Epilepsy is a neurological condition involving the brain that makes people more susceptible to having recurrent, unprovoked seizures. It is one of the most common disorders of the nervous system and affects people of all ages, races, and ethnic background. Almost 3 million Americans live with epilepsy.
Anything that interrupts the normal connections between nerve cells in the brain can cause a seizure. This includes a high fever, low blood sugar, high blood sugar, alcohol or drug withdrawal, or a brain concussion. Under these circumstances, anyone can have one or more seizures. However, when a person has two or more unprovoked seizures, he or she is considered to have epilepsy. There are many possible causes of epilepsy, including an imbalance of nerve-signaling chemicals called neurotransmitters, tumors, strokes, and brain damage from illness or injury, or some combination of these. In the majority of cases, there may be no detectable cause for epilepsy.
The brain is the center that controls and regulates all voluntary and involuntary responses in the body. It consists of nerve cells that communicate with each other through electrical activity.
A seizure occurs when part(s) of the brain receives a burst of abnormal electrical signals that temporarily interrupts normal electrical brain function.
The type of seizure depends on which part and how much of the brain is affected and what happens during the seizure. The two broad categories of epileptic seizures are generalized seizures (absence, atonic, tonic-clonic, myoclonic) and partial (simple and complex) seizures. Within these categories, there are several different types of seizures, including:
Focal or partial seizures. Focal seizures take place when abnormal electrical brain function occurs in one or more areas of one side of the brain. Focal seizures may also be called partial seizures. With focal seizures, particularly with complex focal seizures, a person may experience an aura, or premonition, before the seizure occurs. The most common aura involves feelings, such as deja vu, impending doom, fear, or euphoria. Visual changes, hearing abnormalities, or changes in the sense of smell can also be auras. Two types of focal seizures include:
Simple focal seizures. The person may have different symptoms depending on which area of the brain is involved. If the abnormal electrical brain function is in the occipital lobe (the back part of the brain that is involved with vision), sight may be altered, but muscles are more commonly affected. The seizure activity is limited to an isolated muscle group, such as the fingers, or to larger muscles in the arms and legs. Consciousness is not lost in this type of seizure. The person may also experience sweating, nausea, or become pale.
Complex focal seizures. This type of seizure commonly occurs in the temporal lobe of the brain, the area of the brain that controls emotion and memory function. Consciousness is usually lost during these seizures. Losing consciousness may not mean that a person passes out--sometimes, a person stops being aware of what's going on around him or her. The person may look awake, but may have a variety of unusual behaviors. These behaviors may range from gagging, lip smacking, running, screaming, crying, and/or laughing. When the person regains consciousness, he or she may complain of being tired or sleepy after the seizure. This is called the postictal period.
Generalized seizures. Generalized seizures involve both sides of the brain. There is loss of consciousness and a postictal state after the seizure occurs. Types of generalized seizures include the following:
Absence seizures (also called petit mal seizures). These seizures are characterized by a brief, altered state of consciousness and staring episodes. Typically, the person's posture is maintained during the seizure. The mouth or face may twitch or the eyes may blink rapidly. The seizure usually lasts no longer than 30 seconds. When the seizure is over, the person may not recall what just occurred and may go on with his or her activities, acting as though nothing happened. These seizures may occur several times a day. This type of seizure is sometimes mistaken for a learning problem or behavioral problem. Absence seizures almost always start between ages 4 to 12 years.
Atonic (also called drop attacks). With atonic seizures, there is a sudden loss of muscle tone and the person may fall from a standing position or suddenly drop his or her head. During the seizure, the person is limp and unresponsive.
Generalized tonic-clonic seizures (GTC or also called grand mal seizures). The classic form of this kind of seizure, which may not occur in every case, is characterized by five distinct phases. The body, arms, and legs will flex (contract), extend (straighten out), and tremor (shake), followed by a clonic period (contraction and relaxation of the muscles) and the postictal period. Not all of these phases may be seen in everyone with this type of seizure. During the postictal period, the person may be sleepy, have problems with vision or speech, and may have a bad headache, fatigue, or body aches.
Myoclonic seizures. This type of seizure refers to quick movements or sudden jerking of a group of muscles. These seizures tend to occur in clusters, meaning that they may occur several times a day, or for several days in a row.
Infantile spasms. This rare type of seizure disorder occurs in infants before six months of age. There is a high occurrence rate of this seizure when the child is awakening, or when he or she is trying to go to sleep. The infant usually has brief periods of movement of the neck, trunk, or legs that lasts for a few seconds. Infants may have hundreds of these seizures a day. This can be a serious problem, and can have long-term complications that affect growth and development.
Febrile seizures. This type of seizure is associated with fever and is not epilepsy, although a fever may trigger a seizure in a child who has epilepsy. These seizures are more commonly seen in children between six months and five years of age, and there may be a family history of this type of seizure. Febrile seizures that last less than 15 minutes are called simple, and typically do not have long-term neurological effects. Seizures lasting more than 15 minutes are called complex and there may be long-term neurological changes in the child.
A person may experience one or many different types of seizures. While the exact cause of the seizure may not be known, the more common seizures are caused by the following:
In newborns and infants:
Congenital (present at birth) problems
Fever or infection
Metabolic or chemical imbalances in the body
In children, adolescents, and adults:
Alcohol or drugs
Progressive brain disease
Other possible causes of seizures may include the following:
Use of illicit drugs
The person may have varying degrees of symptoms depending on the type of seizure. The following are general symptoms of a seizure or warning signs of seizures. Symptoms or warning signs may include:
Jerking movements of the arms and legs
Stiffening of the body
Loss of consciousness
Breathing problems or breathing stops
Loss of bowel or bladder control
Falling suddenly for no apparent reason, especially when associated with loss of consciousness
Not responding to noise or words for brief periods
Appearing confused or in a haze
Nodding the head rhythmically, when associated with loss of awareness or even loss of consciousness
Periods of rapid eye blinking and staring
During the seizure, the person's lips may become bluish and breathing may not be normal. The movements are often followed by a period of sleep or disorientation.
The symptoms of a seizure may resemble other problems or medical conditions. Always consult your doctor for a diagnosis.
The full extent of the seizure may not be completely understood immediately after onset of symptoms, but may be revealed with a comprehensive medical evaluation and diagnostic testing. The diagnosis of a seizure is made with a physical examination and diagnostic tests. During the examination, the doctor obtains a complete medical history of the person and family and asks when the seizures occurred. Seizures may be due to neurological problems and require further medical follow-up.
Diagnostic tests may include:
Electroencephalogram (EEG). A procedure that records the brain's continuous, electrical activity by means of electrodes attached to the scalp.
Magnetic resonance imaging (MRI). A diagnostic procedure that uses a combination of large magnets, radiofrequencies, and a computer to produce detailed images of organs and structures within the body.
Computed tomography scan (also called a CT or CAT scan). A diagnostic imaging procedure that uses a combination of X-rays and computer technology to produce horizontal, or axial, images (often called slices) of the body. A CT scan shows detailed images of any part of the body, including the bones, muscles, fat, and organs. CT scans are more detailed than general X-rays.
Lumbar puncture (spinal tap). A special needle is placed into the lower back, into the spinal canal. This is the area around the spinal cord. The pressure in the spinal canal and brain can then be measured. A small amount of cerebral spinal fluid (CSF) can be removed and sent for testing to determine if there is an infection or other problems. CSF is the fluid that bathes the brain and spinal cord.
Specific treatment for a seizure will be determined by your doctor based on:
Your age, overall health, and medical history
Type of the seizure
Frequency of the seizures
Your tolerance for specific medications, procedures, or therapies
Expectations for the course of the condition
Your opinion or preference
The goal of seizure management is to control, stop, or decrease the frequency of the seizures without interfering with the normal activities of daily living (ADLs). The major goals of seizure management include the following:
Proper identification of the type of seizure
Using medication specific to the type of seizure
Using the least amount of medication to achieve adequate control
Maintaining appropriate medication levels
Treatment may include:
Medications. There are many types of medications used to treat seizures and epilepsy. Medications are selected based on the type of seizure, age of the patient, side effects, the cost of the medication, and the adherence with the use of the medication.
Medications used at home are usually taken by mouth (as capsules, tablets, sprinkles, or syrup), but some can be given rectally (into the person's rectum). If the person is in the hospital with seizures, medication may be given by injection or intravenously by vein (IV).
It is important to take your medication on time and as prescribed by your doctor. Different people use up the medication in their body differently, so adjustments (schedule and dosage) may need to be made for the most effective seizure control.
All medications can have side effects, although some people may not experience certain side effects. Discuss your medication's possible side effects with your doctor.
While you are taking medications, different tests may be done to monitor the effectiveness of the medication. These tests may include the following:
Blood work. Frequent blood draws testing is usually required to check the level of the medication in the body. Based on this level, the doctor may increase or decrease the dose of the medication to achieve the desired level. This level is called the therapeutic level and is where the medication works most efficiently. Blood work may also be done to monitor the effects of medications on body organs.
Urine tests. These tests are sometimes performed to see how the person's body is responding to the medication.
Electroencephalogram (EEG). An EEG is a procedure that records the brain's continuous, electrical activity by means of electrodes attached to the scalp. This test is done to monitor how the medication is helping the electrical problems in the brain.
Vagus nerve stimulation (VNS). Some people, whose seizures are not being well-controlled with seizure medications, may benefit from a procedure called vagus nerve stimulation (VNS). VNS is currently most commonly used for people over age 12 who have partial seizures that are not controlled by other methods.
VNS attempts to control seizures by sending small pulses of energy to the brain from the vagus nerve, which is a large nerve in the neck. This is done by surgically placing a small battery into the chest wall. Small wires are then attached to the battery and placed under the skin and around the vagus nerve. The battery is then programmed to send energy impulses every few minutes to the brain. When the person feels a seizure coming on, he or she may activate the impulses by holding a small magnet over the battery. In many cases, this will help to stop the seizure.
There are some side effects that may occur with the use of VNS. These may include, but are not limited to, the following:
Pain or discomfort in the throat
Change in voice
Surgery. Another treatment option for seizures is surgery. Surgery may be considered in a person who:
Has seizures that are unable to be controlled with medications.
Has seizures that always start in one area of the brain.
Has a seizure in a part of the brain that can be removed without disrupting important behaviors such as speech, memory, or vision.
Surgery for epilepsy and seizures is very complicated and performed by a specialized surgical team. The operation may remove the part of the brain where the seizures are occurring, or, sometimes, the surgery helps to stop the spread of the bad electrical currents through the brain.
A person may be awake during the surgery. The brain itself does not feel pain. With the person awake and able to follow commands, the surgeons are better able to make sure that important areas of the brain are not damaged.
Surgery is not an option for everyone with seizures. Discuss this treatment option with your doctor for more information.
Make sure you or your child (if age appropriate) understand the type of seizure that is occurring and the type of medication(s) that are needed.
Know the dose, time, and side effects of all medications.
Consult your doctor before taking other medications. Medications for seizures can interact with many other medications, causing the medications to work improperly and/or causing side effects.
Young women of childbearing age who are on seizure medications need to be informed that seizure medications are harmful to a fetus, and the medication may also decrease the effectiveness of oral contraceptives.
Check with your state to understand any laws about people with epilepsy or seizures operating a motor vehicle.
If a person has good control over the seizures, only minimal restrictions need to be placed on activities, in most cases.
Specific follow-up will be determined by your doctor.
Medications for seizures may not be needed for the person's entire life. Some people may be taken off their medications if they have been seizure-free for one to two years. This will be determined by your doctor.
The following related clinical trials and research studies are currently seeking participants at Massachusetts General Hospital. Search for clinical trials and studies in another area of interest.
The Carol and James Herscot Center for Tuberous Sclerosis Complex (TSC) at Massachusetts General Hospital and MassGeneral Hospital for Children is using genetic research to better understand TSC and other diseases like cancer, autism and obesity.
MassGeneral Hospital for Children’s Pediatric Neurosurgery Program is working to advance surgical treatment options and overall care of children with nervous system problems at all levels of severity. (From Advances Fall 2011 issue.)
When it came time for Bryn Seltzer, 13, of Needham, to choose her bat mitzvah project, she knew she wanted to give back to the Pediatric Epilepsy Program at MassGeneral Hospital for Children (MGHfC), which had cared for her since she was 6 years old.
In this issue: spinal metastases & stereotactic radiosurgery; skull base tumors & endoscopic surgery; pediatric epilepsy dietary therapy; Alzheimer Disease: tau pathology; drug & gene discovery; early treatment; preclinical diagnostic tools.
Recent research is challenging the traditional definition of epilepsy as an expression of increased excitability and firing of a group of neurons. This has major implications for clinical treatment.
Advances in pre-surgical evaluation methods have made it possible to more accurately identify the epileptogenic region and minimize risk of injury to the functional cortex, enabling more epilepsy patients to receive surgical treatment.
When Elton, a young Albanian architect, couldn’t find treatment for his disabling seizures in Albania, he traveled 500 miles to Austria to meet with Massachusetts General Hospital (MGH) Epilepsy Service Director Andrew J. Cole, MD. Dr. Cole, in Austria on a business trip, felt Elton was a good candidate for surgery and brought his case back to his colleagues in Boston.
A young Albanian architect found help for his seizure disorders thanks to a unique team of specialists from the Department of Neurology at Massachusetts General Hospital.
After years of seizures, a new device gives one Mass General epilepsy patient a new lease on life.
A newly developed implantable device aimed at treating adults with epilepsy gave 25-year-old Ashley Sherman back her life.
NeuroBlast: the newsletter of translational neuroscience and clinical care advances in neurology, neurosurgery, and neuroscience from Massachusetts General Hospital.
Several MGH and MassGeneral Hospital for Children (MGHfC) neurologists are saying goodbye to carbohydrates and sweets for the month. In order to support their patients, spread awareness about the effectiveness of dietary therapy and raise funds for the department, six neurologists – both pediatric and adult – are participating in a Low Glycemic Index Therapy (LGIT) diet, which often is used in the treatment of pediatric epilepsy patients.
Mass General ensures that our patients receive the highest quality and safest care possible. Learn about our performance, our improvement goals and how we compare to other institutions.