Identifying an effective course of treatment typically requires patience and persistence. Compared with established treatments for many other medical conditions—the use of antibiotics to fight bacterial infections, for example—epilepsy treatments must be tailored to fit the needs of each individual patient. This is because the cause behind the seizures often varies from person to person. Furthermore, while many treatments are effective in treating or preventing seizures, different individuals may respond differently to the same treatment. Fortunately, treatments do work, and in most cases, through collaboration between doctors, patients, and families, it is possible to treat seizures effectively.
It is important that patients and families understand all of the treatment options available to them. A physician can explain how various treatments work, which treatments might be most effective, and the possible side effects associated with each.
To Treat or Not to Treat
If a child demonstrates any behaviors that parents find particularly unusual, such as staring, fainting, strange movements, sleep problems, or other concerning features, experts recommend that parents have the child evaluated by a doctor as soon as possible. In practice, doctors often do not treat a single seizure because approximately 60 to 70 percent of individuals who have one seizure never have a second. Even so, doctors often obtain an EEG, a test that measures the brain's electrical activity and often reveals abnormal patterns associated with seizures, and recommend that parents watch a child for signs of seizure recurrence. In some specific situations where there is a higher- than-normal risk of recurrence after a single seizure, physicians may begin epilepsy treatment immediately, rather than waiting for a second seizure to occur.
Recurrent seizures can have important consequences on a child's overall health and development and require medical attention. To determine an appropriate course of treatment, physicians must first determine whether an individual's seizures are partial or generalized in origin. To do this they typically use a series of diagnostic tests and tools. The most important of these are eyewitness accounts by family members and by the individual who experiences the seizures. These accounts, along with medical records and EEG recordings, may provide clues as to the seizure type, which will then help to identify treatment options.About diagnosing epilepsy
The list of epilepsy treatment options is varied. It includes medications, nutritional therapies, surgery, and technologies such as the vagus nerve stimulator. The largest category, and the first and most effective line of treatment for nearly all cases, is that of anticonvulsant medications. As a group, these drugs have proven highly effective. For approximately half of all individuals diagnosed with epilepsy, seizures are controlled or eliminated with a single medication—often the first medication prescribed. Such successes, however, require that medications be chosen carefully with respect to the specific seizure type.
Physicians choose anticonvulsant medications based on their demonstrated effectiveness in treating particular types of seizures, as well as the potential risk of side effects they pose. However, the response to any given medication can vary from person to person. The right medication and dosage for every patient is the one that controls that particular individual's seizures without causing significant side effects. Often identifying the right combination requires a process of trial and error.
Today, there are a dozen or so medications that doctors can prescribe—about twice as many as were available a decade ago. Not only are these drugs helping people with seizures that are hard to control, but many of the newer drugs are better tolerated than the older ones, with fewer side effects.
Physicians typically begin treating a patient with a single medication, starting with a low dosage and gradually increasing the dose until the amount of medication reaches the therapeutic dosage range and seizures are controlled. Some older anticonvulsants have a predetermined therapeutic range, and physicians may have to regularly check an individual's blood levels of these medications to determine if safe, therapeutic levels have been achieved.
Newer medications are also prescribed at dosage ranges, and physicians use this range as a guide as they begin to hone in on the proper dose for a specific patient. However, one individual may experience side effects at doses much higher or lower than those taken by another individual, or might have seizures controlled at doses higher or lower than those of someone else. The goal is always to find the lowest dose at which seizures are controlled.
In some cases, medications do cause significant side effects, such as skin rash, dizziness, headache, nausea, blurred vision, and fatigue. Medications may cause more serious side effects, as well, including liver failure, life-threatening cases of anemia, and other blood problems. Anticonvulsant drugs may also impair cognitive function and/or negatively impact attention, mood, or motivation. Doctors take these side effects very seriously and make medication recommendations on a case-by-case basis.
Whenever an anticonvulsant drug proves ineffective over a reasonable trial period, doctors typically prescribe a replacement medication, introduced in the same gradual fashion as the first medication was until a therapeutic level is reached. The original drug may then be either continued or tapered off. In some cases, physicians treat seizures with a multi-drug regimen. This approach is more complex than single-drug therapies, given that many drugs interact with each other and may increase or decrease blood levels of partnered drugs. However, a combination of medications can be highly effective at controlling seizures.
Additional medications may also be required to stop seizures that last several minutes. For example, there are medications available that can be administered at home if a child experiences a seizure lasting more than 5 minutes. It is considered a medical emergency if a child enters a state of status epilepticus, defined as a seizure lasting more than 15 minutes, and he or she should be treated immediately by a medical professional to stop the seizure as soon as possible.
Development of highly sophisticated target drugs, which seek to deliver medication to specific rather than generalized areas of the brain, is one notable trend in drug research. While existing anticonvulsants act on the same handful of molecular targets, many potential new targets are being sought and identified in the research laboratory. Advanced diagnostic and monitoring technologies along with animal studies are helping researchers identify, among other things, chemical abnormalities in the brains of people with epilepsy. The goal of this type of research is to develop anticonvulsant drugs that act on more precise targets and thus provide more effective seizure control with fewer side effects.
Unfortunately, seizures are said to be intractable in approximately 35 percent of individuals with epilepsy. This means that two or more appropriate medications have failed to adequately control seizures. After two so-called "first line" medications have failed, many physicians consider it appropriate to explore other treatment options. Several alternative therapies have already been shown to be effective, and research continues across a wide spectrum of new, non-medicinal therapeutic approaches.Download a list of common medications (PDF)
Dietary therapies are an important alternative for some children with intractable seizures. Importantly, they can be effective in the treatment of both generalized and partial seizures. It is essential to remember that dietary therapies are medical treatments, and like other epilepsy treatments, should be administered closely by a physician, in consultation with a registered dietitian who has been trained in the nuances of these therapies. Treatment of epilepsy through the use of nutrition has become increasingly popular since the early 1990s. Its use represents a resurgence in one of the oldest forms of medical treatment, dating as far back as the third century b.c.
Long before modern medicine, people thought that epileptic seizures resulted from the body being polluted by toxins. To cleanse the body of this presumed toxicity, the therapy most commonly prescribed was fasting. Somewhat surprisingly, and for reasons still not known, fasting greatly reduced seizures in many people. However, for nutritional reasons, this mode of treatment cannot be continued indefinitely, and breaking a fast often caused seizures to return.
One such modern dietary therapy attempts to duplicate the effectiveness of fasting but with a regimen that is sustainable for long periods of time. This is done with a diet that stimulates metabolic processes that occur during fasting—in particular, the burning of fats as an energy source rather than carbohydrates. The by-products of the process of fat metabolism are ketones (primarily betahydroxybuterate and acetoacetate). Most experts think it is these processes and/or their by-products that help to control seizures.
The ketogenic diet was devised in 1925 and is now one of the most effective epilepsy therapies. When the diet was developed, few drug therapies existed to treat seizures, and those that did exist were not necessarily effective. The ketogenic diet provided an effective alternative. However, as other drugs were developed, the diet fell out of favor among many physicians because it was perceived as difficult, rigid, and expensive. In the past decade, however, because of the knowledge of the diet's efficacy, its popularity as a treatment option has increased.
The ketogenic diet consists mostly of fats, with limited carbohydrates and the recommended daily allowance of protein. Dietitians carefully calculate individualized meal plans for patients based on their calorie and protein needs for growth and development, and their ketogenic diet ratio. The prescribed ratio refers to grams of fat to grams of protein and carbohydrates combined. The higher the ratio, the larger the percentage of fat in the diet.
Foods are weighed to the nearest tenth of a gram and are consumed in the prescribed ratio of fat to carbohydrates and proteins. A typical ratio of 4:1 means that the vast majority of calories come from fat, typically in the form of butter, cream, and mayonnaise. Although the diet is high in fat, excessive weight gain is avoided as it can affect the metabolic process of the diet. Dietitians also work to ensure that a patient receives sufficient vitamins and minerals to avoid deficiencies. It is also essential to routinely monitor the blood levels for any side effects from the diet.
As the body metabolizes high-fat foods, it produces chemical compounds called ketone bodies, resulting in a physiologic state known as ketosis. It also increases the acidity of the blood. Experts hypothesize that the presence of ketone bodies may be involved in the reduction of the abnormal brain activity responsible for seizures, but still very little is known as to the actual mechanisms of this process.
The ketogenic diet requires a short hospital stay and may require an initial fasting period under the supervision of a physician familiar with the treatment.
Equally important to the impressive efficacy of the ketogenic diet is the fact that it is generally well tolerated, although the dietary restrictions may be difficult to accept. For patients whose seizures are somewhat controlled on medication but who experience significant side effects from those medications, the diet represents a possible alternative. Potential side effects of the diet include constipation, acidosis, and elevated serum lipids, as well as kidney stones. All of these are relatively easily mitigated provided the diet is administered properly.
Two of the greatest challenges of the ketogenic diet for patients and their caretakers are time-consuming food preparation and maintaining strict compliance with the diet's regimen. Some newer variations on the ketogenic theme have been designed to control seizures while offering a dietary menu that is more practical and user friendly.
Modified Atkins Diet
The modified Atkins diet was first developed in 2003 as an alternative to the classic ketogenic diet. The modified Atkins diet is also high in fat and low in carbohydrates. Families following this treatment regimen no longer have to weigh and measure foods or follow specific meal plans. Daily carbohydrates are restricted to 10 grams per day for the first month and subsequently liberalized to 15-20 grams per day if 10 grams is too restrictive. Other benefits of this treatment include the outpatient initiation, no initial fast to begin treatment, and no caloric or fluid restriction. Nearly two-thirds of patients experience half their usual number seizures after six months on the diet, and many are able to reduce their medication dosage.
Low Glycemic Index Treatment (LGIT)
The low glycemic index treatment (LGIT) is another dietary therapy currently being studied to treat epilepsy. Like the modified Atkins diet, the LGIT also attempts to reproduce the positive effects of the ketogenic diet. However, it allows for a broader range of food types and, again, does not require the weighing of foods.
Carbohydrate intake on the LGIT is less restricted than on the ketogenic diet. The LGIT allows for approximately four times as many grams of carbohydrates, provided that they come from foods with a low glycemic index. The glycemic index is a measure of a particular food's effect on the body's blood-sugar level. Foods that contain simple sugars, such as sucrose (table sugar), have a high glycemic index because they rapidly raise blood sugar after consumption. Conversely, many grains and legumes have a low glycemic index because they affect blood-sugar levels more slowly than high glycemic index foods. Counting carbohydrates and rough portion control is usually sufficient for the treatment to have a seizure-reducing effect.
As with other epilepsy treatments, it is not known how the LGIT works, but preliminary study results suggest that it may be as effective as the ketogenic diet, reducing seizures by half in 70 percent of patients. Because it is more easily tolerated than other dietary therapies, physicians and patients may be more likely to consider the LGIT a treatment option.
Vagus Nerve Stimulator (VNS)
The vagus nerve is a cranial nerve within the autonomic nervous system that influences the brain in addition to motor functions in the larynx, diaphragm, stomach, and heart. Neurologists have found that electrical stimulation of this nerve can help to treat patients whose seizures have been unresponsive to drug therapy. This technique uses a pacemaker-like device called a vagus nerve stimulator (VNS). The VNS is implanted under the skin of the chest and supplies intermittent electrical impulses to the vagus nerve. This therapy is most often used in conjunction with medications.
Technologies in Development
Scientists are hopeful that in the coming years they will be able to develop much more selective and specific treatments for epilepsy. In addition to the VNS, there are several other devices currently under development, some of which attempt to directly stimulate the seizure focus.
One such design modifies the brain stimulation therapy occasionally used for individuals with Parkinson's disease. Another utilizes the technology from cardiac defibrillators to respond to electrical activity in the brain. In this model, electrodes are placed where seizures are expected to originate and connected to a recording device that samples brain activity. The device then fires an electrical pulse to disrupt abnormal patterns when they are detected. Similar devices may help to warn an individual with epilepsy that a seizure is imminent.
The unpredictability of seizures is one of their most challenging aspects. Studies demonstrating that the brain undergoes subtle changes prior to a seizure have led several groups of researchers to engineer an implantable device that may be able to predict seizures and warn an individual of their approach up to three minutes before they begin. Given advance warning, individuals prone to falls and injuries could prepare accordingly.
Researchers are continually improving magnetic resonance imaging (MRI) and other brain imaging technologies as well. Pre-surgical brain imaging can better identify abnormal brain tissue, and brain scans, such as magnetoencephalograms (MEGs), magnetic resonance spectroscopy (MRS), and other technologies, are being developed to better understand brain function. Research findings may lead to a better understanding of epilepsy and thereby improve treatments.
For some people, medications and other therapies have little or no effect on seizure activity. For others, treatment options are effective but cause intolerable side effects. In these cases, or in other cases in which the seizure cause is readily identifiable and considered surgically treatable, physicians may recommend epilepsy surgery. As with any epilepsy treatment, epilepsy surgery requires that patients, families, and doctors accurately weigh the benefits and risks of treatment. For some individuals, the benefits of long-term seizure control that surgery may provide outweigh the risks that the procedure might pose.
Although surgical therapy for epilepsy has been used for more than a century, it has become far more common in the last decade. Today, physicians may consider surgery after just a few trials of other treatments, whereas in the past they may have considered this option only after exhaustive attempts at other alternatives. This shift is, in part, the result of advances in imaging technologies that make identification of lesions responsible for the seizure focus and surgery itself far more precise and safe.
Just as seizure types vary, so do seizure surgeries. This is because particular seizure types originate in particular regions of the brain—sometimes confined regions, sometimes regions that are more widespread. As a result, there are two main types of seizure surgery. The first and most common, called resective surgery, removes the portion of the brain where seizures are thought to originate. This approach is used in cases of partial epilepsy, wherein seizures originate from an identifiable location.
Another, less common, type of surgery interrupts critical neural networks that connect large portions of the brain with one another. For example, neurosurgeons may interrupt abnormal signals between the brain's right and left hemispheres by cutting the corpus callosum, the bundle of nerves that connects these regions. This treatment is often used in cases of intractable epilepsy that result in atonic seizures, or drop attacks.
Prior to surgery, physicians are careful to characterize and understand the seizure types that are typical to an individual, considering both their clinical manifestations and their localization within the brain. They conduct this preoperative assessment using tools such as EEG monitoring, to characterize the electrical patterns of the seizures, and MRI, to generate detailed images of brain anatomy. Both of these tools help physicians pinpoint a single source of seizure activity if possible. Other imaging procedures may also be part of a preoperative assessment. The positron emission tomography (PET), which analyzes brain metabolism, and single-photon emission computed tomography (SPECT), which analyzes blood flow in the brain, may both be used to identify seizure focus. WADA testing and functional MRI (fMRI) can help physicians identify regions of the brain involved in language and memory.
The notion of epilepsy surgery may raise many questions, concerns, and fears for patients and their families. However, with surgery, seizure reduction can be significant for patients who otherwise would have little hope of controlling their seizures. Depending on the type of surgery, from 25 percent to more than 80 percent of patients experience either a significant decrease in or elimination of seizures. These potential benefits will likely continue to improve as researchers develop new technologies and surgical therapies.
Beyond Seizure Control
The future of epilepsy research, as with that for many other human disorders, may lie in our DNA. Identifying genes associated with epilepsy can help reveal the underlying molecular processes that influence the disorder and thus point to new treatments.
Scientists have already identified the gene mutations responsible for some types of epilepsy. For most types, however, they have not yet identified genetic abnormalities. One goal of genetic research is to develop drugs that specifically target the abnormal proteins resulting from these abnormal genes. Studying the genetics of the disease could also provide the information necessary for doctors to more accurately diagnose and treat individual patients. Another long-term target of genetic research involves the actual modification of DNA. In gene replacement therapy, abnormal genes are spliced out and replaced with normal ones.
The goal of modern epilepsy treatment is to both control seizures and minimize negative side effects. Within the population of people with epilepsy whose seizures are controlled using prescribed medications, dietary therapies, and surgery, many—but not all—have reached that goal. However, with a greater understanding of the underlying mechanisms behind seizures and with research directed to obtain this information, an increasing number of children and adults should be able to achieve a seizure- free life.
It Is Important to Remember
- Even when epilepsy diagnosis is relatively simple, identifying an effective treatment may require a great deal of patience and persistence.
- Anticonvulsant medications are typically the first line in epilepsy treatment.
- There is no absolute, correct epilepsy medication for all patients or seizure types, nor is there one correct dose for any given medication.
- Treatment options for seizures include medications, specialized diets, vagus nerve stimulation, and surgery.
A dietitian is a medical professional who specializes in diet and metabolism. A dietitian who is knowledgeable about epilepsy and has had specialized training in administering the ketogenic diet and other dietary therapies can instruct patients on how to implement this therapy.
An EEG technologist is a person who administers the EEG test and who is trained to recognize the abnormal patterns that are characteristic of epileptic seizures.
A neurologist and a pediatric neurologist are physicians who care for people affected by disorders of the nervous system. An epileptologist is a neurologist or a pediatric neurologist who specializes in the treatment of epilepsy.
A neuroradiologist is a physician who interprets images, including x-rays, ultrasounds, CT scans, and MRIs of the central nervous system, including the brain. A neuroradiologist is trained to recognize abnormalities in brain structure.
A neurosurgeon is a surgeon who specializes in performing surgery on the nervous system, including the brain. A neurosurgeon who treats people with epilepsy is trained in the identification and resection (surgical removal) of brain regions where seizures originate. These neurosurgeons are often also qualified to treat epilepsy with implants such as the vagus nerve stimulator (VNS).
Patient & Family Stories
In addition to describing experiences common to most people affected by epilepsy, each story illustrates a particular issue that has been important to that family and that other families affected by epilepsy may encounter.