Epilepsy

In about 50% of cases, the cause of epilepsy remains unknown (idiopathic). For the other half, the condition can be traced to various factors that damage the brain or alter its wiring. Research published in Nature Reviews Neurology (2022) highlights that any process that disrupts the delicate balance of the brain's neural circuits can lead to epilepsy. This includes structural changes, genetic mutations, or metabolic imbalances.

Non-Modifiable Risk Factors

• Genetics: Some types of epilepsy run in families, suggesting a genetic predisposition. Over 500 genes have been linked to epilepsy.
• Age: While it can develop at any age, new-onset epilepsy is most common in children and adults over age 60.
• Family History: Having a first-degree relative with epilepsy increases the risk.

Modifiable Risk Factors

• Head Injuries: Traumatic brain injuries (TBI) from car accidents or falls are a leading cause of 'acquired' epilepsy.
• Brain Conditions: Strokes (the leading cause in adults over 35) and brain tumors can trigger seizures.
• Infections: Meningitis, encephalitis, and neurocysticercosis (a parasitic infection) are significant causes, especially in developing regions.
• Prenatal Injury: Brain damage occurring before birth due to infection, poor nutrition, or oxygen deficiencies.

According to the National Institute of Neurological Disorders and Stroke (NINDS, 2023), individuals who have suffered a stroke or a severe head injury have a significantly higher risk of developing epilepsy within the following years. Veterans and athletes in high-contact sports are also identified as higher-risk populations due to the prevalence of TBI.

While genetic epilepsy cannot be prevented, many cases of acquired epilepsy are preventable. The WHO (2024) estimates that 25% of epilepsy cases could be prevented by reducing head injuries through better road safety, preventing strokes through blood pressure management, and improving perinatal care to reduce birth-related brain injuries.

The diagnostic journey typically begins after a patient experiences one or more seizures. Because doctors rarely witness the seizure, a detailed medical history and eyewitness accounts are the most critical components of the diagnosis.

A healthcare provider will perform a neurological exam to test motor abilities, mental function, and sensory responses. This helps determine if there are underlying brain abnormalities or signs of other neurological conditions.

• Electroencephalogram (EEG): This is the most common test. Electrodes are attached to the scalp to record the brain's electrical activity. Spikes or sharp waves in the recording can indicate a predisposition to seizures.
• Magnetic Resonance Imaging (MRI): High-resolution imaging used to look for structural abnormalities in the brain, such as tumors, scarring, or malformed blood vessels.
• Computed Tomography (CT) Scan: Used primarily in emergency settings to rule out acute bleeding or tumors.
• Blood Tests: These are used to check for signs of infection, genetic conditions, or metabolic imbalances (like low blood sugar or electrolyte issues) that might be triggering seizures.

According to the ILAE (2014) clinical definition, epilepsy is diagnosed if a person meets any of the following:

1. 1At least two unprovoked seizures occurring more than 24 hours apart.
2. 2One unprovoked seizure and a probability of further seizures similar to the general recurrence risk (at least 60%) over the next 10 years.
3. 3Diagnosis of an epilepsy syndrome.

Doctors must rule out other conditions that mimic seizures, including syncope (fainting), migraines, sleep disorders (like narcolepsy), and Psychogenic Non-Epileptic Seizures (PNES), which are seizures triggered by psychological distress rather than electrical activity.

The primary goal of epilepsy treatment is the complete elimination of seizures with minimal side effects, allowing the patient to lead a normal, active life. Success is often measured by the 'seizure-free' interval and the improvement in the patient’s overall quality of life scores.

According to the American Academy of Neurology (AAN) guidelines, the standard first-line treatment for most patients is monotherapy with an anticonvulsant medication. Approximately 70% of people with epilepsy can achieve seizure control with the first or second medication tried.

Anticonvulsants (Anti-Seizure Medications - ASMs)

• Mechanism: These work by stabilizing nerve cell membranes, typically by blocking sodium or calcium channels or by enhancing the inhibitory effect of the neurotransmitter GABA.
• When Preferred: They are the gold standard for almost all types of epilepsy.
• Common Side Effects: Fatigue, dizziness, weight gain, mood changes, and cognitive 'clouding.'
• Typical Duration: Often long-term, though some patients may taper off after two or more years of being seizure-free under medical supervision.

Benzodiazepines

• Mechanism: They enhance the effect of GABA to rapidly slow down brain activity.
• When Preferred: Used primarily as 'rescue medications' to stop a prolonged seizure or for short-term 'bridge' therapy.
• Common Side Effects: Sedation, dependence, and respiratory depression if used in high doses.

Hydantoins

• Mechanism: They slow down the impulses in the brain that cause seizures by affecting sodium channels.
• When Preferred: Often used for generalized tonic-clonic seizures.

If the first medication fails, a doctor may try a different class or combine two medications. For drug-resistant epilepsy (failing two or more medications), other options include:

• Vagus Nerve Stimulation (VNS): A device implanted under the skin of the chest that sends regular pulses of electrical energy to the brain via the vagus nerve.
• Responsive Neurostimulation (RNS): An implanted device that monitors brain waves and delivers a pulse to stop a seizure before it starts.

• Epilepsy Surgery: If seizures consistently originate in a small, well-defined area of the brain that does not control vital functions (like speech or movement), that tissue may be removed.
• Ketogenic Diet: A high-fat, low-carbohydrate diet used primarily in children when medications are ineffective. It must be strictly monitored by a medical team.

• Pregnancy: Most women with epilepsy can have healthy babies, but medications may need adjustment to prevent birth defects while maintaining seizure control.
• Elderly: Older adults may require lower doses due to changes in metabolism and potential interactions with other medications.

> Important: Talk to your healthcare provider about which approach is right for you.

While a general healthy diet is recommended, the Ketogenic Diet and the Modified Atkins Diet have been clinically proven to reduce seizures in certain populations, particularly children with drug-resistant epilepsy. A 2020 Cochrane review confirmed that these diets can significantly reduce seizure frequency. It is also vital to avoid excessive alcohol, as withdrawal from alcohol is a potent seizure trigger.

Exercise is generally encouraged and may even improve seizure control by reducing stress. However, patients should avoid high-risk activities where a loss of consciousness could be fatal, such as solo swimming or mountain climbing. The CDC (2023) recommends that people with epilepsy stay active but use the 'buddy system' for water-based activities.

Sleep deprivation is one of the most common triggers for seizures. Maintaining a consistent sleep-wake cycle is critical. Patients should aim for 7-9 hours of quality sleep and practice good sleep hygiene, such as avoiding screens before bed and keeping the bedroom cool and dark.

Emotional stress can trigger the release of hormones that increase brain excitability. Evidence-based techniques like Mindfulness-Based Cognitive Therapy (MBCT) and progressive muscle relaxation have shown promise in reducing seizure frequency by lowering overall cortisol levels.

• Yoga and Meditation: May help with stress-related triggers, though they are not a replacement for medication.
• Biofeedback: Some patients use this to learn how to recognize and 'calm' the brain activity that precedes a seizure.
• Caution: Always consult a doctor before using herbal supplements (like Ginkgo Biloba or St. John's Wort), as they can interfere with anticonvulsant medications.

Caregivers should learn 'Seizure First Aid':

1. 1Stay calm and track the time.
2. 2Keep the person safe (clear the area of sharp objects).
3. 3Turn the person onto their side to keep the airway clear.
4. 4Do NOT put anything in their mouth.
5. 5Stay with them until they are fully awake.

The outlook for most people with epilepsy is positive. According to the ILAE (2023), approximately 70% of individuals can achieve long-term seizure remission with appropriate medication. For many, epilepsy is a manageable chronic condition rather than a progressive or terminal one.

• Status Epilepticus: A seizure lasting more than 5 minutes, which is a medical emergency and can lead to permanent brain damage or death.
• SUDEP (Sudden Unexpected Death in Epilepsy): A rare but serious risk where a person with epilepsy dies suddenly without an obvious cause. It affects about 1 in 1,000 people with epilepsy annually (NINDS, 2023).
• Psychological Issues: Higher rates of depression and anxiety are reported in the epilepsy population due to the social and biological impacts of the disorder.

Management involves regular check-ups with a neurologist or epileptologist to monitor medication levels and side effects. Periodic EEGs may be required to assess brain activity. Long-term success often depends on strict adherence to medication schedules.

Many people with epilepsy lead full, productive lives. Utilizing support resources, such as the Epilepsy Foundation, can help patients navigate challenges related to employment, driving laws, and social stigma.

Contact your healthcare provider if you experience:

• An increase in seizure frequency or severity.
• New or worsening side effects from medications.
• Mood changes, such as suicidal thoughts (a rare side effect of some anticonvulsants).
• If you are planning to become pregnant.