pharmacotherapeutics epilepsy

2. Introduction
Epilepsy is a chronic neurological disorder characterized by
recurrent episodes of seizures.
• Types of epilepsy:
 1.Generalised seizures
i)Tonic – clonic seizures: The usual sequence is aura , epileptic cry
unconsciousness and sudden fall due to tonic convulsions followed by
clonic jerking and then prolonged sleep and depression. The attack
lasts for 1-2 mins.
ii)Absence seizures: This is prevalent in children. No aura ,no loss of
consciousness , no fall. The patient appears to go blank for less than
30 sec and staring in one direction.It has two types typical and
atypical.
iii)Tonic seizures: The muscle tone is increased. The body arms or legs
become stiff.They are short less than 20 sec.

3. iv)Atonic seizures: There may be loss of consciousness with
relaxation of all muscle.
V)Myoclonic seizures: Sudden, brief, repetitive contraction of
muscles of limb and whole body.
 2.Focal Epilepsy: Focal seizures start in one side of the brain
and seizure activity is restricted to one cerebral hemisphere
only.

4. Etiopathogenesis
Epilepsy is associated with abnormal excessive electrical discharges
from a group of CNS neurons. It is due to disruption in the normal
balance between excitatory and inhibitory neurotransmission in the brain.
 Causes of epilepsy:
• Genetic:
(i) Genetic mutations affecting transmitter receptors
(ii) Chromosomal abnormalities
(iii) Genetic metabolic disorders
(iv) Mitochondrial diseases
• Structural:
(i) Perinatal injury
(ii) Brain tumors
(iii) Traumatic brain injury

5. • Metabolic:
(i) Inborn errors of metabolism
(ii) Porphyria (abnormal metabolism of haemoglobin)
• Immune:
(i) Autoimmune encephalitis (inflammation of the brain)
• Infections:
(i) Chronic CNS infection (e.g., toxoplasmosis, malaria)
(ii) Complication of acute CNS infection (e.g., viral or bacterial
meningitis)

6. Clinical Manifestations of Epilepsy
• Aura.
• Cyanosis (a bluish coloration of the skin).
• Sudden falls.
• Motor symptoms such as involuntary stiffening or jerky
movements of limbs.
• Cognitive symptoms such as blank spells, speech arrest with
or without conscious thought.
• Sensory symptoms such as numbness, auditory, olfactory or
visual hallucination.
• Autonomic symptoms such as urinary incontinence or tongue
biting with loss of awareness, or during sleep.
• Alteration of mental status such as episodes of confused
behavior with lack of awareness.

7. Diagnosis and Investigation of Epilepsy
• Apart from routine laboratory investigations, EEG and MRI
should be done.
• Electroencephalography should be done to help in the
diagnosis and classification of seizure and epilepsy.
• Brain imaging (MRI) should be done to identify cause of
epilepsy.

8. Non-Pharmacological Management of Epilepsy
• Avoid precipitating factors like sleep deprivation, fasting,
video games, CNS stimulating drugs, etc.
• Surgical procedures including;
(i) Resection (surgical removal of pathological lesions)
(ii) Disconnection (surgical section of neuronal circuits)
• Stimulation techniques: vagus nerve stimulation, deep brain
stimulation.
• Dietary measures: ketogenic diet.

9. The choice of antiepileptics is based on the seizure type
and need of the individual patient.
• Antiseizure drugs are CNS depressants. They stabilize
cell membranes and suppress abnormal electric
impulses in the cerebral cortex. These drugs prevent
seizures but do not provide a cure.
• Antiepileptic (anticonvulsant) drugs are classified as:
• First-generation (classic) agents: e.g. Valproate,
Carbamazepine, Phenytoin, Phenobarbital,
Benzodiazepines.
• Second-generation agents: e.g. Lamotrigine,
Gabapentin, Pregabalin ,Vigabatrin, Topiramate.
Pharmacological Management of Epilepsy

10. Treatment options
Focal seizures First line treatment: Phenytoin, carbamazepine,
lamotrigine, phenobarbital
Second line treatment: Valproate, gabapentin,
pregabalin, topiramate
Primary generalized
seizures
Tonic-clonic:
Typical absence:
Atypical absence,
myoclonic, atonic:
First line treatment: Valproate, lamotrigine,
phenobarbital
Second-line treatment: Carbamazepine, zonisamide
First line treatment: Valproate
Second line treatment: Lamotrigine, clonazepam
First line treatment: Valproate
Second line treatment: Clonazepam, felbamet

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