Epilepsy
Brain cells talk to one another in electrical discharges, and normally that conversation is orderly.
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Medicines commonly prescribed for Epilepsy
For informational purposes only. Always consult a doctor before using any medicine.
Dosage form: ORAL SOLUTION/SUSPENSION, 100 mg/mlActive substance: levetiracetamManufacturer: Tarbis Farma S.L.Prescription requiredDosage form: TABLET, 250 mgActive substance: levetiracetamManufacturer: Towa Pharmaceutical S.A.Prescription requiredDosage form: TABLET, 500 mgActive substance: levetiracetamManufacturer: Sandoz Farmaceutica S.A.Prescription required
Brain cells talk to one another in electrical discharges, and normally that conversation is orderly. Sometimes the order breaks down: a large group of cells fires all at once and out of step. For as long as that lasts, a person has no command of whatever the excited area governs — hence the fall, the convulsions, the smell of burning that nobody else notices, the minute missing from memory. That failure is called a seizure, and seizures that keep coming on their own are epilepsy. It is a heavy word for something largely manageable: in most people the right medicine stops the seizures altogether.
What a seizure looks like
A seizure is by no means always a fall and convulsions, and because of that misconception many people go years without connecting their odd moments to epilepsy.
The discharge may start in a small patch of cortex and stay there. The person is then fully conscious but experiences something that is not there: a feeling rising from the stomach to the throat, a sharp smell, a metallic taste, tingling in one arm, a flash of fear with no cause, a sense that all this has happened before. It lasts seconds and repeats to the same script — and that repetition is the giveaway. If the discharge spreads, awareness clouds over: the person goes still, smacks their lips, plucks at their clothes, does not answer to their name, and afterwards remembers nothing.
Seizures in which awareness switches off from the outset:
- a blank few seconds with a sentence cut off mid-word. In children this gets put down to daydreaming, and there may be dozens of episodes a day;
- a jerk of the arms or the whole body, as if startled, most often in the first hour after waking: the cup flies out of the hand and that is the only trace;
- the muscles stiffen all at once, or instead go limp, and the person drops where they stand and comes round almost immediately; such falls are dangerous because of head injuries;
- what people usually picture at the word epilepsy: a cry, a fall, the body going rigid, then rhythmic jerking. The lips turn blue, the tongue is often bitten, and there may be loss of urine.
A major seizure lasts a minute or two and ends by itself, but the person does not come round instantly: they sleep, then wake exhausted, with a headache, and may not know where they are. This can take up to an hour, and it is part of the seizure rather than a complication.
A seizure in front of you
Helping consists almost entirely of doing nothing, which is harder than it sounds: a seizure cannot be cut short, only waited out while keeping the person from coming to harm.
- Note the time. Whether an ambulance is needed depends on how long it lasts, and in the panic two minutes feel like ten.
- Move away anything they could strike, put something soft under the head, loosen the collar.
- Do not hold them down or straighten their limbs — convulsions cannot be stopped by force, and that is how dislocations happen.
- Put nothing in the mouth: not a spoon, not your fingers. Swallowing the tongue is impossible, it is a myth, whereas broken teeth and a lost finger are not.
- Once the jerking stops, roll them onto their side and tilt the head back slightly, so saliva runs out rather than into the airway.
- Give nothing to eat or drink until they are fully clear-headed, stay with them, and explain briefly what has happened.
Not every seizure needs hospital: someone who has lived with epilepsy for years will recover from a typical seizure and carry on, and often carries a rescue medicine given into the cheek or the nose, which trained relatives use to a plan agreed with the doctor. An ambulance is for anything outside that familiar pattern:
- it is the first seizure of their life;
- the convulsions last longer than five minutes and show no sign of stopping;
- seizures follow one another and consciousness does not return in between;
- awareness has not come back after half an hour, speech stays confused, or one side of the body is weaker;
- breathing has not settled and the face stays blue;
- the seizure happened in water, at height, at the wheel, or with a significant injury, particularly to the head;
- the person is pregnant or has diabetes, or the seizure followed poisoning or came with a high temperature, severe headache and a stiff neck.
A seizure that drags on is not simply a longer seizure. When the discharge will not die down on its own it is called status epilepticus: the brain runs short of oxygen, and damage builds up the longer it goes on. It is stopped with medicine given into a vein, and the five-minute mark exists precisely so that nobody has to guess. The emergency number in Spain, Italy, Portugal, Poland and Ukraine is the same — 112. While the ambulance is on its way, take note of how it began and whether one side jerked more than the other; the patient will not be able to tell anyone.
Why the brain misfires
In roughly half of all cases no cause is found even after a thorough work-up. That does not mean it was looked for badly: a tendency to discharge can be built into how the nerve cells work and shows on no scan. Of what is found, the commonest are genetic peculiarities — not necessarily inherited, since the fault can arise for the first time in that person; a scar or a malformation of the cortex after a head injury, a difficult birth or meningitis; and the aftermath of a stroke, much the commonest reason when seizures begin after fifty.
Some causes are rare, but they are exactly why the work-up is done in full. A seizure can be the first sign of a brain tumour — not necessarily a malignant one, and the sooner it is seen the easier it is to deal with. Autoimmune encephalitis, in which the immune system attacks a person's own nerve cells, and vascular malformations begin the same way. What should raise concern are seizures growing more frequent month by month and always starting in the same way on the same side of the body, especially alongside a new morning headache, a change in character, gaps in memory or increasing weakness in an arm.
Convulsions also occur in people without epilepsy: with a sharp fall in blood glucose, with poisoning, and above all on abrupt withdrawal from alcohol or sleeping tablets after long use. There the cause is treated, not the brain.
How the diagnosis is confirmed
A single seizure is not yet epilepsy. The diagnosis is made when there have been at least two seizures arising on their own, or when tests after the first show clearly that more will follow.
The most valuable thing here is not the equipment but the account. If someone witnessed the seizure, bring that person along — their five minutes are worth more than most scans. A video on a phone is now a routine part of the assessment too. After that, the usual tests are:
- an electroencephalogram. One thing is worth understanding: a normal recording does not rule the diagnosis out. Between seizures the trace is often quiet and has to be chased, with a sleepless night beforehand, with a daytime nap, or with a recording over twenty-four hours;
- an MRI scan of the brain, which looks for what can be seen: a scar, a malformation, a tumour. It needs to be an MRI done to an epilepsy protocol; an ordinary CT scan is too coarse for this;
- an ECG, and sometimes a day-long recording of the heart rhythm. This is no formality: a rhythm disturbance interrupts the blood supply to the brain and looks very like a seizure, yet is treated entirely differently;
- blood tests, and genetic testing if the seizures began in early childhood or similar cases run in the family.
There is a separate trap: seizures of psychological origin, outwardly indistinguishable from epileptic ones. They are genuine, the person is not inventing them, but antiepileptic medicines do nothing for them whatsoever. What tells them apart is video recorded alongside the electroencephalogram, and here the exact diagnosis changes the whole of treatment.
How it is treated
The mainstay is medicines that stop discharges from spreading. They are taken not in courses but continuously, every day at the same time. The choice depends on the type of seizure, on age, sex, other illnesses and other drugs: what works beautifully for one kind of seizure can make another kind worse, so copying an acquaintance's prescription is particularly ill-advised here. Treatment starts at a low dose and is built up gradually; if the first drug does not suit, a second is tried. For about two people in three a single well-chosen medicine is enough to stop seizures completely. If two suitable drugs at adequate doses have failed, working through a third and a fourth has little promise: it is time for a specialist centre.
Rules that matter more than the choice of tablet:
- a missed dose is the commonest reason things go wrong. An alarm, a weekly pill box, a spare supply in the bag and when travelling;
- never stop abruptly or change the dose yourself: sudden withdrawal brings on not just a seizure but often a prolonged one;
- tell every doctor and every pharmacist. Interactions are numerous and some are far from obvious, from antibiotics to St John's wort in a herbal blend;
- if there have been no seizures for several years, your specialist may suggest coming off the medicine gradually. It is a decision to be discussed: some seizures return, and work, driving and plans for pregnancy all weigh in.
When medicines do not hold the seizures, what remains is nothing exotic. If the small focus where everything starts can be pinpointed, it is removed surgically, and in temporal lobe epilepsy that gives the best results available. There are implanted devices that stimulate the vagus nerve. In children with severe forms the ketogenic diet works, but it is a strict regime supervised by a dietitian, not something to improvise.
Pregnancy and contraception
A woman with epilepsy can carry a pregnancy and have a healthy baby — that is the rule, not the exception. But the preparation begins long before conception. Certain antiepileptic medicines seriously harm the developing baby, raising the risk of malformations and of problems with the development of the nervous system. Doctors try not to prescribe them to women who could become pregnant, and where there is no alternative only alongside reliable contraception and a detailed conversation about the risks. There is also evidence about these medicines taken by the father, so the conversation concerns both partners.
- a safe regimen is arranged before conception, not after a positive test: the baby's organs form in the first weeks, when a pregnancy is often still unknown;
- folic acid is started in advance and the dose is set by the doctor; in epilepsy it is usually higher than the standard one;
- some medicines reduce the reliability of the contraceptive pill, while certain contraceptives in turn lower the level of the antiepileptic drug in the blood. This is settled with a doctor, not from the leaflet in the box;
- on finding out about a pregnancy, do not stop the medicine. A seizure is more dangerous to the baby than most drugs are; get in touch with your specialist and the regimen will be reviewed calmly;
- breastfeeding is usually possible, and it is sensible to bathe the baby only with someone else present.
What is in your hands
Seizures rarely come out of nowhere. Keep a diary: date and time, what happened the day before, how much sleep, what was taken, which day of the cycle. Within a couple of months the pattern usually shows itself. What most often provokes a setback is lack of sleep and a broken routine, a missed dose, alcohol (especially the morning after a large amount), a high temperature and heavy stress. Flashing lights are dangerous for a noticeable minority of people with epilepsy, but where that sensitivity is confirmed it is worth avoiding strobe lighting.
Safety is built around one simple idea: a seizure can catch you at any second, and in that second there should be nothing lethal nearby.
- a shower rather than a bath, and a door that does not bolt from the inside;
- never swim alone, in the sea or in a pool: water remains the leading cause of accidents;
- in the kitchen, the back ring, pan handles turned inwards, and the microwave rather than an open flame when you are home alone;
- cover sharp corners and radiators, tell family and colleagues what to do, and carry a card or bracelet with the diagnosis and the medication;
- no work at height or with moving machinery while seizures are not controlled.
On driving it is worth being blunt: a seizure at the wheel is dangerous both to the driver and to everyone else. In every country we serve, driving is allowed only after a set seizure-free period, but that period and the paperwork differ from country to country, so check the local rules rather than someone's account on the internet. Concealing epilepsy when applying for a licence is a poor bargain: after an accident it brings legal and insurance consequences.
And one thing people are reluctant to mention, wrongly so: on rare occasions a person with epilepsy dies suddenly, at night, without drowning, injury or a prolonged seizure, and no other cause is found. It is a rare event, and the important part is that the risk falls appreciably. It is higher in those who still have major convulsive seizures, particularly at night, who take their medicines irregularly, and who live alone. Hence what is worth doing: getting the seizures under control, not missing doses, sleeping enough, and discussing night-time seizures with the doctor specifically.
Online consultation
A remote appointment covers a good deal of what epilepsy involves and what needs no hands-on examination. If the seizure was the first, the doctor will work out from your account and from video what it resembles and where to begin the investigation, so that months are not lost on the wrong tests. If the diagnosis is long established, it is convenient online to go over seizures that have become more frequent, side effects, compatibility with other medicines, planning a pregnancy and contraception, and to read the diary together and find the trigger in it. The doctor will help set out a clear plan for the family: what to do during a seizure and at what point to call an ambulance. For a prolonged seizure, several seizures in a row, or a first seizure with injury, what is needed is not a consultation but an ambulance.
This material is for information only and does not replace medical advice.
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