any sphere.

What is Epilepsy?

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Epilepsy is a condition of recurring seizures. A seizure is an abnormal firing of cerebral neurons, which may or may not have a clinical manifestation. We are familiar with seizures, where people fall down and shake all over.

Epilepsy is not a single disorder, but covers a wide spectrum of problems characterized by unprovoked, recurring seizures that disrupt normal neurologic functions. Epileptic seizures occur when a group of nerve cells in the brain (neurons) become activated simultaneously, emitting sudden and excessive bursts of electrical energy. This hyperactivity of neurons can occur in various locations in the brain and, depending on the location, have a wide range of effects on the sufferer from brief moments of confusion to minor spasms to loss of consciousness.

The nerves themselves may be damaged or problems might occur in neurotransmitters (die chemicals that act as messengers between nerve cells). The neurotransmitter, gamma aminobutyric acid (GABA) seems to be particularly important in suppressing seizures. Experiments also suggest that deficiencies in a receptor of the neurotransmitter serotonin may help promote epileptic seizures.

Definition of Epilepsy
Epilepsy can be defined as a group of disorders characterized by abnormal electrical activity in the brain leading to altered behavior which may manifest as a change in a person’s consciousness, movement, or actions. These physical changes are called epileptic seizures. Epilepsy is therefore sometimes called a seizure disorder. Epilepsy affects people in all nations and of all races at every age.

It must be emphasized that every seizure may not be an indication of an epileptic disorder. Many times young children with high fever go into convulsive seizures. These are called as febrile convulsions & do not occur throughout life. Similarly seizures caused due to metabolic imbalances, drug interactions or alcohol/narcotic withdrawals are also not classified as epilepsy. Moreover a single seizure does not mean that the person has epilepsy.

Classification
The two categories of seizures are generalized and partial. Generalized seizures result due to electrical impulses from the entire brain. Partial seizures are caused by activity in a portion of the brain. The part where a seizure is triggered is called the seizure focus.

Partial Seizures
Partial means that the electrical discharge starts focally at one point in the brain, eg., the left hippocampus. If the seizure spreads to other areas of the brain, but does not interfere with consciousness, then it is termed Simple. An example of a Simple Partial Seizure is clonic activity of only the right arm. If the seizure spread involves neuronal circuits affecting consciousness, then it is termed Complex. An example of a Complex Partial Seizure is when a person stops speaking, smacks his lips and is unresponsive to verbal commands for several minutes. Afterwards he will feel tired and not remember everything about the preceding seizure. Either type of partial seizure can go on to spread sufficiently so as to result in a generalized “Grand mal” seizure. Since the seizure first started focally, we say it was a Partial Seizure (simple or complex) with secondary generalization. Partial seizures are divided into simple, complex and those seizures that evolve from partial–onset into generalized tonic–clonic seizures. The difference between simple and complex seizures is that during simple partial seizures, you retain awareness. During complex partial seizures, you lose awareness.

Primary Generalized Seizures
When the abnormal electrical discharges are bilaterally synchronous at the onset. Because these seizures are without a focal onset, there can be no “Aura”, which is a warning sign and actually represents a focal or partial seizure. There are six types of generalized seizures.

Tonic–clonic (“Grand–mal” seizure)
You may lose consciousness and often collapse. The body becomes stiff and shakes, and finally, one falls into a deep sleep. Injuries such as tongue–biting can occur, or you can lose bladder control.

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Absence seizure (“Petit mal” seizure)
You may lose awareness and gaze blankly for a few seconds. Most often there are no other symptoms except the seizures may occur a few times everyday.

Myoclonic seizure
Your body may jerk, as if being electrocuted, from a single muscular jerk to the entire body.

Clonic seizure
Both sides of your body jerk rhythmically at the same time.

Tonic seizure
Muscles suddenly become very stiff.

Atonic or akinetic seizure
Muscles relax suddenly, which can cause a sudden fall causing injuries.

Etiology
By and large, the primary generalized epilepsies, such as absence, grand mal (tonic–clonic), and myoclonic are genetically determined and present in childhood and adolescence. The partial epilepsies are more likely to be acquired (congenital, post traumatic, infection, tumor) and present in any age.

Natural history
Although certain stimuli can increase the probability of having a seizure, their occurrence is unpredictable. Many of the patients with primary generalized epilepsy will stop having seizures as they enter adulthood (independent of treatment). Medications (anticonvulsants, antiepileptics, antiseizure are valid terms to precede the word medication or drug) help prevent seizures but do not cure the patient of his epilepsy. The partial epilepsies are the most difficult to treat.

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