The Facts about Seizures and Epilepsy

Epilepsy is a brain disorder in which clusters of nerve cells, or neurons, in the brain sometimes signal abnormally. More than 2 million people in the United States - about 1 in 100 - have experienced a seizure or been diagnosed with epilepsy.

While any seizure is cause for concern, having a seizure does not by itself mean a person has epilepsy. Many people have a single seizure at some point in their lives. Unless the person has suffered brain damage or there is a family history of epilepsy or other neurological abnormalities, these single seizures usually are not followed by additional seizures.

While epilepsy cannot currently be cured, for some people it does eventually go away. This is more likely if the epilepsy has been well-controlled by medication or if the person has had epilepsy surgery.

Causes
Epilepsy may develop because of an abnormality in brain wiring, an imbalance of nerve neurotransmitters, or some combination of these factors. Anything that disturbs the normal pattern of neuron activity - from illness to brain damage to abnormal brain development - can lead to seizures.

About half of all seizures have no known cause. However, in other cases, the seizures are clearly linked to infection, trauma, or other identifiable problems. These causes include genetic factors; prenatal injury and developmental problems; head injury; poisoning from exposure to lead, carbon monoxide, street drugs or medications; disorders such as brain tumors, alcoholism, Alzheimer's disease, strokes or heart attacks; or infectious diseases such as viral encephalitis.

Epilepsy is also associated with a variety of developmental and metabolic disorders, including cerebral palsy, neurofibromatosis, pyruvate dependency, tuberous sclerosis, Landau-Kleffner syndrome, and autism. Epilepsy is just one of a set of symptoms commonly found in people with these disorders.

Seizures are often triggered by factors such as lack of sleep, alcohol consumption, stress, or hormonal changes associated with the menstrual cycle. These seizure triggers do not cause epilepsy but can provoke first seizures or cause breakthrough seizures in people who otherwise experience good seizure control with their medication. For some people, light flashing at a certain speed or the flicker of a computer monitor can trigger a seizure. Smoking cigarettes also can trigger seizures. Seizures are not triggered by sexual activity except in very rare instances.

Diagnosis
Doctors have a number of different tests to determine whether a person has epilepsy and, if so, what kind of seizures the person has. These might include EEG monitoring, brain scans, a detailed medical history, blood tests and developmental, neurological, and behavioral tests.

Treatment
There are many different ways to treat epilepsy. For about 80% of those diagnosed with epilepsy, seizures can be controlled with modern medicines and surgical techniques. However, about 20% of people with epilepsy will continue to experience seizures even with the best available treatment.

Once epilepsy is diagnosed, it is important to begin treatment as soon as possible. Research suggests that medication and other treatments may be less successful in treating epilepsy once seizures and their consequences become established.

When seizures cannot be adequately controlled by medications, doctors may recommend that the person be evaluated for surgery. To decide if a person may benefit from surgery, doctors consider the type or types of seizures he or she has. They also take into account the brain region involved and how important that region is for everyday behavior. Surgeons usually avoid operating in areas of the brain that are necessary for speech, language, hearing, or other important abilities.

While surgery can significantly reduce or even halt seizures for some people, it is important to remember that any kind of surgery carries some amount of risk. Surgery for epilepsy does not always successfully reduce seizures and it can result in cognitive or personality changes, even in people who are excellent candidates for surgery. Patients should ask their surgeon about his or her experience, success rates, and complication rates with the procedure they are considering.

Even when surgery completely ends a person's seizures, it is important to continue taking seizure medication for some time to give the brain time to re-adapt. Doctors generally recommend medication for 2 years after a successful operation to avoid new seizures.

In cases where seizures are caused by a brain tumor, hydrocephalus, or other conditions that can be treated with surgery, doctors may operate to treat these underlying conditions. In many cases, once the underlying condition is successfully treated, a person's seizures will disappear as well.

Devices
The vagus nerve stimulator is a battery-powered device that is surgically implanted under the skin of the chest, much like a pacemaker, and is attached to the vagus nerve in the lower neck. This device delivers short bursts of electrical energy to the brain via the vagus nerve. On average, this stimulation reduces seizures by about 20% to 40%.

Several new devices may become available for epilepsy in the future. Researchers are studying whether transcranial magnetic stimulation (TMS), a procedure which uses a strong magnet held outside the head to influence brain activity, may reduce seizures. They also hope to develop implantable devices that can deliver drugs to specific parts of the brain.

Daily Life
Most people with epilepsy lead outwardly normal lives, however, the condition can and does affect daily life for people with epilepsy, their families, and their friends. People with severe seizures that resist treatment have, on average, a shorter life expectancy and an increased risk of cognitive impairment, particularly if the seizures developed in early childhood. These impairments may be related to the underlying conditions that cause epilepsy or to epilepsy treatment rather than the epilepsy itself.

It is not uncommon for people with epilepsy, especially children, to develop behavioral and emotional problems. In children, these problems can be minimized if parents encourage a positive outlook and independence, do not reward negative behavior with unusual amounts of attention, and try to stay attuned to their child's needs and feelings.

People with epilepsy have an increased risk of poor self-esteem, depression, and suicide. These problems may be a reaction to a lack of understanding or discomfort about epilepsy that may result in cruelty or avoidance by other people. Many people with epilepsy also live with an ever-present fear that they will have another seizure.

Driving and Recreation
For many people with epilepsy, the risk of seizures restricts their independence, in particular the ability to drive. Most states and the District of Columbia will not issue a driver's license to someone with epilepsy unless the person can document that they have gone a specific amount of time without a seizure.

People with epilepsy should not participate in sports such as skydiving or motor racing where a moment's inattention could lead to injury. Other activities, such as swimming and sailing, should be done only with precautions and/or supervision. Many sports are reasonably safe for a person with epilepsy. There is some evidence that regular exercise may even improve seizure control in some people. The person with epilepsy and the coach or other leader should take appropriate safety precautions. It is important to take steps to avoid potential sports-related problems such as dehydration, overexertion, and hypoglycemia, as these problems can increase the risk of seizures.

Education and Employment
By law, people with epilepsy or other handicaps in the United States cannot be denied employment or access to any educational, recreational, or other activity because of their seizures. However, one survey showed that only about 56% of people with epilepsy finish high school and about 15% finish college. The same survey found that about 25% of working-age people with epilepsy are unemployed.

Restrictions on driving limit the employment opportunities for many people with epilepsy, and many find it difficult to face the misunderstandings and social pressures they encounter in public situations. Antiepileptic drugs also may cause side effects that interfere with concentration and memory. Children with epilepsy may need extra time to complete schoolwork, and they sometimes may need to have instructions or other information repeated for them. Teachers should be told what to do if a child in their classroom has a seizure, and parents should work with the school system to find reasonable ways to accommodate any special needs their child may have.

Pregnancy and Motherhood
Women with epilepsy have a 90% or better chance of having a normal, healthy baby, and the risk of birth defects is only about 4% to 6%. The risk that children of parents with epilepsy will develop epilepsy themselves is only about 5% unless the parent has a clearly hereditary form of the disorder.

Women who are thinking about becoming pregnant should talk with their doctors to learn any special risks associated with their epilepsy and the medications they may be taking. Some seizure medications, particularly valproate, trimethidone, and phenytoin, are known to increase the risk of having a child with birth defects such as cleft palate, heart problems, or finger and toe defects. For this reason, a woman's doctor may advise switching to other medications during pregnancy. Women should begin prenatal vitamin supplements - especially with folic acid, which may reduce the risk of some birth defects - well before pregnancy.

Women with epilepsy sometimes experience a change in their seizure frequency during pregnancy. About 25% to 40% of women have an increase in their seizure frequency while they are pregnant, while other women may have fewer seizures. Women should have their blood levels of seizure medications monitored closely during and after pregnancy, and the medication dosage should be adjusted accordingly.

Pregnant women with epilepsy should get plenty of sleep to avoid seizures caused by sleep deprivation. They also should take vitamin K supplements after 34 weeks of pregnancy to reduce the risk of a blood-clotting disorder in infants called neonatal coagulopathy that can result from fetal exposure to epilepsy medications. Finally, they should get good prenatal care, avoid tobacco, caffeine, alcohol, and illegal drugs, and try to avoid stress.

Doctors can administer antiepileptic drugs intravenously and monitor blood levels of anticonvulsant medication during labor to reduce the risk that the labor will trigger a seizure. Babies sometimes have symptoms of withdrawal from the mother's seizure medication after they are born, but these problems wear off in a few weeks or months and usually do not cause serious or long-term effects.

Women with epilepsy should be aware that some epilepsy medications can interfere with the effectiveness of oral contraceptives. Women who wish to use oral contraceptives to prevent pregnancy should discuss this with their doctors, who may be able to prescribe a different kind of antiepileptic medication or suggest other ways of avoiding an unplanned pregnancy.

Prevention
Many cases of epilepsy can be prevented by wearing seatbelts and bicycle helmets, putting children in car seats, and other measures that prevent head injury and other trauma. Prescribing medication after first or second seizures or febrile seizures also may help prevent epilepsy in some cases. Good prenatal care, including treatment of high blood pressure and infections during pregnancy, can prevent brain damage in the developing baby that may lead to epilepsy and other neurological problems later. Treating cardiovascular disease, high blood pressure, infections, and other disorders that can affect the brain during adulthood and aging also may prevent many cases of epilepsy. Finally, identifying the genes for many neurological disorders can provide opportunities for genetic screening and prenatal diagnosis that may ultimately prevent many cases of epilepsy.

If You See Someone Having a Seizure
If you see someone having a seizure with convulsions and/or loss of consciousness, here's how you can help:

• Roll the person on his or her side to prevent choking on any fluids or vomit.
• Cushion the person's head.
• Loosen any tight clothing around the neck.
• Keep the person's airway open. If necessary, grip the person's jaw gently and tilt his or her head back.
• Do NOT restrict the person from moving unless he or she is in danger.
• Do NOT put anything into the person's mouth, not even medicine or liquid. These can cause choking or damage to the person's jaw, tongue, or teeth. Contrary to widespread belief, people cannot swallow their tongues during a seizure or any other time.
• Remove any sharp or solid objects that the person might hit during the seizure.
• Note how long the seizure lasts and what symptoms occurred so you can tell a doctor or emergency personnel if necessary.
• Stay with the person until the seizure ends.

Call 911 if:

• The person is pregnant or has diabetes.
• The seizure happened in water.
• The seizure lasts longer than 5 minutes.
• The person does not begin breathing again or does not return to consciousness after the seizure stops. Another seizure starts before the person regains consciousness.
• The person injures himself or herself during the seizure.
• This is a first seizure or you think it might be. If in doubt, check to see if the person has a medical identification card or jewelry stating that they have epilepsy or a seizure disorder.

After the seizure ends, the person will probably be groggy and tired. He or she also may have a headache and be confused or embarrassed. Be patient with the person and try to help him or her find a place to rest if he or she is tired or doesn't feel well. If necessary, offer to call a taxi, a friend, or a relative to help the person get home safely.

If you see someone having a non-convulsive seizure, remember that the person's behavior is not intentional. The person may wander aimlessly or make alarming or unusual gestures. You can help by following these guidelines:

• Remove any dangerous objects from the area around the person or in his or her path.
• Don't try to stop the person from wandering unless he or she is in danger.
• Don't shake the person or shout.
• Stay with the person until he or she is completely alert.

Conclusion
Many people with epilepsy lead productive and outwardly normal lives. Medical and research advances in the past two decades have led to a better understanding of epilepsy and seizures than ever before. Advanced brain scans and other techniques allow greater accuracy in diagnosing epilepsy and determining when a patient may be helped by surgery. More than 20 different medications and a variety of surgical techniques are now available and provide good control of seizures for most people with epilepsy. Research on the underlying causes of epilepsy has led to a greatly improved understanding of epilepsy that may lead to more effective treatments or even new ways of preventing epilepsy in the future.

The information in this article has been made available by the National Institute of Neurological Disorders and Stroke.

Each year, Medical College of Wisconsin physicians care for more than 180,000 patients, representing nearly 500,000 patient visits. Medical College physicians practice at Children's Hospital of Wisconsin, Froedtert Memorial Lutheran Hospital, the Milwaukee VA Medical Center, and many other hospitals and clinics in Milwaukee and southeastern Wisconsin.