Seizure Disorder

Introduction

Millions of Americans suffer from a disorder called epilepsy, or the reoccurrence of seizures. Despite its prevalence, many people are frightened by this disorder because they don't have a clear understanding of it. This fear can easily be overcome by learning more about the disease.

What is it?

Epilepsy is a chronic condition. Affected individuals suffer from periodic seizures over an extended period. A seizure occurs when a cell or group of cells in the brain is overstimulated. It's possible to have a seizure and not have epilepsy, and there is no certain number of seizures that must occur before epilepsy is diagnosed. Epilepsy is not associated with any particular type of seizure.

To determine the type of seizure experienced by an individual, a doctor must first classify the seizure. Seizures are usually divided into two classes--generalized and partial. They are placed into these classes based on how much of the brain is involved at the onset of the seizure. With generalized seizures, the entire brain is involved. In partial seizures, only part of the brain is involved. However, the portion of the brain that is initially responsible for partial seizure activity may become larger and eventually progress into a generalized seizure.

Generalized Seizures

The most common types of generalized seizures include:

• Absence seizures
• Myoclonic seizures
• Tonic-clonic seizures
• Atonic seizures

All types of generalized seizures share several characteristics. All result in a loss of consciousness, which usually manifests as a loss of awareness during the seizure. This means that affected individuals can't respond to their environment. There is almost always a recovery period after a generalized seizure; during this time individuals may be abnormally drowsy or confused. Generalized seizures usually last only a few minutes.

Partial Seizures

Partial seizures are divided further into two groups--simple and complex.

1. Simple Partial Seizures
• Individuals do not lose consciousness and are usually able to respond to their environment.
• Individuals suffering from a simple partial seizure may demonstrate a variety of symptoms during the seizure. These symptoms include but are not limited to hallucinations, deja vu, and increased perception of fear or pleasure.
• This type of seizure usually lasts only about a minute.
2. Complex Partial Seizures

• Individuals lose consciousness during complex partial seizures; however, they are still able to interact with their surroundings. They are unaware of what they are doing and upon returning to consciousness have no recollection of what they did. Those experiencing this type of seizure may wander around or cry.
• The loss of consciousness typically lasts only 2 minutes.
• Like individuals who suffer generalized seizures, those who experience complex partial seizures may have a recovery period during which they appear drowsy or confused.

Status Epilepticus

A progressive condition associated with seizures is referred to as status epilepticus. Individuals with status epilepticus suffer from a single seizure lasting more than 30 minutes or have recurrent seizures without a period of consciousness between seizures.

Although status epilepticus can result from any type of seizure, tonic-clonic seizures are associated with this condition most commonly. This type of status epilepticus, called generalized convulsive status epilepticus (GCSE), accounts for 75% of status epilepticus cases every year. This is the most serious kind of seizure, and individuals should receive medical attention as soon as possible because of the possibility of brain damage or death.

What causes it?

Seizures

For the most part, the exact cause of seizures is unknown. However, certain stimuli can cause seizures or increase the frequency of seizure activity. These triggers include the following:

• Head trauma
• Brain infections
• Genetics
• Tumors
• Fevers
• Drug withdrawal
• Lack of food
• Metabolic disorders
• Hyperventilation
• Sleep depravation
• Hormonal changes
• Emotional stress
• Certain drugs (theophylline,bupropion alcohol, phenothiazines, antidepressants, cocaine and other street drugs, anti-epileptic drugs at excessive doses, and oral contraceptives)
• Sensory stimuli (for example, flashing lights)

Status Epilepticus (GCSE)

The precipitating factors for GCSE are split into two categories--type I and type II. Type I precipitating factors are not associated with any new structural changes in the brain. The most common cause is an insufficient dose of anti-epileptic medication. Withdrawal of anti-epileptic medication and consumption of alcohol are other type I precipitating factors. Type II precipitating factors are associated with structural lesions and generally a poor prognosis. The most common type II precipitating factor in adults is a stroke. Others include decreased oxygen supply, brain tumor, and head trauma.

Who has it?

Seizures

A seizure can happen to anyone. It is estimated that 8% of the general population will have at least one seizure during their lifetime. The number of individuals who actually have epilepsy, however, is slightly different. Of the general population, approximately 1% suffers from epilepsy. Roughly 180,000 new cases of epilepsy are diagnosed each year. Of affected individuals, 30% are younger than 18.

Status Epilepticus

Between 50,000 and 150,000 Americans have an episode of status epilepticus every year; of these individuals, 22% die as a result of the event. Status epilepticus is most common among the very young and the elderly. In all age groups, status epilepticus is more common among non-Caucasians than Caucasians.

What are the risk factors?

Risk factors include:

• Severe head trauma
• Tumors
• Brain infection
• Stroke
• Childhood seizures
• Cerebral palsy
• Mental retardation

What are the symptoms?

Absence Seizures

Often mistaken for daydreaming, absence seizures usually occur during childhood. They are characterized by a sudden interruption of consciousness, which may be accompanied by a fixed stare, lip smacking, or chewing. Jerking is not associated with this type of seizure. The seizure only lasts a few seconds and a return to consciousness is immediate once the seizure is over, and there is no recovery period.

Myoclonic Seizures

Characterized by jerking of a single muscle group, most commonly in the face, arm, and chest, myoclonic seizures usually manifest as a shoulder shrug, a suddenly fling of the hand, an abrupt kick, or an entire body jerk. Myoclonic seizures are one of the few types of generalized seizures that don't lead to loss of consciousness. Although individuals are aware of what is going on, they can't control what they are doing.

Tonic-Clonic Seizures

When picturing a seizure, most people think of a tonic-clonic seizure. Tonic-clonic seizures are characterized by a period of stiffness affecting a group of muscles, followed by rapid, jerking motions of the same muscle group. Most commonly these seizures involve the entire body, but they can involve only the legs or arms.

Typically, when a tonic-clonic seizure begins, the individual lets out a short cry then falls to the floor. This event is followed by muscle contractions and jerking of the arms and legs lasting a couple seconds. This episode may occur just once or repeatedly.

After the seizure, the individual slowly regains consciousness, which usually takes anywhere from 5 minutes to several hours. In rare instances, it may take several days or even up to a week for the individual to feel completely healthy again.

Atonic Seizures

During an atonic seizure, the individual's muscles become completely limp. These seizures commonly affect the entire body but may affect only a group of muscles. Most often, the neck and arm muscles are affected.

When the muscles go limp, the individual can no longer support the weight of whatever is ordinarily supported by those muscles. Thus, if the neck muscles are affected by the seizure, the head will fall forward and rest on the individual's chest. If the seizure affects all of the individual's muscles, he or she will drop to the ground. During such falls, individuals are unable to protect themselves, which can lead to head injuries, broken limbs, or other injuries, depending on where and how they fall. To prevent injuries, affected individuals often take special precautions, such as wearing protective headgear.

Simple Partial Seizures

Simple partial seizures have a variety of symptoms, including:

• Jerking arms or legs
• Self-damaging actions
• Posturing
• Hallucinations
• Abnormal sense of smell
• Nervous stomach
• Dry eyes
• Deja vu (the feeling that places or situations that should be unfamiliar are normal or familiar)
• Jamais vu (the feeling that places or situations that should be familiar are strange and unrecognizable)
• Increased perception of fear or pleasure

Individuals who suffer simple partial seizures differ from those who suffer complex partial seizures in that, while the symptoms mentioned above are occurring, they are able to respond to their surroundings. They are aware of what they are doing but are unable to control themselves.

Complex Partial Seizures

Individuals who suffer complex partial seizures usually have an "aura," or a feeling that a seizure is going to occur. While the seizure is occurring, individuals become unconscious but may still interact with their surroundings. Common activities while unconscious include:

• Wandering around
• Lip smacking
• Buttoning or unbuttoning clothing
• Acts of violence
• Crying

Status Epilepticus

The symptoms of status epilepticus depend on the type of seizure involved. Most commonly, status epilepticus is associated with tonic-clonic seizures. These seizures occur in the same way that tonic-clonic seizures do except that there are multiple seizures and there is no recovery period between the seizures.

How is it treated?

Seizures

Currently, seizures are treated with anticonvulsants, or drugs that prevent seizures. Frequently, doctors start with one anticonvulsant and increase the dose until seizures are controlled. If seizures begin to reappear after they are controlled, the doctor may switch to a different medication. Or, the doctor might recommend that the individual start taking another drug while continuing the first one. These secondary drugs are called alternative anticonvulsants.

The concern with most of these drugs is that they can cause numerous side effects as the dose is increased. (That is, the higher the dose of the drug, the greater the chance for side effects.) Examples of possible side effects include drowsiness, increased seizure activity, and blood disorders.

Individuals may find the side effects intolerable and stop taking the medication without the advice of their doctor; however, this is not recommended. Individuals who suddenly stop taking the medication can suffer increased seizures. If you experience intolerable side effects from your seizure medications, it is best to talk to your physician about your concerns. Your doctor can then work to figure out the best plan for your drug therapy.

Yet another problem is that many of these drugs interact with one another. Many single-therapy drugs can increase or decrease the levels of other single-therapy drugs in the body, which can lead to loss of seizure control. It is important that all of your health care providers, including your physician and pharmacist, are aware of all of the medications you are taking to maintain the maximum effectiveness of the medications.

Status Epilepticus

1. Benzodiazepines
• Benzodiazepines are used to stop a seizure quickly. The drugs from this class most commonly used to treat status epilepticus include lorazepam, diazepam, clorazepate, and midazolam.
2. Hydantoins
• Hydantoins are used to help prevent additional seizures. Drugs in this class include phenytoin and fosphenytoin.
3. Barbiturates

• The only commonly used barbiturate is phenobarbital, which is used to prevent the spread of seizure activity.

Helping Yourself

Always keep your doctor appointments, and notify your doctor if you experience any of the side effects that drugs used to treat epilepsy can cause. Also inform your doctor of all other prescription and nonprescription drugs you are taking. You should always consult your doctor before you stop taking any seizure medication.

You may want to keep a seizure log to record how often you are having seizures and to see if you can associate the seizure with an activity. What follows is a list of some actions you can take to help prevent a seizure.

• Maintain a healthy, well-balanced diet.
• Take a multivitamin that contains folic acid every day.
• Talk to your doctor about starting a well-regulated exercise regimen.
• Get plenty of sleep.
• Avoid activities that trigger seizures. These triggers are patient specific, meaning the things that cause one individual's seizures may not cause another individual's seizures.

There are also some things your friends and family can do to help you while you are having a seizure. These things include:

• Cushioning your head
• Loosening anything that may be tight around your neck
• Turning you on your side so you don't choke on any saliva
• Removing anything in the area that could cause injury if you jerk during the seizure
• Calling for medical assistance if the seizure lasts more than 5 minutes or if you start having multiple seizures.

Ask your friends and family to avoid:

• Placing anything in your mouth or trying to hold your tongue, which will just block your airway. making it harder for you to breathe
• Holding you down

What is on the horizon?

Researchers are always studying new drugs that are designed to cause fewer side effects and have fewer interactions with other drugs used in the treatment of epilepsy. Retigabine is a new drug currently being studied for safety and effectiveness. Retigabine is currently the only drug being studied that has an activity in the potassium channels. Researchers hope this new approach to treatment of seizure disorder will work in patients with refractory epilepsy that have taken between one to three other anticonvulsant agents. Researchers are trying to determine whether any of the drugs considered for use only after initial drug treatment fails are effective in the initial treatment of seizures. Using these drugs at the beginning of therapy would be desirable because they cause fewer side effects and drug interactions. Behavioral treatments such as relaxation techniques and life style changes are also being studied for seizure disorders.

Other research is focused on the development of seizure disorders. Studies are being conducted to find the genes involved in seizure disorder. A better understanding of the development of seizure disorders could lead to improved treatments. Because available antiepileptic agents are still inadequate for many patients researchers in this area will continue to strive to improve therapy for seizure disorders.

References

Graves NM, Garnett WR. Epilepsy. In: Dipiro JT, Talbert RL, Yee GC, et al., eds. Pharmacotherapy: A Pathophysiologic Approach. 6th ed. Stamford, Conn.: Appleton & Lange; 2005.

McNamara JO. Drugs effective in the therapy of the epilepsies. In: Goodman-Gilman A, Hardman JG, Limbird LE, eds. Goodman & Gilman's the Pharmacological Basis of Therapeutics. 10th ed. New York: McGraw-Hill; 2001.

Benbadis SR, Agrawal VK. Partial epilepsies. 2(7). eMedicine Journal Available at: http://www.emedicine.com/NEURO/topic623.htm. Accessed November 2007.

Epilepsy Ontario Home Page. Available at URL: http://epilepsyontario.org/index.html Accessed November 2007.

Phelps SJ, May WN, Rose DF. Status epilepticus. In: Dipiro JT, Talbert RL, Yee GC, et al. eds. Pharmacotherapy: A Pathophysiologic Approach. 6th ed. Stamford, Conn.: Appleton & Lange; 2005.

National Epilepsy Foundation. First Aid for Seizures. Available at: http://www.epilepsyfoundation.org/. Accessed November 2007.

Gidal BE, Garnett WR. Epilepsy. In: Dipro JT, Talbert RL, Yee GC, et al. eds. Pharmacotherapy: A Pathophysiologic Approach. 6th ed. Stamford, Conn.: Appleton & Lange; 2005.

Drug Topics Online News Magazine.Taking Control of Epilepsy. Available at: http://www.drugtopics.com/drugtopics/article/articleDetail.jsp?id=310322&pageID=1. Accessed June 7, 2006.

ClinicalTrials.gov. Seizure Disorders. Available at http://www.clinicaltrials.gov. Accessed November 2007.

Seizure Disorder Health Condition Last Updated: December 2007

Note: The above information is intended to supplement, not substitute for, the expertise and judgment of your physician, pharmacist, or other healthcare professional. It is not intended to diagnose a health condition, but it can be used as a guide to help you decide if you should seek professional treatment or to help you learn more about your condition once it has been diagnosed.

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