By: Rosabel R. Young, M.D., M.S. Pharm, F.A.A.N., Q.M.E.
Certified, American Board of Psychiatry and Neurology with Added Qualifications in Neurophysiology
Board Certified in Brain Injury Medicine (American Board of PM&R)
Certified, American Board of Electrodiagnostic Medicine
Certified, American Board of Clinical Neurophysiology
Epilepsy is one of the most common brain disorders worldwide, it affects individuals of all ages, genders, and backgrounds. There are many causes of epilepsy and the different types have been reclassified several times over the years as we learn more about epilepsy. Currently, neurologists classify first by Seizure Type, because understanding how a seizure itself occurs from beginning to end is the first clue to understanding the cause, and knowing the cause leads to finding a cure.
Generalized Epilepsy
Generalized Epilepsy refers to patients whose seizures are caused by abnormal electrical activity that occurs in both sides of the brain simultaneously from the onset of a seizure. The causes include genetic, metabolic syndromes, or widespread encephalitis. These epilepsy types include the usually benign and easily controlled Absence Epilepsy and Myoclonic epilepsy, but also the more severe epilepsy syndromes with frequent intractable seizures.
Treatment for generalized epilepsy:
Since the seizures do not start in a specific (focal) area of the brain, a treatment or cure would have to involve the whole brain. Medications are the best approach, but some patients require multiple drugs. Vagal nerve stimulation also has proven benefit even for some of the epilepsy syndromes.
Known triggers for breakthrough seizures despite medication control include sleep deprivation, fever, low blood sugar, and some types of repetitive stimulation, such as flashing lights or sounds. Alcohol withdrawal and alcohol itself, as well as stimulants, including caffeine, can also trigger breakthrough seizures. Thus, certain lifestyle factors and protective environmental changes can help reduce seizures. It is important to get enough sleep, eat several meals a day instead of one or two large meals followed by fasting, and avoid alcohol and other drugs. Always tell your other doctors that you have epilepsy or a history of seizures because some common drugs can cause seizures, including Wellbutrin (prescribed for depression and smoking withdrawal) and Baclofen prescribed for muscle spasm.
Focal Onset Epilepsy
If the seizure activity starts in one specific area on one side of the brain and continues there, or spreads to other areas, even to the other side of the brain and generalize, causing a gran mal seizure, it is still considered a focal onset epilepsy.
Treatment for focal onset epilepsy:
If recurrent seizures always begin in the same area, the neurologist will further explore possible pathology in that area with brain imaging (MRI) and Electroencephalography (EEG). These studies may reveal abnormal blood vessels, old infections (Cysticercosis), scar tissue from prior brain injury, or a brain tumor. While focal onset seizures are considered the most difficult to treat and least likely to be “cured” permanently, they can be controlled or even eliminated if the identified cause is a “benign” single lesion not likely to spread or recur.
Treatment options include surgery or laser ablation of the lesion, neuromodulation devices, deep brain stimulation, and more recently, targeted ultrasound. Even after the best surgery is performed and the outcome is considered successful, this does not guarantee that the patient will never have a seizure again. More often, the result post surgery is a reduction in seizure medications, but not total freedom from them.
SUMMARY:
By cause of seizure –
Based on causes of seizures and epilepsy risk associated with those causes, there may be some types of epilepsy that can be “cured.” Those are:
Primary Generalized caused by drugs or chemical injury – if the exposure was temporary and the offending toxin is removed, there is a good chance that the epilepsy is “cured.”
However, some chemicals do inflict permanent damage, such as amphetamines and cocaine because these can cause brain microinfarction (mini-strokes).
Hypoxic injury – such as after cardiac arrest with loss of cerebral blood flow for 1-5 minutes. The patient survives, but has lost thousands of brain cells. They may have seizures for a few days or weeks, but as long as there is no scar tissue or residuals from hemorrhage, seizures stop once the immediate treatment is implemented. Still there is no cure for the loss of function due to brain cell loss.
Children compared with adults –
We used to believe that children “would grow out of it” after one or even multiple seizures, but over the years, studies have shown that children who stop having seizures in late childhood or teens may have recurrent seizures many years later. While it is still considered safe to stop medications for some benign childhood epilepsies, (benign childhood absence, Rolandic epilepsy), if the child had any provoking factors, such has a head injury, encephalitis, or a focal lesion, they have a lifelong risk for recurrent seizures even 10-20 years later. When these patients are asked about past seizure symptoms, many of them turn out to have experienced “silent” complex partial episodes, auras, automatisms, etc, but never told anyone.
When is it safe to go off medications?
Generally, the patient should be on medications with seizures controlled for 2-5 years, then medications can be withdrawn by gradually tapering one medication at a time. If the patient remains seizure-free at 0 (ZERO) medications, repeat the EEG in six weeks, sleep deprived, and do not release the patient to operate a motor vehicle until they are seizure -free with NO medications for another 12 months. Remember that in most states in the US, a 14 year old child will be driving in 2 years!
Patients who are on multiple antiseizure medications, or have a history of having “failed” multiple medication trials are less likely to remain seizure-free during this tapering and waiting period.
In the 1990s, Dr. Rivares Young was the “ringside doctor” for the Juvenile Justice Correctional programs for the California Athletic Commission. In that capacity, her job was to examine Juvenile delinquents as young as 12 years old that were participating in boxing, Mixed Martial Arts, and football as part of the Corrections Department rehabilitation activities.
Dr. Young observed that some of these juveniles exhibited more severe behavioral derangements after these activities, including poor school performance, loss of socialization, more violent behavior, and epilepsy. Joined by her colleagues in Neurology, Psychiatry, Psychology, and Behavioral Medicine, Dr. Young advised the State of California to discontinue sports activities that might cause head injuries. Eventually other activities did replace the violent sports, with more focus on rehabilitation and skills development training programs.