What is a seizure?

Seizure is an abnormal electrical discharge in brain. It is not a problem with plumbing of the brain, and not a stroke. It is a problem with the electrical circuitry of brain. Brain is a complex electrochemical circuitry with billions of cells and their innumerable connections. Brain cells communicate through electrical, chemical, and combination of electrical and chemical (electrochemical) connections. Looking deeply at the number of brain cells and the amount of connections they make, it is surprising that malfunction does not happen that often. In a patient with seizure disorder, there is an abnormal circuitry that causes electrical malfunction, which ultimately results in seizures.

What are different types of seizures?

There are two ways to determine a type of seizure: clinical or based upon its symptoms, and by a test called electroencephalogram (EEG). Following are the types of seizure:

A: Partial seizure: mild symptoms without causing any amount of confusion. Typical partial seizures are shaking, or numbness of a part of body, or abnormal perception but with intact mentation (meaning patient is fully aware of his/her surroundings).

B: Complex partial seizure: when any amount of confusion or change in mental status is involved with symptoms of a partial seizure.

C: Generalized seizure: when patient’s whole body is affected leading to loss of consciousness, falling, and sometime generalized body shaking.

How do you figure out if it is a seizure or a stroke?

In two ways: most of the time with analysis of symptoms and rarely with an MRI of brain. In general, a stroke causes negative symptoms. By negative I mean loss of function such as loss of vision, loss of strength, loss of ability to speak, loss of sensations, etc. In contrast, a seizure usually causes positive symptoms. By positive I mean flashes of light instead of blindness, shaking instead of not able to move, loud shouting, or a scream instead of not able to speak, and an abnormal sensation instead of loss of sensation. In some patients this type of analysis is difficult to perform or is not conclusive. In such cases, an MRI of brain can help, which can easily diagnose a stroke.

What is epilepsy?

This term simply means that the patient has a condition causing unprovoked seizures. If a patient with diabetes takes a larger dose of insulin than what is needed, blood sugar can drop to dangerous levels and a seizure may occur. If blood sodium drops to very low levels, one may have a seizure too. If someone drinks a bottle of vodka daily, and one day decides to quit cold turkey, one or multiple seizures may happen. All of these patients are not given a diagnosis of epilepsy, because seizures are provoked by known reasons that are preventable and fixable. On the other hand, if someone is having an otherwise normal day and for no explainable reason gets confused, falls down and have a generalized seizure, we may call it epilepsy.

What causes seizures in epilepsy?

There are varieties of known causes. As I stated above that a seizure is caused by abnormality of brain circuitry, all of the conditions that can cause abnormality of brain circuitry can cause seizures. More common causes are as follows:

A: Hereditary causes when a person is born with an abnormality in the brain. Some abnormalities can be diagnosed or visualized by a good brain MRI, but many are so small that our present technology cannot visualize it.

B: Significant head trauma; minor or mild concussion is unlikely to cause seizures

C: Meningitis or encephalitis (brain infection)

D: Strokes

E: Inflammatory conditions of brain, such as multiple sclerosis

F: Drug of abuse, alcohol being the leading causes

G: Tumors

H: Unknown. In many patients a cause of seizures or epilepsy cannot be determined

How do we diagnose a seizure, or a seizure disorder?

In many cases, if one is with the patient having a seizure, the diagnosis of seizure can be abundantly clear. In most cases though, patient or the family presents a description of what has happened. Seizures do not leave any permanent mark on brain, and imaging of brain does not diagnose seizures. The only practical way to confirm a seizure disorder is with an electroencephalogram (EEG). EEG records brain electrical activity. A seizure causes particular type of changes in otherwise normal brain electrical waves, which confirms seizure disorder.

What is electroencephalogram (EEG)?

EEG is recording of electrical activity of brain. In some ways it is similar to an ECG or EKG that records electrical activity of heart. Unlike heart, the electrical activity in the brain is very weak, so the electrodes are placed as close to the brain as possible. Routine EEG involves putting about 16 leads on the head. A small area of scalp is cleaned with a cleanser, and the lead is attached with help of a tape. All leads are attached to a machine that amplifies the signal. Electrical signals in shape of waves are displayed on a computer screen. Abnormalities are determined based upon pattern recognition.

EEG is typically ordered to look for seizure type activity. It can help to confirm seizure disorder, help to determine its type, and the location in the brain.

My EEG is normal, so I don’t have seizures, right?

An abnormal EEG confirms seizure disorder or epilepsy, but a normal EEG does not exclude that possibility. This is because in a patient with seizure disorder, abnormal electrical discharges do not happen all the time. Chances of finding an abnormal EEG depend upon how often that happens. In many cases more than one EEG, and frequently long-term EEG monitoring for a day or two, or for many days is done to increase chances of finding an abnormality.

What is the role of CT scan or MRI of brain in seizure disorder or epilepsy?

For seizure disorder, CT scan does not provide appropriate or full information. It can be useful only in acute settings in emergency room if a stroke or brain trauma is suspected. MRI of brain is the right test to help find cause of seizure disorder. As stated above, even with modern MRI machines, cause of seizure at times is not found. MRI can help diagnose stroke, trauma, abnormalities patients are born with, tumors, abscess, or similar structural abnormalities of brain known to cause seizure disorder.

If not seizure, what else can be the cause of my symptoms?

There are other medical problems that can look like or present like seizure type symptoms. Whenever a physician is consulted for a seizure, the first priority is to get appropriate history and all related information to figure out if it is a seizure or something else? Other conditions that can present with similar symptoms are minor stroke, the so-called “TIA,” migraine, anxiety, syncope, or a psychological and/or psychiatric disorder. Many times diagnosis is relatively clear from history, and one can easily narrow it down to one or two possibilities.

What are the repercussions of seizure?

Unlike a stroke, seizures usually do not leave any permanent physical mark on the brain or the body, unless the patient is hurt while having a seizure. For a few hours to a day or two, patient may have number of symptoms like confusion, aching, or headache. But a seizure may still have significant repercussions otherwise. Talking to my patients, I usually divide them in three categories: medical, social, and legal repercussions. Main medical issue is the risk of having another seizure, or an injury from it. One has to figure out the cause and take appropriate measures to minimize its recurrence. This usually means consultation with a neurologist, many tests, and may include long-term use of seizure controlling medicines.

In the social category, in spite of tremendous changes in society’s behavior during the last century, there still is some level of stigma attached to this diagnosis. This in combination with patient’s feeling of vulnerability may result in many psychosocial issues. The social repercussion is equally significant for a child or an adult, but its impact varies depending upon a number of factors. Starting a conversation on this topic can help to mitigate and minimize these issues. Patient may also benefit from counseling.

There are many legal repercussions after a seizure or an episode of loss of consciousness. Every state in USA has some type of driving restrictions after such an incident; e.g., the state of Massachusetts puts a six-month restriction on driving privileges. Other than personal driving, it may become almost impossible to drive a commercial vehicle, or fly a plane, or captain a boat. I have been witness to many lost jobs and shattered dreams.

I had a seizure recently; what are the chances I can have it again?

This is one of the most important questions in every case of seizure disorder but its answer is not that straightforward; it depends. Mainly it depends upon the cause of the seizure, and the circumstances that may have contributed to its occurrence. For example, if someone with a seizure has no underlying medical condition, does not abuse chemicals, has no history of head injury, and has normal neurological examination, normal brain MRI, and normal EEG; chances of another seizure are much smaller than a person who has been drinking excessive alcohol, or had significant head injury or stroke in the past. Every patient’s situation is evaluated and a recommendation is made based upon the level of risk.

Other than a medical treatment, what else can I do to prevent further seizures?

There are certain factors that can increase chances of having a seizure. For example, very low blood glucose can put anybody into a seizure. So for a patient with diabetes mellitus, it is important to avoid abnormally low blood sugar. Examples of some other factors that typically can increase chances of seizures (for a person who has seizure disorder and not otherwise) are following: sleep deprivation, sudden severe stress, head trauma, alcohol, cocaine and other stimulants, certain medicines like some antibiotics or some antidepressants. Avoiding all these situations and exposures can help avoid seizures.

Can a stroke cause a seizure?

Overall, a stroke is probably one of the most common reasons of seizure disorder. Rarely, a stroke can present with a seizure, but most of the time seizures happen as a result of the scarring of brain from an old stroke.

Do all patients with seizures need a medicine?

It depends. A seizure is an indication for a structural or biological abnormality in brain that, most of the time, cannot be permanently fixed. Every seizure results in some kind of symptoms, upon which the patient has little control on. Many times, it leads to loss of mental or full body control. This puts the patient in a risky situation. To avoid any emotional or physical injury, a medicine is taken to minimize chances of further seizures.

Many times I reflect on the question that if someone has a seizure once in 5 to 10 years, does prescribing a daily medicine make sense? Generally speaking, every patient and every situation is reviewed and a risk assessment is taken. If the seizure is significant (e.g., causing alteration of consciousness), the cause is obvious (e.g., a previous stroke on imaging), and patient’s lifestyle may result in dangerous situation (e.g., patient drives a vehicle), an anti seizure medicine is warranted. In USA, with a history of this type of seizure, one may not be able to reinstate drive license unless appropriate measures are taken to prevent its recurrence.

Which is the best medicine for seizure control?

It depends upon a few factors including the type of seizure, age of the patient, other medical conditions, other medicines that patient may be taking, and also the price of the medicine. There is no use prescribing a medicine that a patient may not be able afford, or his insurance may not cover. Usually, there are choices and one can prescribe one of many effective medicines. Generally, the principle is to pick the most effective medicine for the type of seizure disorder, and if there is more than one choice, opt for the safest one.

What about the dose of the medicine?

Dose of a medicine vary for different people based upon many factors including their body/mass index, age, what other medicines patient may be taking, and how good their kidney and liver functions are. A small dose can be safer but it may not do the job, and a very high dose may cause intolerable side effects; the best dose is the dose that can control seizures with no obvious side effects.

Does every seizure medicine require blood-level test?

Not necessarily, in fact most medicines do not, and they can easily be managed without checking their blood level. This is true even for many old or first generation drugs. Frequent or routine drug levels do not help the patient, and in fact can significantly impact their quality of life and compliance with the medicine. There are some genuine situations when a drug level is helpful, for example, if a drug is prescribed and patient reports no effect from it, checking a level can be helpful to confirm that patient is really taking the medicine, or to adjust the dose. It is also helpful if there are some signs of toxicity and we like to make sure it is from the drug, in which case a level may be found. Most clinical situations can be managed without checking a drug level, as one can make clinical decisions based upon many other factors.

Other than a blood test to check the level of the drug patient is taking, blood test are also done to monitor liver functions, kidney functions, and sometime level of white blood cells. Not all seizure medicines require this type of routine testing, but it is prudent to do it at least once a year.

Are newer seizure medicines more effective than the older ones?

This question can be reliably answered in only those situations where a comparison trial has taken place, and in most cases that has not been the case. In general, seizure medicines differ less in term of effectiveness, and more in term of safety profile. Newer drugs are relatively safer than the older ones, but one has to be careful about this notion, as some of the old medicines are also as safe as some of the new ones.

Is it OK to take more than one seizure medicines?

The fact that the second medicine is prescribed suggests that the first medicine alone has not worked. Sometimes more than one medicine is required for better seizure control. This situation is not different from high blood pressure where most people may be taking just one medicine to control their blood pressure but many others require more than one.

What is my responsibility about driving after a seizure?

Other than taking care of oneself, and getting a consultation with a neurologist, in the state of Massachusetts, one is required to report the incident to the Department of Motor Vehicle and temporarily surrender driving privileges. In most situations, medical practitioners are not required to make a report to the department; instead they are required to educate and inform the patient of his/her responsibility.

What happens when my driving privileges are suspended after a seizure?

The issue of driving privileges after a seizure is frequently a source of stress, both for the patient and the health care provider, partly because of its impact on their professional relationship. The first priority always is patient’s health, so the process of evaluation and investigation after a seizure has to be accomplished first. An automobile is a heavy piece of machinery, which if gets out of control can cause property damage, or tremendous injury or death. To avoid any such issues, the state of Massachusetts mandates temporary suspension of driving privileges, generally for six months.

Once a proper diagnosis is made and appropriate steps taken to prevent its future reoccurrence, one may apply for reinstatement of driving privileges. This requires a form to be filled by a doctor, which specifies the diagnosis, its treatment, and assessment of future risk. It is the Department of Motor Vehicle, and not the doctor, who makes the final decision to let one drive or not. The information here is for private driving; the rules about commercial driving are different and in general stricter. They may also vary between industries, and not discussed here.

Can a person die from a seizure?

Rarely, a seizure can cause severe physical injury and death. Patient may die from the seizure itself, or an accident resulting from a seizure. Seizure patient is advised to avoid sitting in a soaking tub alone, swim alone, and avoid similar activities alone that could put his life in danger, in case a seizure affects him.

I have seizure disorder; am I disable for work?

It depends. Some patients have severe epilepsy with severe and frequent seizures making it very difficult to work. But a lot many are able to work in most professions. There are certain areas of work that put the patient at risk of injury, or other people at risk. My general recommendations are to avoid any line of work where driving is a part of work, or working with heavy machinery. There are a few professions restricted for a seizure patient, including driving a truck or a bus, flying a plane, or similar type of work with heavy machinery. I have treat seizure patients with multiple professions including doctors, lawyers, nurses, teachers, preachers, and many others. For a younger patient with seizure disorder, it is important to plan life accordingly.

Other than medicines, are there any other treatments effective for epilepsy?

Other than medicines, there are a few treatments for epilepsy but they are generally used in patients when medicines do not work well. More common are insertion of a device in the neck area called Vagus Nerve Stimulator or VNS, and specialized epilepsy surgery. There are some upcoming promising surgical procedures that are not widely available at this time.

What is a VNS or Vagus Nerve Stimulator?

Vagus is a large nerve in the neck area. In this procedure, a wire is looped around the nerve, and the other end of the wire ends in a small metallic unit. This metallic unit has a battery and small computer chip. The unit and the wire are inserted under the skin by doing a small surgical procedure. The unit is controlled from outside by electromagnetic communication, like a Wi-Fi. When the unit is turned on, it sends low-voltage electrical signals to the nerve, and through the nerve to the brain. The unit turns on ever few seconds and the signal last for a few seconds too. Once the unit is fully turned on and functioning, it helps to control seizures. It may also have some antidepressant effect.

Usually, there are no serious side effects from this procedure, other than associated with any surgical procedure. The electrical signal can cause scratchy feeling in throat or difficulty speaking, but this can be managed by adjusting the signal strength. Its battery can last for a few years, after which a similar procedure is needed to replace the battery. VNS alone seldom controls epilepsy; it is one of the additional tools used with medicines for better control.

What is epilepsy brain surgery?

As I described above, seizure disorder is caused by an abnormality of electrical circuitry in the brain. Sometimes, depending upon the location of this abnormality, a small part of brain can be resected or removed to stop seizures altogether. This procedure is not for every seizure patient, and it does not help in all seizure or epilepsy types. But in very carefully selective patients, it can be a very useful procedure. It is considered for patients with partial onset seizures, which means that their seizures start as partial and then may become complex-partial or generalized. Also, the location in the brain where seizure originates has to be in a surgically reachable area, and not in an area controlling any critical function (e.g., language control area).

If a neurologist considers this treatment option for a patient, the patient is referred to a specialized epilepsy center. Patient goes through a series of tests involving multiple EEGs, MRIs and some other types of brain imaging. The purpose of these tests is to precisely localize the area of brain triggering seizures. A neuropsychological test is also done. A comprehensive team including neurologists, radiologists, psychologists, and neurosurgeons carefully evaluate the data, and select the right patient for the procedure. After the procedure, the patient may go back to his/her regular neurologist and may continue taking medicines; sometimes much less than before the surgery, and sometimes none. This is done carefully with close clinical monitoring.

Common complications of this type of surgery are forgetfulness, change in personality, or sometimes lack of full control of seizures. In rightfully selected patients though, it can be an extremely useful procedure. In fact, because epilepsy centers are not easily accessible for a lot of patients, and because of insurance and financial reasons, this treatment is relatively under utilized.

What is neuromodulator treatment for epilepsy?

It is also called Responsive Neurostimulation treatment. In this surgical procedure, a patient is selected in similar manner as in epilepsy brain surgery, but instead of removing a part of brain a tiny electronic unit is placed close to the area of the brain where seizure originates. This unit can detect minute changes in brain electrical activity and can detect a seizure before it causes any symptom. Once it detects abnormal seizure discharge, the unit automatically sends a neutralizing electrical discharge and stops it from spreading. Patient selection criterion and testing for this procedure are similar to the brain surgery procedure. Because it does not involve removing a part of the brain, its side effect profile is better than surgery. Hopefully, as technology gets cheaper, it may become widely available.

I have been taking older seizure medicines for years, do I need to change them to newer ones?

Generally speaking, if seizures are controlled by the medicine prescribed with no side effects, it is not prudent to make any change.

Epilepsy in women

Monthly hormonal cycles in young women can affect seizure control. Similarly, the medicines prescribed for seizure control can affect hormonal cycle. Sometimes these issues are significant requiring adjustment in seizure medicines, or the mean of contraception. These issues are less significant after menopause. The issue of pregnancy is discussed separately.

Pregnancy and seizure disorder

Pregnancy and the time of breastfeeding are biologically special states in a woman’s life. Hormonal changes and changed metabolism can affect seizure control and level of seizure medicine in her blood. Briefly, following are some of the commonly asked questions:

A: Can I get pregnant with epilepsy?

Yes, but it should be a planned pregnancy after discussing any potential issues with an obstetrician and a neurologist. It is best to do that before any unprotected sexual intercourse to prevent any possible harmful exposure to the fetus.

B: Are there any seizure medicines completely safe to take during pregnancy?

No seizure medicine has been proven to be completely safe to take during pregnancy, because of lack of clinical trial data with pregnant patient. Our knowledge about medicines in pregnancy is based upon many years of collective experience using them. This type of evidence is not perfect but that is what we have. Based upon this type of knowledge, some medicines should clearly not to be used during pregnancy. For many others, data is inconclusive, and it is impossible to say if they are harmful or completely safe. The goal usually is to avoid a larger problem by taking a calculated risk, a risk that may not be completely avoidable.

In general it is best to avoid all chemicals during pregnancy, especially during the first 4 months. Because a seizure itself may also cause harm to the patient or the fetus, instead of stopping completely, the safest possible medicine is prescribed. Many times patient may require some kind of dose adjustment during pregnancy.

C: Can I breast-feed with medicines?

With some medicines yes, and with many others it is not recommended.

Do I have to take seizure meds all my life?

It depends upon the type of seizure disorder and the reason for seizures. Some seizures seem to stop after a certain age and when the medicine is stopped. In every case, a risk assessment analysis is done; if the risk is permanent, it is better to continue taking the medicine. If someone taking seizure medicines do not have any seizure like symptom for many years, one may try to slowly taper off the medicine off. But this is done after fully understanding the risks and benefits.

Do travel or traveling in a plane increase risk of seizures?

Indirectly, it may. During travel one may be stressed and relatively sleep deprived, which can increase chances of having a seizure. One should be extra careful taking medicine on regular intervals, especially when traveling across time zones, and sleep on regular basis.

What are the so-called pseudo-seizures or non-epileptic spells?

Pseudo-seizure is an improper term and should be avoided. Sometimes patients have symptoms that look like a seizure, like shaking, confusion, or passing out, but not from epilepsy. If no other medical reason is found, these episodes may be called non-epileptic spells or non-epileptic convulsions. An EEG is used to make the correct diagnosis. Unlike a patient with epilepsy, a patient with non-epileptic spells has normal EEG during the attack or while having symptoms.

What is the cause of non-epileptic spells?

Possible causes include syncope, Transient Ischemic Attack or TIA, migraine, drug use, movement disorders, or psychological reasons.

How are non-epileptic spells treated?

If the reason is something like syncope, a TIA, migraine, or a movement disorder, appropriate treatment is recommended for the right diagnosis. More difficult are the spells triggered by psychological reasons. It requires psychoanalysis of the patient’s life and environment, and its management. Medicines seem not to help for this diagnosis.

Where can I get more information about seizures and epilepsy?

A: American Academy of Neurology
B: American Epilepsy Society
C: Child Neurology Foundation
D: Centers for Disease Control and Prevention