Controlling Epilepsy: Science Replaces Superstition
by Margie Patlak

The sight of someone having a severe epileptic seizure is hard to forget.     
The person suddenly cries out, loses consciousness, falls to the ground, and  
foams at the mouth. Arms and legs jerk convulsively for several minutes.

It's no wonder such high drama has inspired supernatural interpretations of   
epilepsy in the past. During ancient times, most Greeks thought seizures      
were brief visits from the gods and called epilepsy "the sacred disease."     
During the Renaissance, in contrast, many people believed demons were behind  
seizures, and those with epilepsy were burned to death as sorcerers,          
according to Richard Restak, M.D., author of The Brain.

Today science has replaced superstition, and we realize that epilepsy is      
simply a common neurological disorder that can be diagnosed and treated with  
devices and drugs regulated by the Food and Drug Administration.

One out of every hundred people in this country has epilepsy. Their seizures  
stem from overly active nerve cells (neurons) in the brain. The strong and    
rapid bursts of electrical signals emitted from these hyperactive neurons     
temporarily disrupt normal functioning, much as a lightning storm can         
disrupt electrical power in a neighborhood.

The hallmark of epilepsy is recurring seizures--sometimes as many as several  
hundred a day--under normal circumstances. Anyone can develop a seizure if    
given the right bodily insult, such as poisoning or a lack of sugar in the    
brain brought on by diabetes. But in people with epilepsy, seizures can be    
triggered by something as minor as lack of sleep or the flickering of a       
light. 

What causes epilepsy in all cases is not known. In some people it results     
from brain damage from head injuries, brain tumors, lead poisoning,           
meningitis, encephalitis, or measles. Lack of oxygen to the fetus during      
pregnancy, labor or delivery may cause epilepsy to develop during childhood.  
Brain damage incurred by a stroke is a common cause of epilepsy in people     
over 65.

Epilepsy can first appear at any age, although three-quarters of all cases    
surface during childhood. Epilepsy sometimes runs in families, but a genetic  
predisposition alone probably cannot cause most forms of the disorder;        
usually other factors, such as a head injury, must also be present.

Types of Seizures

There are more than 20 different types of epileptic seizures, ranging from    
the dramatic "grand mal" seizure described at the beginning of this article   
to the slight few-seconds loss of consciousness (known as an absence          
seizure) that often goes unnoticed. A person with epilepsy can have more      
than one type of seizure. Accurate diagnosis of the specific types of         
seizures is critical to determining appropriate therapy.

The kind of seizure depends on where in the brain the electrical signaling    
has gone awry, and how far that "brainstorm" has spread. If only the portion  
of the brain controlling movement of a limb is involved, that limb may        
tremble or jerk uncontrollably. If the affected brain area spreads, more of   
the body may begin to move erratically.

If the brain section governing hearing or vision is involved, the person may  
experience auditory or visual hallucinations. Sometimes the emotional         
centers of the brain are the hardest hit during a seizure and a person        
starts to cry for no apparent reason, or becomes angry or afraid. These       
seizures are termed partial because only part of the brain is involved.

Many people mistake a person undergoing a partial seizure as drunk or         
mentally ill. A complex partial seizure, for example, may cause the person    
to be dazed, unresponsive and clumsy, and to mumble, pick at clothing, or     
make chewing movements.

In contrast, during a generalized seizure such as a grand mal seizure (also   
known as a generalized tonic clonic seizure), the whole brain is suddenly     
swamped with extra electrical energy so the entire body undergoes             
convulsions and the person loses consciousness. Another type of generalized   
seizure called atonic causes abrupt loss of muscle tone, and the person       
falls to the ground.

Sometimes people, particularly those with complex partial seizures,           
experience a distinctive warning sign before a seizure, called an aura. The   
aura is itself a form of partial seizure, but one in which the patient        
retains awareness. It may be a peculiar odor, "butterflies" in the stomach,   
or a sound. One man with epilepsy, an ardent racetrack gambler, always hears  
the roar of a crowd followed by the name of a favorite racehorse just before  
falling unconscious. Another person hears rock music.

Although the average individual seizure doesn't appear to have any lasting    
effects, repeated seizures may be associated with damage such as memory       
loss. "There's growing evidence that seizures are not good for the brain,"    
says Roger J. Porter, M.D., deputy director of the National Institute of      
Neurological Disorders and Stroke in Bethesda, Md.

A person may also be injured in a seizure-induced fall. Rarely, a person who  
has had a convulsive seizure may need resuscitation if breathing does not     
resume automatically.

Although seizures rarely cause death, they can be life-threatening if they    
occur in hazardous situations, such as while driving or swimming. Most cases  
of death from epilepsy stem from a series of seizures in a short span of      
time, or a seizure that lasts longer than a half hour. Both conditions can    
deprive the brain of oxygen or cause heart or kidney failure. People          
experiencing such seizures should receive immediate hospital care.

The diagnosis of epilepsy, clarification of the type of seizures, and         
determination of possible causes, are based on laboratory tests (see          
accompanying article) and a detailed medical history.

Drug Treatment

Drugs, surgery, a special diet, or a combination of these treatments is used  
to prevent seizures. Drug therapy alone can control seizures in about         
three-quarters of all people with epilepsy.

FDA has approved 16 drugs to treat epilepsy. The most commonly prescribed     
epilepsy drugs are carbamazepine (Tegretol), clonazepam (Clonopin),           
phenytoin (Dilantin), valproic acid (Depakene or Depakote), phenobarbital,    
primidone (Mysoline), and ethosuximide (Zarontin). Seizures can usually be    
controlled with one drug, although, rarely, patients may have to take more    
than one.

Researchers have yet to pinpoint exactly how most epilepsy drugs prevent      
seizures. Some epilepsy drugs appear to prevent seizures by boosting the      
amount or actions of certain brain compounds, called neurotransmitters, that  
inhibit the transfer of electrical impulses from neuron to neuron. Others     
may influence the passage of electrically charged atoms (ions) through the    
neuron membrane. These ions trigger the firing of neurons.

Many epilepsy drugs cause unwanted side effects, such as drowsiness,          
confusion, clumsiness, nausea, increased appetite, and behavioral or          
learning problems. These side effects can often be relieved by adjusting the  
dosage or by switching to a different drug.

To find the appropriate dose of medication, doctors usually take frequent     
blood samples to measure the amount of drug circulating in the patient's      
bloodstream. The blood levels are monitored at various drug dosages until     
the dose that best controls seizures with the fewest side effects is          
determined. Monitoring can take from a week to several months to establish    
the optimum dose of the appropriate medicine for a given patient. Children    
and pregnant women need to continue to have their dosages adjusted.

Pregnancy Risk

Women taking epilepsy medication during pregnancy have about two to three     
times the standard risk of bearing a child with birth defects. Nevertheless,  
at least 90 percent of women who take epilepsy drugs during pregnancy give    
birth to normal, healthy infants. A seizure during pregnancy carries its own  
risks. The fetus may be deprived of oxygen due to the mother's impaired       
breathing during a seizure, for example, or both mother and child may be      
injured from a seizure-induced fall. Therefore, most doctors advise pregnant  
women with epilepsy to continue taking their medication unless it is likely   
that a woman will be seizure-free without it. 

Many epilepsy drugs are excreted in breast milk, but usually in such small    
amounts that they are unlikely to affect the infant. Most physicians          
recommend that women with epilepsy breast-feed their newborns, although they  
may suggest alternating breast- and bottle-feeding to lower the infant's      
exposure to medication.

Drug Interactions

Several drugs interact with some kinds of epilepsy medicine, lessening or     
intensifying the effects of one or the other drug. To avoid such drug         
interactions, patients should tell their doctors about any other medications  
they are taking whenever a new drug is prescribed. Similarly, patients        
taking an epilepsy drug should check with the pharmacist about possible       
interactions with over-the-counter drugs they purchase. Birth control pills,  
the antibiotic erythromycin, some types of asthma, ulcer or heart medicines,  
and alcohol are known to interact with certain epilepsy drugs.

People taking epilepsy drugs should not change the dose or stop a medication  
without first consulting a doctor. Suddenly stopping epilepsy medicines can   
prompt a series of seizures that can be fatal.

Most epilepsy medicines need to be stored in a dry place because any          
moisture that seeps into the drugs can dramatically alter the medicine's      
strength. "In general, you shouldn't keep epilepsy drugs on a bathroom shelf  
where they might be exposed to steam from showers," says Russell Katz, M.D.,  
deputy director of FDA's division of neuropharmacological drug products.

Epilepsy drugs are taken daily by mouth for a period of years or, for some    
patients, a lifetime. Recent research reveals that when epilepsy drugs are    
slowly withdrawn after a person has been free of seizures for a few years,    
most people can stay free of seizures without medication. This is especially  
true for children. On the other hand, people with certain forms of epilepsy,  
such as those that cause partial or mixed seizure types, are less likely to   
be seizure-free after stopping medication.

If drugs cannot control a person's seizures, a doctor may prescribe a         
ketogenic diet. This high-fat diet produces a chemical condition in the body  
called ketosis, which in some people, particularly children, prevents         
seizures. Most people find the ketogenic diet hard to swallow, however,       
because it makes them nauseous and is expensive and difficult to administer.  
Moreover, the diet often doesn't work, according to Porter.

Surgical Cures

When all else fails, some people with epilepsy may benefit from surgical      
removal of the malfunctioning brain cells that spark their seizures. To       
benefit from such surgery, patients' seizures must begin in one fairly small  
area of the brain that is not responsible for speech, language, hearing, or   
other major faculties and that can be detected with an imaging technique      
(see accompanying article).

Between a half to nearly three-quarters of patients with epilepsy who         
undergo such surgery are relieved of their seizures for at least five years,  
according to a recent consensus statement published by the National           
Institutes of Health. Some of these patients, however, may still require      
epilepsy medication to stay seizure-free. The surgery carries a less than 5   
percent risk of death.

Occasionally, surgery is performed to sever the connections between the two   
halves of the brain to try to prevent the spread of abnormal discharges from  
one side of the brain to the other. Although this surgery doesn't entirely    
prevent seizures, it does appear to lessen their severity or frequency.

The decision to have surgery depends on the frequency, type and severity of   
seizures, possible brain damage or injury from frequent seizures, and the     
effect seizures have on quality of life, according to the NIH consensus       
statement. Drug therapy must be tried before surgery is considered.

Scientific knowledge about epilepsy has banished the demons and ancient       
stigmas surrounding the disease. Modern drugs, diet or surgery have made      
possible normal lives, free from frequent seizures, for most people with      
epilepsy.

Margie Patlak is a writer in Elkins Park, Pa.
For more information on epilepsy contact:
- The Epilepsy Foundation of America at 1-800-EFA-1000
- The Neurological Institute at P.O. Box 5801, Bethesda, MD 20824; telephone  
(301) 496-5951
Pinpointing Epilepsy

When diagnosing epilepsy, physicians first try to rule out short-term causes  
of seizures that may be treated directly. Tests of the patient's blood,       
urine, or cerebrospinal fluid, which bathes the brain, may reveal             
uncontrolled diabetes, poisoning, a kidney disorder, or an infection.

Doctors use the electroencephalograph to help diagnose epilepsy. This         
machine detects, via electrodes taped to the head, electrical charges that    
pass between the brain cells near the electrodes. These charges are recorded  
as a series of wavy lines (brain waves) in what is known as an                
electroencephalogram (EEG). If a person has a seizure during an EEG           
recording, the device may reveal special brain wave patterns that help the    
doctor decide whether a person has epilepsy and what type it is. Some forms   
of epilepsy are associated with specific EEG patterns that can be seen        
between seizures. An EEG recording session may last as little as 35 minutes   
or as long as 24 hours.

Some clinics have small TV cameras set up in the EEG test area to film the    
person's actions during the test. Review of the film together with the EEG    
results may give added clues to the kind of seizure occurring. Patients may   
also be given a portable EEG device that records their brain waves            
continuously for a day while they are in their normal environment.

To induce a seizure during an EEG recording, patients may be asked to         
breathe deeply during the session, limit their sleep the night before, or to  
fall asleep during the session. (Some types of seizures are more likely to    
occur with a lack of sleep, whereas others occur more often during sleep.)    
Patients may also be exposed to flashing lights or other images or sounds     
that can prompt a seizure. Electroencephalography is a painless, safe         
procedure.

A device similar to the EEG, called the magnetoencephalograph is being used   
experimentally. This device records the magnetic signals that accompany the   
electrical discharges of neurons. A recording from this device resembles      
that of an EEG, but an magnetoencephalograph can detect seizure activity      
from deeper in the brain than is possible with the standard EEG.

Sometimes computerized tomography (CT) and magnetic resonance imaging (MRI)   
are used to provide pictures of the brain that may reveal tumors, cysts, or   
excess fluid. If these conditions can be treated successfully, the seizures   
may stop.

CT scans and MRI images are also used to detect damaged areas or scars in     
the brain that may be sparking seizures. Such information determines the      
type of epilepsy a person has and guides therapy.

PET (positron emission tomography), which is being used experimentally, can   
also point to the origin of epilepsy by measuring sugar uptake. In the        
responsible brain region, sugar uptake increases during a seizure and falls   
below normal between seizures.
--M.P.