Epilepsy is a neurological disorder that alters the brain activity, resulting to seizures or periods of abnormal behaviour, sensations and occasional loss of consciousness. Two spontaneous seizures at least are generally needed for an epilepsy diagnosis and confirmation. Epilepsy manifests in various ways. During an attack, it can make some people to stare aimlessly for few seconds and others to exhibit twitching of arms or legs repeatedly.
In the developing countries, 75% cases of epilepsy are either untreated or improperly treated partly due to inappropriate, unavailable or expensive drugs. Epilepsy has no cure, but it can be controlled with medications and other strategies. “Treatment” of epilepsy varies. Medications, surgery, lifelong treatment and spontaneous disappearance are ways seizures can be controlled for the majority of people. Some children may outgrow the condition with age. Seizures resulting from low blood sugars, for example, could be prevented by careful management and prevention of hypoglycemia (low blood sugar). Seizures related to progressive medical conditions such as brain tumors or metabolic conditions may be difficult to control and may have a poor outcome in response to therapy. Epilepsy does not affect childbearing ability. But some epilepsy drugs can affect the fetus. During pregnancy, medications should be continued under expert medical advice, counseling and monitoring.
Presently, epilepsy is of significant public health implications, as around 70 million people worldwide are under the attack of epilepsy. The organizations that provide support internationally for people and families affected by epilepsy are: The Out of the Shadows campaign ( a joint effort by the World Health Organization), the International League Against Epilepsy and the International Bureau for Epilepsy.
What is epilepsy or seizures?
Epilepsy is a condition in which a person experiences unprovoked, repeated sizures. It is a brain disorder associated with an increased susceptibility to seizures. Active epilepsy can be described as when someone had at least one unprovoked seizure in the last five years. When someone has been diagnosed with epilepsy it indicates that they have had a seizure (usually 2 or more) and they are considered to have an increased risk of future seizures due to a brain-related cause. The Centers for Disease Control and Prevention (CDC) describe epilepsy as “a common neurological condition characterized by recurrent seizures.”
A seizure is defined as an abnormal, disorderly discharging in the brain’s nerve cells, resulting in temporary disturbances of motor, sensory or mental functions of the brain. Also it is a varying brief and nearly undetectable episodes caused by transient disruption of brain activity that interferes with one or more brain functions. When people experience seizure it does not necessarily indicate that they have epilepsy because there are many possible reasons that could result to seizure. There are many types of seizures which primarily depend on part of the brain that is concerned and the patient’s age.
For the purpose of general basic understanding, epilepsy and seizure are used interchangeably in this document. Therefore, epilepsy or seizures (in Greek means “to seize, possess, or afflict”) is chronic neurological condition resulting to sudden recurrent episodes of sensory disturbance, loss of alertness or convulsions due to abnormal surge of electrical activity in the brain cells. It is regarded as a group of unusual disorderly discharging occurring in the nerve cells of the brain, causing temporary disturbance of motor, sensory or mental function. Epilepsy occurs in a number of other animals including dogs and cats; and it is the most common brain disorder in dogs. The highest numbers of new cases are in seniors and young children, but epilepsy can begin at any age. About 5–10% of people will have an unprovoked seizure by the age of 80, and the chance of experiencing a second seizure is between 40 and 50%.
There are two main types of seizures or epilepsy. Generalized seizures affect both hemispheres of the whole brain. Focal or partial seizures happen in just one part of the brain.
A mild seizure may be difficult to recognize. It can last a few seconds during which you lack awareness because of sudden surge of electrical activity in the brain that cause a temporary disturbance in the messaging systems between brain cells.
The prevalence of epilepsy
The oldest medical records indicate that epilepsy has been affecting people since the beginning of recorded human history. The World Health Organization (WHO) estimates that epilepsy affects 50-65 million people, resulting to about 40 million deaths globally. It is reported that epilepsy affects 1% of the population by age 20 and 3% of the population by age 75. Generally, epilepsy is most likely in children under 2 years and adults over 65 years of age. Most of those with the disorder (80%) are in the developing world. In the developing world its onset is more in older children and young adults due to the higher rates of trauma and infectious diseases. In the developed nations epilepsy most commonly starts either in the young or in the old. Epilepsy can occur in any male and female of all races, ethnic backgrounds and ages. It can affect several parts of our lives. Globally, anyone can develop epilepsy, but it is most common in young children and older adults. It is more prevalent in males than in females. In 2013, researchers from the University of Oxford and University College London in the U.K. reported that people with epilepsy are 11 times more likely to die prematurely, compared with the rest of the population. The risk appears to be greater in patients with mental illness. Epilepsy-related falls or status epilepticus, suicides, accidents, assaults and sudden unexpected death in epilepsy (SUDEP) are common, accounting for about 17.8% of untimely deaths especially among the elderly.
Causes of epilepsy
Epilepsy has no present identifiable or well understood cause(s) but in most cases, the disorder may be traced to various health problems, genetic and acquired causes which mainly include:
- Brain conditions: Such as brain tumors or cyst or strokes can cause epilepsy. Stroke is a major cause of epilepsy in adults above 35 years of age. Scarring in the brain after brain injury can cause post-traumatic epilepsy. Epilepsy may begin weeks, months or years after an injury inside the brain.
- Infections: Diseases such as meningitis, dementia, Alzheimer, AIDS and viral encephalitis can cause epilepsy. Serious illness or very high fever; and other vascular and neurological diseases can cause epilepsy.
- Pre/postnatal injury: Before birth, babies can be exposed to brain damage caused by several factors like infection from the mother, poor nutrition or oxygen deficiencies. Also during and after birth, poor management of mothers with epilepsy can cause fatal brain injuries to babies. The brain damage can cause epilepsy or cerebral palsy. Also maternal drug use/abuse can cause brain malformation at birth resulting to epilepsy.
- Heredity factor: Some types of epilepsy, which are classified by the type of seizure they exhibit or the part of the brain involved, run in families. Some researchers have linked some types of epilepsy to specific genes. Certain genes may expose a person to environmental conditions that trigger seizures.
- Head trauma: Head trauma occasioned by car accident or other traumatic injury may result to epilepsy.
- Structural developmental disorders: Sometimes epilepsy can be linked to developmental disorders such as autism and neurofibromatosis. Epilepsy due to a structural abnormality may begin early in life, during adolescence or in adulthood.
- Chemical imbalance: Such as low blood sugar or sodium and certain toxic chemicals or drugs of abuse can cause epilepsy.
Risk factors of epilepsy
Definite modifiable and non-modifiable factors which may increase the risk of epilepsy are:
- Stroke and other vascular diseases. Stroke and other blood vessel (vascular) diseases can lead to brain damage that may trigger epilepsy.
- Dementia. Dementia increases the risk of epilepsy in adults.
- Brain infections. Infections such as meningitis which causes inflammation in the brain or spinal cord can increase risk of epilepsy.
- Age. Though epilepsy can occur at any age but it is most common in children and the elderly.
- Family history. Family history of epilepsy may increase the risk of developing seizure disorder.
- Head injuries. Head injuries or trauma increase the risk of some cases of epilepsy.
- Seizures in childhood. The risk of epilepsy increases if a child has long seizure, other nervous system problems or a family history of epilepsy. Sometimes childhood high fevers can be associated with increased risk of seizures.
- Poverty. It is believed that poverty or residing in a poor country or community increases the risk of epilepsy.
- Dietary problems. Such as very low blood sugar and alcohol withdrawal increase the risk of epilepsy.
Complications of epilepsy
Having an attack of seizure at certain times can lead to adverse circumstances or life-threatening complications. The rare but possible complications of epilepsy include:
- Falling: If fall during seizure occurs, there may be head injure or trauma or bone fracture.
- Drowning: A patient who experiences a sudden attack of epilepsy while swimming or bathing inside a large body of water can drown if there is no immediate reliable help.
- Accidents: A seizure attack while driving or operating other machines can cause either loss of awareness or control leading to dangerous or fatal accidents.
- Pregnancy problems: Epilepsy or seizure that happen during the periods of pregnancy can pose many dangers to both mother and baby. Also certain anti-epileptic medications can cause major birth defects and complications.
- Emotional health issues: Epilepsy often gives psychological problems, especially depression, anxiety and suicidal tendencies and behaviours.
- Status epilepticus: This condition of severe seizures that lasts for more than five minutes can result to permanent brain damage and death.
- Sudden unexpected death in epilepsy (SUDEP): Researches show that epilepsy can cause sudden unexpected death which may result from heart or respiratory problems; frequent tonic-clonic seizures or medications failure.
Effects of epilepsy
Epilepsy can have adverse consequences on neurobiological, cognitive, social, economic, cultural and psychological well-being of people. These consequences or effects may include social isolation, stigmatization or learning disability especially among children who equally express uncertainty and withdraw in their lives. It is observed that epilepsy is more common in children with autism. There may be low educational achievement leading to worst employment outcomes. The epilepsy stigma can affect the families of patients with the disorder.
Generally, epilepsy can affect many aspects of a patient’s life including emotions, behaviour, social development, interactions or relationships, and ability to study or work. In many parts of the world, people suffering from epilepsy have certain restrictions placed on their ability to drive. Some people present changes in behaviour (epileptic aura) as a result of abnormal brain activity, shortly before a seizure. These changes could be feeling of inattentiveness, irritability, hyperactivity and aggressiveness.
Triggers of epilepsy
People with epilepsy especially, are able to identify most commonly reported seizure triggers which are:
- Lack of sleep or stress.
- High fever or illness.
- Sudden noise.
- Bright lights, flashing lights or patterns.
- Caffeine, alcohol or drugs prone to abuse.
- Skipping meals, overeating or specific food /ingredients (high glycemic or refined carbohydrate foods such pizza, soft drinks, white bread/rice, cakes, chips, mango, banana, dates, potato, monosodium glutamate, excess ginkgo nuts).
Classes of epilepsy
Generally there are three descriptions of epilepsy or seizures, depending on where the abnormal brain activity started. They are generalized, secondary generalized and partial seizures with focus on the underlying causes. Epilepsy has a range of severity depending on the individual. The classes of epilepsy or seizures are:
A generalized seizure happens when both hemispheres of the brain experience epileptic activity. Without warning, the patient loses awareness while the seizure is in progress. The six types of generalized seizures are:
- Tonic-clonic seizures (grand mal seizures): This may be the most dramatic and well known type of generalized seizure. They cause abrupt loss of consciousness, body stiffness and shaking. Sometimes loss of bladder control and biting of tongue are observed. The seizures occur with contraction, then the extension of the limbs along with backaches which lasts 10–30 seconds (the tonic phase). There may be a cry caused by the contraction of chest muscles, followed by a uniform shaking of the limbs (clonic phase).
- Absence seizures (petit mal seizures): Here clusters and short lapse in consciousness is observed as the affected individual appears to be staring off into space. It often occurs in children and causes subtle and slight body movements such as turning of the head or eye, blinking or lip smacking. Often response to treatment is good.
- Tonic seizures: They cause muscles stiffness and may cause falling spell. These seizures usually affect muscles of the back, arms and legs. This type of seizure often produces constant contractions of the muscles and turns the patient blue as breathing stops.
- Atonic seizures (drop seizures): Typically involve the loss of muscle activity for greater than one second, which may result to sudden collapse or fall due to loss of muscle control on both sides of the body.
- Clonic seizures: This is associated with repeated or rhythmic, jerking muscle movements of such as the neck, face and arms. Also limbs shake in unison here. At the end of the shaking, the patient may return to normal after about 10–30 minutes. During the seizure, there may be loss of bowel or bladder control and biting of tongue either at the tip or on the sides.
- Myoclonic seizures: Usually appear as sudden momentary jerks or twitches of the arms and legs. This seizure involves spasms in either a few areas or all over the muscles.
Secondary generalized seizure
A secondary generalized seizure occurs when the epileptic activity begins as a partial seizure, but later spread to both hemisphere of the brain. As this develops, the patient loses consciousness.
A partial seizure happens when the epileptic activity occurs in a part of the brain. There are two types of partial seizure:
- Simple partial seizure: Here the patient is conscious during the progress of the seizure. Often, the patient is aware of what goes on in the surroundings. There may be altered emotions, perception, smell, feel, taste or sound. Involuntary jerking of body parts such as arms or legs, and spontaneous sensory symptoms such as tingling, dizziness and flashing lights are common presentations.
- Complex partial seizure: The consciousness of the patient here is altered. Generally the seizures involve a change or loss of consciousness or awareness where the patient can hardly remember the seizure. This seizure may cause patient to stare into space and not respond normally to the environment or perform repetitive movements such as hand rubbing, chewing, swallowing or walking in circles.
Signs and symptoms of types of epilepsy
Seizures are the main symptom of epilepsy. Signs and symptoms differ from person to person and according to the type of seizure. The epilepsy types- related signs and symptoms include:
Focal (partial) seizures
A simple partial seizure does not cause loss of consciousness. It presents signs and symptoms of:
- Alterations of sense of taste, smell, sight, hearing or touch.
- Tingling and twitching of limbs.
Complex partial seizures cause loss of awareness or consciousness with signs and symptoms of:
- Staring blankly.
- Short periods of unresponsiveness to instructions or questions or temporary confusion.
- Inappropriate repeating of movements.
The six types and their signs and symptoms include:
Absence or petit mal seizures:
- Blank stare.
- Sudden bouts of lip smacking or blinking without apparent stimuli.
- Short spells of blackout or confused memory or loss of awareness.
- Muscle stiffness.
- Loss of muscle control.
- Sudden fall for no clear reason.
- Uncontrollable jerking movements of the face, neck and arms muscles with no temperature or fever. In babies this will appear as a cluster of rapid jerking movements.
- Fast involuntary arms and legs twitching.
Tonic-clonic or grand mal seizures:
- Sudden body stiffness for no apparent reason.
- Fear or panic or anger for no obvious cause.
- Intermittent fainting spells, during which bowel or bladder control is lost, which is frequently followed by extreme tiredness.
- Biting of the tongue.
- Short time daze or loss of communication or awareness.
Diagnosis and treatment of epilepsy
Diagnosis of epilepsy can be difficult because other conditions that might present similar signs and symptoms must be carefully ruling out. An effective medical diagnosis of epilepsy or seizures which have repeated two or more times is based on multiple pieces of information on: the description of the episodes, the patient’s medical and family history and the results of laboratory tests. Basically, the diagnoses are idiopathic, cryptogenic and symptomatic presentations during early childhood or after age 60.
Fortunately, epilepsy or seizures is treatable. However, it is very difficult to cure unless early treatment is initiated. Generally, it can be successfully managed. Seizures treatment plan will be based on severity of signs and symptoms, patient’s health status and response to therapy for an improved quality of life. The first-line or mainstay treatment for epilepsy is the strict use of the prescribed anticonvulsant or antiseizure drugs possibly for entire life. The choice of anticonvulsant is based on seizure type, epilepsy syndrome, drug interactions, other health problems; and the patient’s age and lifestyle. Anticonvulsant drugs help to reduce the frequency and severity of seizures in about 70% of cases. They neither stop a seizure already in progress nor cure epilepsy. Often, four out of five people will achieve good seizure control with medications. Not all cases of epilepsy are lifelong; many can improve to the point where treatment is no longer necessary.
When medication is ineffective in preventing seizures, there are other available treatment options which can restore patients to normal, active and productive life. Surgery, neurostimulation or dietary modifications may then be considered. Researches into new treatment options are ongoing. Epilepsy surgery may be a good option for people with focal seizures that persist despite other treatments. The goal of surgery is to totally control seizures; and this may be achieved in 60–70% of cases.
Prevention and management of epilepsy
Many cases of epilepsy are not preventable but efforts are made to reduce head injuries, provide good child care during birth; and reduce environmental parasites such as the pork tapeworm, thereby decreasing new cases of epilepsy. If the seizures are occasioned by another medical condition, the key to preventive measure is to identify and treat that medical condition. Alcohol, sleep deprivation and stress should be avoided.
People’s self management of their seizure conditions should be supported. Different management options such as special diet, implantation of a neurostimulator or neurosurgery should be carefully considered in drug-resistant cases. The prescribed anticonvulsant drugs should strictly be taken and completed as recommended on the schedule. A patient with an active tonic-clonic seizure can be rolled sideways and into a recovery position to prevent fluids from getting into the lungs. The initially recommended home medication for seizure that lasts a long time is midazolam placed in the mouth before the patient is taken to the hospital for intensive care.
Precautionary measures to reduce impact of epilepsy
- Since seizures period is unpredictable, keep your hospital visits regular and follow your counseling and treatment plans.
- Seek emergency medical attention if seizure lasts for more than five minutes and a second one follows immediately with injury or when breathlessness or unconsciousness persists after seizure.
- Limit your intake of alcohol, avoid cigarettes, eat healthy diet and exercise regularly.
- Wear a seat belt while riding inside a car and protect your head with helmet while cycling, skiing or engaging in other risky activities that can expose your head to injury.
- Epilepsy does not stop women from giving birth to healthy babies but your pregnancy should be carefully planned and monitored; and your medications adjusted to suit your condition.
- Identify preventable seizure triggers and avoid them.
- Wear a medical alert bracelet to enable people know how to help in case of sudden seizure attack.
- Teach close relations about seizures and what to do during emergency.
- Seek expert medical advice on how to manage epilepsy -induced depression or anxiety.
- Join Epilepsy Support Group to share soothing experiences.
Diets for epilepsy
- Ketogenic diet: Researches show that more than half of the people with epilepsy who hardly respond to medications benefit from this high fat, low carbohydrate and adequate-protein diet which appears to reduce the frequency or number of seizures and eliminate seizures in some patients. Also it is said to be a reasonable option for patients who are not ready to undergo surgery. This diet is often recommended for children with epilepsy. Children on this diet must be carefully monitored by a nutritionist or dietitian who will strictly balance the amounts of fats, carbohydrates and protein in the diet. The ketogenic diet foods include red meats, poultry, whole egg, bacon, beef tallow, dark and leafy vegetables (asparagus, broccoli, celery, garlic, onions, mushrooms, lettuce), butter, avocado and nuts (macadamia, walnuts, almonds, cashews, pistachio; avoid peanuts). Other ketogenic diet foods are Omega 3’s from tuna/fish or supplements, shellfish, dairy products, seeds, beverages (coffee, herbal teas, cocoa), fats (chicken fat) and oils (coconut and olive oil). Ketogenic diet can cause dehydration, so keep yourself hydrated by drinking 3-5 litres of water daily.
- Gluten-free diet: A gluten-free diet may equally decrease the frequency of seizures. The gluten-free diet includes naturally gluten-free food such as meat, fish, seafood, eggs, milk and dairy products, nuts, legumes, fruits, vegetables, potatoes, pseudocereals (amaranth, buckwheat, chia seed, quinoa), grains (corn, rice, sorghum), cereals (fonio, Job’s tears, millet, teff), other plant products (arrowroot, mesquite flour, sago, tapioca).
- Modified Atkins diet: For about half of adolescents and adults with epilepsy, a modified Atkins diet may be recommended. Also this diet which reduces seizures in few months, involves intake of high fat and controlled quantity of carbohydrates. Modified Atkins diet is made up of fatty foods such as bacon, eggs, mayonnaise, butter, meats, heavy whipping cream and oils. Vegetable oils, chicken, eggs, fish, nuts, fruits, avocados, olives, cheeses, diet soda, flavored waters, blueberries or chocolate. Also, seafood salad with orange and honey dressing has promising effects on people with seizures.
However it is good to mention that constipation is a common side effect of these diets because of their low fiber and high fat content.