This document discusses epilepsy and seizure disorders. It defines key terms like seizure and epilepsy. It provides information on prevalence, classification, triggers, diagnosis and differential diagnosis. It discusses the role of EEG, evaluation, and management principles. These include destigmatization, driving recommendations, considerations during pregnancy, first aid, and options for refractory cases. Drug treatment focuses on monotherapy as first line using anti-epileptic drugs like Tegral which is effective with a low side effect profile.

1. Understanding Epilepsy
Fareed A. Minhas
Prof. & Head
Institute of Psychiatry
Rawalpindi Medical College

2. Introduction
• Seizure: the result of excessive
synchronous discharge of cortical neurons
• Convulsion: violent, involuntary
contraction of voluntary muscles
• Epilepsy: a clinical condition characterized
by recurrent unprovoked seizures

3. Definitions
Seizure
A paroxysmal and time-limited neurological event that
results from abnormal neuronal activity in the brain
Epilepsy
Recurrent seizures

4. Prevalence
• 1.4 M in USA with 8.4 M visits to office-based
neurologists
• i% in Pakistan
• Chronic seizure disorder in 1-2% of general
population (6.1 per 1000)
• Ten percent of general population have at least
one seizure in their lifetime
• Minority groups may have higher rate
– Acquired (symptomatic) epilepsy
– Socioeconomic status

5. Epileptic Neuron
Presynaptic
Neuron
Stimulus
Repeated influx of
sodium ions
Excessive Glutamate &
Aspartate release
Excessive stimulation leading
to a seizure
An increase in the presynaptic release of glutamate and aspartate
may lead to excessive stimulation of the postsynaptic membrane.

6. Triggers
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Hyperventilation (absence)
Too much sleep
Too little sleep
Sensory stimuli
Emotional stress
Hormonal changes
Drug overdose or withdrawal

7. Classification
• Partial (focal, local)
– Simple (w/o impairment of consciousness)
• With motor symptoms
• With special sensory or somatosensory symptoms
• With psychic symptoms
– Complex (consciousness impaired)
• Simple partial onset followed by impairment
• Impaired consciousness at onset
– Secondarily generalized

8. Classification
• Generalized (convulsive or non-convulsive)
– Onset occurs bilaterally and symmetrically
– absence, atonic, clonic, myoclonic, tonic, tonicclonic, infantile spasms
• Unclassified seizures
• Status epilepticus

9. Diagnosis of Seizure
History and observation
EEG

10. Diagnosis
• Seizure characteristics
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Frequency and duration
Precipitating factors
Time of occurrence
Aura
Ictal and post-ictal state
• Laboratory
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CBC
Chem panel with Mg and Ca
UA
Lumbar puncture
• PE and NE
• EEG
• MRI or CT

11. Features suggestive of seizure
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Impairment of consciousness
Deviation of the eyes
Facial automatisms
Rhythmic jerking of body parts
Bladder or bowel incontinence
Physical injury (e.g., tongue-biting)
Pre-episode aura
Post-episode confusion
Family history of epilepsy

12. Role of EEG
 Only test of brain function available in routine
clinical use
 Can reveal interictal “signature” of underlying
epilepsy through the appearance of epileptiform
discharges (spikes, sharp waves, and spike and
slow-wave complexes)
 Single EEG has sensitivity of 60%
 Sensitivity can be enhanced by repeating the test
(up to 90% for 3 EEGs) and by sleep deprivation

13. Evaluation of a patient with suspected
seizure
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Careful history
Thorough neurological examination
Standard labs (CBC, glucose, lytes, BUN/Cr, UA)
EEG
 Brain MRI in case of abnormal exam
 CSF analysis in case of suspected infection

17. Differential diagnosis of seizures
Breathholding spells (children)
REM sleep behavior (children)
Tics
Confusional migraine
Syncope
Panic attacks
Narcolepsy
Transient ischemic attack
Transient global amnesia
Psychogenic seizures (pseudoseizures)

18. Management: Central issues
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Destigmatization
Judicious use of AEDs
Recommendations about driving
Pregnancy and epilepsy
First-aid advice to family
Options for refractory cases

19. Destigmatization
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Demystifying superstitions
Educating about nature of epilepsy
Counseling about marriage and pregnancy
Reassuring that epilepsy is compatible with a
normal and productive life

20. Driving recommendations
 No driving after a seizure until seizure-free
for 6 months
 No driving after medication decrement until
seizure-free for 6 months
 Also applies to swimming, water sports and
other activities in which seizure could be
lethal

21. Pregnancy & Epilepsy
 Epilepsy is compatible with marriage
and motherhood
 Pre-conception control is best predictor
of seizure control during pregnancy
 All AEDs are potentially teratogenic but
seizure may carry greater risk to fetus
 If possible, have patient controlled on
lamotrigine prior to conception and stay
the course

22. First-aid for acute seizure
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Turn the patient on to his or her side
Remove eyeglasses if any
Clear the area of harmful objects
Do not try to restrain movements
Loosen neckwear like necktie or dupatta
Do not force anything into the patient’s mouth
No need for emergency medical help unless …
Seizure doesn’t stop in 3 min., another seizure
happens, or an injury has occurred

23. Options for refractory cases
 Add 2nd or, if necessary, 3rd AED
 Consider surgical treatment
 Requires specialized evaluation
 Options include temporal lobectomy,
lesionectomy (corticectomy), callosal
commissurotomy, hemispherectomy
 Consider Vagal Nerve Stimulator
 Implanted electrical stimulator of vagus,
effective as adjunct to AEDs

24. Treatment Goals
• Normal lifestyle
• Reduce frequency of seizures
– Balance between suppression and AEs
• Encourage compliance
• Assess the concerns of the patient
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Driving
Education
Relationships
Housing
Social stigma
• Epilepsy Foundation of America

25. Principles of Pharmacotherapy
• Positive correlation between the early
initiation of therapy and the ability to control
seizure activity
• Failure to control seizures may lead to an
increase in seizure activity and also the
occurrence of other seizure types
• “No regimen like the first regimen”

26. Principles of Pharmacotherapy
• Drug choice is based on seizure type and side
effect profile
• Always start with monotherapy
– ~70% of patients can be maintained with one drug
– Of 35% with unsatisfactory control, 10% will be wellcontrolled on two drugs
– ~20% will be medically refractory
– 15% will become surgery candidates
• Success rate is 80-90% in properly selected patients
• Risks include learning,memory, and general intellectual
impairment

27. Principles of Pharmacotherapy
• Seizure control may be achieved at doses
corresponding to less than “normal”
therapeutic serum levels; likewise, doses
corresponding to higher than “normal”
therapeutic serum levels may be tolerated
and required by some patients
• Begin dosing at 1/3 to ¼ anticipated
maintenance dose and titrate over 3-4
weeks

28. Judicious use of AEDs
 Do not treat single uncomplicated seizure
 If AEDs are needed, use monotherapy as much
as possible (e.g: Tegral)
 Classic AEDs (phenytoin, Tegral and valproic
acid) have long experience but significant sideeffects, esp. valproic acid in women
 Newer agents very expensive & 2nd line therapy
 Gabapentin is a weaker AED but almost no
interactions and best for medically complex
patients

29. Treatment Failure
• Number one cause of treatment failure is
• AED is not considered ineffective until
patient has continued seizures AND some
concentration-dependent side effects
• Substitute
• Generics (Low bioavailability)
• Mixed seizure types are more likely to
require more than one AED
• Seizure chart a must

30. Principles of Pharmacotherapy
• Kinetics
– Plasma protein binding
• Measure free instead of total
– DPH
– Age
• Neonates
• Infants, children
• Elderly
– Metabolism
• Induction or inhibition of the CYP450 enzyme system
• Many AEDs have active metabolites

31. Principles of Pharmacotherapy
• Female patients
– Enzyme-inducing AEDs
• PHT, PHB, Tegral , primidone
• VPA is an inhibitor
– Seizures before or during menses or at time of
ovulation
• All female patients should take PNV with
folate

32. Principles of Pharmacotherapy
• Pregnancy
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25-30% increased or decreased frequency
Increased VD and clearance
Altered protein binding
Increased incidence of adverse outcomes
Twice the incidence of congenital malformations (4-6%)
• PB and PHT – congenital heart malformations, facial clefts
• CBZ and VPA – spina bifida and hypospadias
– Monotherapy preferred

33. Principles of Pharmacotherapy
• Discontinuation of AEDs
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Seizure-free for 2-5 years
Single type of primary GTC or partial
Neurological exam and IQ are normal
EEG normalized with treatment
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High frequency
Repeated SE
Combination of seizure types
Development of abnormal functioning
• Not possible in all patients

34. Drugs of Choice – First Line
• Partial Seizures
– Tegral , PHT, VPA
– Lamotrigine, oxcarbazepine
• Generalized Seizures
– Tonic-Clonic
• CBZ, PHT, VPA
– Absence
• VPA, ethosuximide
– Myoclonic
• Clonazepam, VPA

35. Summary
 Seizures and epilepsy are a common problem
in primary care medicine
 Diagnosis relies on careful history and
examination, supplemented by EEG
 Treatment involves educating about the
illness, judicious use of AEDs, instructions
about driving and similar activities
 Treatment options exist for refractory cases
 Tegral is the first line therapy
 Tegral is effective & has low side effects
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