Epilepsy. Diagnostics, Therapy & Surgery
What types of treatment are available for epilepsy?
In cases where people have occasional single epileptic seizures, which occur with very long intervals of time between them, or where seizure have clearly identified triggering causes, anti-epileptic therapy is generally delayed. Long-term pharmaceutical anti-epileptic therapy is only commenced once a firm diagnosis of epilepsy has been made.
The reasons for treating epilepsy.
There may be many different reasons behind a doctor's decision to advise, and for the parents to agree to a particular course of therapy for a child's epilepsy.
If any of several of the following factors applies to your child, these would be good reasons to consider treatment:
- Your child has repeated seizures
- An EEG scans reveals definite and clear changes in the child's brain.
- The child's epilepsy is having a limiting effect on their life.
- Not treating the epilepsy is extremely likely to cause negative consequences for the child's development.
- The child is at risk of being injured during seizures (e.g. because of the sudden loss of consciousness or from injury during falls).
Treatment objectives in epilepsy.
Before beginning a course of treatment it is sensible to think about the treatment objectives because there are many different possible objectives to aim for. Treatment objectives will be determined in joint discussions by doctors, parents and, as far as possible also by the child affected.
Therapy objectives could be:
- Freedom from seizures
- less frequent or milder seizures
- to avoid injury during seizures
- to have as few limitations as possible in everyday life
- the lowest possible number of side effects from the treatment and no disruptions to the child's normal development
- improvement in quality of life.
- It is important to formulate realistic objectives so as to reduce the risk of being disappointed. Freedom from seizures is not always the primary therapy objective.
Individual therapy strategy in a case of epilepsy.
Once the treatment objectives have been determined, the therapy is planned. Various treatment options are available, depending on the form of epilepsy, the progress of the condition and the family situation. The first line of treatment for epilepsy is with pharmaceutical medications. There are, however, other treatment options available: Because of the other problems associated with epilepsy a limitation to treatment of the seizures alone is in many cases insufficient. Treatment should therefore be holistic and include counselling and training.
Treatment options in epilepsy.
- Pharmaceutical therapy
- Counselling (social support etc.)
- Surgical therapy
- Vagus nerve stimulator
- Ketogenic diet
- Psychotherapeutic procedures: Self-control of epileptic seizures, biofeedback, natural healing methods / homeopathy
Epilepsy. Diagnostics, Therapy & Treatment
Diagnostics. How is epilepsy identified?
The decisive factors in the diagnosis of epilepsy are:
1. Case history, including description of a seizure
2. Neurological investigations
- EEG (Electroencephalogram which measure electrical current or activity within the brain)
- MRI (MRI is an abbreviation of Magnetic Resonance Imaging - also known as Nuclear Magnetic Resonance Imaging - NMRI). In this process measurements are made in a strong electromagnetic field)
- PET, Spect ( PET = Positron emission tomography) and SPECT = Single Photon Emission Computed Tomography: These are two types of investigation in which short-lived radioactive isotopes are introduced into the body. Their progress through the body can be used to measure cerebral blood circulation and metabolism).
- Occasionally, blood investigations and lumbar puncture may be used in the diagnosis of epilepsy. In lumbar puncture (LP) cerebrospinal fluid (CSF) is drawn off through a special spinal needle which is inserted into the spine. This fluid is then analysed. In febrile convulsions this procedure is primarily used to exclude the existence of an inflammation of the meninges of the brain (meningitis) or of the brain itself (encephalitis), either of which could also be the cause of the seizures. Other rarer conditions which can cause seizures can also be diagnosed using this procedure.
Pharmaceutical therapy, ketogenic diet.
What are the properties of an ideal antiepileptic medication?
- The best possible effect on the condition (e.g freedom from seizures)
- Ease of use (e.g. medication to be taken just once a day, pleasant tasting, small pills)
- Absence of side-effects and risks from medication
- Targetted doses to prevent individual seizures (not a permanent long-term therapy)
Targeted use of medications during an epileptic seizure.
The targeted taking of medication to prevent individual seizures from occurring is usually not possible for two reasons: Often it is not possible to say when the seizures are about to occur. When they do occur it often happens very quickly. This is why the medications have to be taken regularly every day of the year, even if the person only actually has seizures on five or ten days of the year.
Delayed, dosis-dependent effect.
In the case of medications which are well tolerated by patients, it will sometimes take a few weeks or even months until they begin to have a reliable effect on the seizures. The effectiveness of many anti-epileptic medications depends on the dosage taken! Generally speaking, these medications have to be taken regularly and over a long period of time. This is true even when the seizures begin to disappear under the effects of the therapy. As a general rule, patients will have to continue taking medication for at least another 1-2 years after they stop having seizures.
Medications and their active ingredients used in epilepsy.
A distinction is usually made between the "older" and the "newer" types of antiepileptic medication (or "anticonvulsants"). The so-called new types of anti-epileptic medication have been available since the nineteen nineties. They are the result of years of targetted development work whereas the effects of the older medications tended to be disovered by chance. Many of the newer medications have now been licensed for several years for use by children too. Amongst the older medications there are many very well proven drugs which are still frequently used today. The use of some of the other older drugs has generally declined, however, because of the range of side effects which they produce. There have also been many positive results using the newer medications so that we can say that they have definitely extended the opportunities for providing effective therapy for epilepsy. They have produced a real change for may children who have had great difficulties in their treatment. The various types of anti-epileptic medication have different levels of effectiveness against the different types of seizures.
The choice of medication is based on:
- the types of seizures
- forms of epilepsy ("epilepsy syndromes"),
- the causes of epilepsy
- the age of the child,
- how easily the medication is tolerated by the patient,
- possible preceding or accompanying conditions,
- any previous antiepileptic treatment which the patient has had,
Therapy is usualy commenced using the "medication of first choice." This is a medication which has been shown to be particularly effective and easy to tolerate for the particular form of epilepsy which the patient has. Because patients each react in often very different ways to a particular medication, however, it is not always possible to guarantee that this will be successful. If a particular therapy is not effective the doctor will try using a different medication.
The use of every further type of medication means, on the one hand having a new therapy option and therefore a greater chance of successful treatment, but on the other it means that every time a patient changes to a different type of antiepileptic medication the group of patients who can be described as being symptom-free becomes smaller. Every change of medication can be difficult and tiring for a patient. It can also lead to a deterioration in the success in the management and control of seizures which has already been achieved. Prior to any change of medication, therefore, the therapeutic objectives should be reassessed to ensure that the expenditure is in proportion to the anticipated benefits for the patient. The possibility of using non-pharmaceutical treatment strategies should also always be explored.
Treatment of individual epileptic seizures/"emergency medication".
Additional medications are available which are desigend to interrupt the course of an epileptic seizure. Once these have been prescribed by a doctor they may given to children by their parents or other primary carers (teachers or guardians). These drugs are only to be administered during an emergency. As a general rule, epileptic seizures stop of their own accord without the need for the administration of emergency medication. Emergencies which require the administration of emergency medication are primarily seizures which last for a very long time and which threaten to develop into a so-called "status epilepticus" (this is a seizure or a continuous series of seizures which lasts for more than 20 minutes). Unless anything to the contrary has been agreed by a patient who suffers from epilesy in consultation with his doctor and relatives, in the event of a seizure or series of seizures lasting more than 3 minutes, medication should be administered to interrupt the course of the seizure(s). In most cases this medication will be one of the benzodiazepines. The precise procedure for dealing with this type of emergency should, if possible always be discussed by the patient and his doctor. The emergency procedure should also be clear to any non-medical people who come into contact with the patient even if they do not know him personally. In these circumstances it is particularly useful if the patient carries a so-called "emergency passport" with him at all times.
Natural remedies / Homeopathy in Epilepsy.
Parents are also becoming increasingly interested in the possibilities of using natural remedies or other alternative therapies for treating their children's epilepsy. Parents are right in wishing to explore these options and they should discuss them with their children's doctors. These procedures could prove a useful supplement to the standard treatments for epilepsy but they are no replacement for treatment using antiepileptic medication. Alternative treatments which have proved successful include, for example, homeopathy, acupuncture, herbal remedies and dietetics. What these treatments have in common is that they are based on a common traditional experience and a holistic approach to medicine which aims at achieving a balanced regulation of the body's natural processes. The primary objective of these treatments is not a specific and perhaps isolated treatment of a particular symptom, but the emphasis is rather on activating and strengthening the body's own abilities to regulate itself. These approaches therefore stress the importance of careful attention to nutrition, simple living, maintaining a healthy environment and attention to breathing and movement. The emphasis which is placed on these factors is little different from the recommendations which the practice of social medicine makes in relation to epilepsy, namely that the following factors are important as an adjunct to treatment with pharmaceutical medications: Adequate sleep, a consistent daily routine, movement, healthy nutrition and an anxiety free mood. If a child with epilepsy becomes ill he or she will also have specific types of treatment and medications.
Ketogenic diet in epilepsy.
A ketogenic diet is recommended in cases where medications have not been sufficiently effective in controlling a patient's epilepsy, anti-epileptic surgery is not possible and/or the epilepsy is extremely likely to have a negative impact on the child's development.
Process of the diet.
This diet creates a condition in the body which is similar to that produced by prolonged fasting. This is achieved by encouraging the body to consume a diet which contains a large proportion of fat. This type of diet must be commenced in a hospital because making such a fundamental change in the patient's diet is not without risks. Prior to commencing this diet the patient must undergo a period of fasting.
When the diet commences every meal must consist of 80% fat. Each meal is usually made up of four parts of fat, one part of carbohydrate and one part of protein. The ingredients must be carefully selected and weighed in accordance with strict rules. It is essential for the child's parents to undergo a short course in nutrition advice to ensure that they know how to prepare tasty meals for their children in the correct way.
This diet must be consistently adhered to over a period of 1-2 years. Every item of food which is eaten which is not part of the diet and every other mistake in keeping to it can break the whole condition of fasting and can thus throw the success of the whole diet into doubt.
Around 30% of children on this diet will show a clear reduction of seizures in the first eight weeks, indicating that they are responding well to the diet. Recorded undesired side-effects include constipation, loss of appetite, nausea, fatigue, difficulties in concentration, kidney stones, growth problems, increased blood fat levels, eating disorders and other problems. Regular check ups with the doctor are therefore just as important with this kind of treatment as they are with normal therapy with pharmaceutical drugs. A ketogenic diet may be attempted in all forms of epilepsy. Younger children up to the age of about 6 tolerate the diet far better than older children, however.
Teenagers and adults are often more likely to dismiss the diet out of hand. Some of the disadvantages of this type of therapy are that it involves enormous additional expense, the child's intake of food has to be strictly controlled, the child has necessarily to assume a special position during family meal times which in itself can causes tremendous stresses in the life of the family.
Surgical treatment of epilepsy.
Surgery for the treatment of epilepsy is recommended in cases where the following conditions apply:
- At least two types of medication have not been sufficiently effective
- The cause of a person's epilepsy has been shown to be a localised change of tissue structure in the brain, such as a tumour, scarring or a malformation in the brain cortex or of a blood vessel in the brain.
- There must be no doubt that the seizures are originating from a point in the brain. In addition, this point of origin of the seizures must not control, or be immediately adjacent to a part of the brain which controls any of the brain's vital functions.
- It must be possible for the surgeon to be able to remove brain tissue without causing a greater injury to the brain.
It is currently estimated that around 5% of all people with epilepsy may benefit from this type of surgical treatment.
Extensive preliminary investigations must first be carried out. Two years after the operation the doctors will attempt to gradually discontinue the patient's medication.
Vagus nerve stimulation in epilepsy.
Vagus nerve stimulation is especially recommended when 2-3 different medications have not been sufficiently successful and surgery to treat the epilepsy is impossible.
During an out-patient procedure an electronic device the size of a flat box of matches is inserted into a a fold in the skin beneath the collar bone (similar to the insertion of a cardiac pacemaker). This stimulator sends out electrical impulses via a fine wire to the vagus nerve which relays them to the brain. The duration, strength and frequency of the impulses must be regulated step by step during the following treatment in such a way that the optimum effect on the seizures is achieved.
Few complications and side-effects.
Complications during this operation are rare. The most important undesired side effect of this procedure is that the child's voice is altered so that it sounds a little hoarser for the duration of the period of vagus nerve stimulation. In small children it is possible for this device to become slightly dislodged so that it is visible when the child is bare chested.
One desirable side effect of this treatment which has been reported is that vagus nerve stimulation may also have a positive impact on depressive moods as well as on epileptic seizures.
This treatment method may be used in both focal and generalised types of epilepsy. Patients who usually experience warning symptoms before a seizure can use a magnet to alter the settings of this device in specific ways. Sometimes they are able to disrupt the course of a seizure like this.
It is rare for vagus nerve stimulation to help patients become completely seizure-free. Significant reductions of between 50 and 70% in the numbers of seizures have, however, been frequently reported. One of the main advantages of this treatment is that it does not have any adverse interactions with anti-epileptics or other medications. The main disadvantage is, however, that another operation is required around 7-12 years after the first one in order to change the batteries in the device.
Therapy with medications also has to be maintained concurrently with this treatment.
Psychotherapy: learning self-control.
Psychotherapy: self-control of seizures in epilepsy.
In recent years behaviour-oriented therapy strategies have also been developed in Germany which are designed to develop and promote specific "self-control of epileptic seizures". These methods are usually used to supplement pharmaceutical therapies. They may also form part of a general psychotherapeutic treatment program for epilepsy.
Two basic approaches are used in the self control of seizures:
- Dealing with triggers of epileptic seizures and with other factors which promote seizures
- The use of specific methods to interrupt "auras" which some people experience prior to having a seizure
- Triggers and other factors which promote epileptic seizures
In some people particular triggers, e.g receiving a shock or seeing will almost always cause them to have a seizure (Reflex epilepsy -see Basic Knowledge). Many factors in the causation of seizures increase the likelihood of a seizure only in combination with other causal factors. This means that taken on its own, each causal factor will sometimes lead to the development of a seizure and sometimes will not lead to seizure. For example, a shock may not always trigger a seizure but may sometimes just lead to an increase in tension of fatigue. In such cases it is much more difficult to prove the link between the cause of a seizure and the seizure which it triggers.
A seizure diary may be helpful.
In order for a patient to be able to make the connections between his brain activity and seizure in a reliable way, very careful observations are required.
It may be useful for him to complete a "seizure diary" as a record of his observations and experiences of seizures. In keeping these records, the patient should not only ask what factors trigger or make seizures more likely, but in which situations do seizures never or only rarely occur?
These "stable life situations" are just as important for finding the best treatment as are the records of the seizures themselves. For example: It is suspected that lack of adequate sleep is an important factor in causing a patient's seizures. If it is then established that the patient actually does have significantly fewer seizures during periods when he gets regular sleep, this suspicion is confirmed.
Knowledge about a patient's stable life situations is useful for two reasons: It helps to avoid the necessity of limiting a child's life through unnecessary rules and prohibitions. These stable situations may also reveal a child's strengths and thus give indications about possible approaches for dealing with seizure-inducing situations. This will help to reduce the child's anxiety about seizures. Sometimes despite the best efforts of the child and his carers no clear triggers or other factors which induce seizures can be found.
Sometimes too the "suspected" triggers will turn out to be completely innocent. In any case, parents and carers must examine the circumstances very carefully before deciding to deprive a child of something which he loves in order to protect him from a possible danger of triggering seizures.
Prevention of seizures.
Once causal factors for epileptic seizures have been identified, the next step is to find ways of dealing with these situations which will promote the patient's health. Many causal factors for seizures are avoidable, such as flashing lights (dark glasses provide protection), while others are not. These include shock, changes in weather or recovery phases. Where it has been found that additional risk factors are at work in a person's epilepsy, e.g. sleep deprivation or stress, attempts may be made to influence these factors. Emotions, such as stress, anxiety and joy cannot be avoided but a person can learn to manage them better. Counselling or psychotherapy may play a part in helping a person to manage these emotions.
Interrupting an epileptic aura.
If a child's seizures begin with an aura there is another possible way to prevent a full-blown seizure: Interrupting the aura: Many people with epilepsy have personal experience of the techniques of interrupting an aura, often without even fully being aware that they are able to do this. The countermeasure specifically targets the nerve cells in the brain which are adjacent to the focus of the seizure so that it can be stopped from spreading to other areas of the brain. This means that the seizure is either interrupted or delayed giving the child time to reach a place where he will be safe if the seizure does follow.
Effective measures for interrupting epileptic auras.
The basic rule for taking effective "counter measures" to interrupt an aura which precedes a seizure is that an attempt should be made to do the "opposite" of the seizure symptoms. A tingling sensation, which may be the precursor to a seizure, may be countered by rubbing the arm or other part of the body where it occurs. An unusual taste in the mouth may be countered by putting a pinch of salt into the mouth and a sudden and intense perception of the colour red may be displaced by thinking as intensively as possible of the colour green.
EEG-Biofeedback as a strategy for interrupting seizures.
The development of strategies to interrupt seizures may be supported by EEG biofeedback procedures. In these the patient learns to create a wakeful and relaxed condition in his brain which is not compatible with the type of EEG (electroencephalogram) activity typically found during seizures.
The prospects for success in self-control of seizures.
Up until now we have had experience of these treatment methods being used by adults only. This is probably because they require the ability to observe one's own behaviour very carefully and to exercise great self discipline. They therefore place great demands on children and young adults. If parents are looking for ways to help their child to avoid or to shorten the duration of seizures it is a good idea for them to talk to psychotherapist who specialises in this field.
Psychotherapy helps patients to deal with their epilepsy better.
As with other conditions, epilepsy often imposes strong emotional and mental burdens on a person which can have a negative effect on the course of the condition. A course of psychotherapeutic treatment may therefore help a patient to reduce conflicts and anxieties and to learn to develop more effective behaviours for dealing with difficult situations. It can also help a person to better manage their condition and its consequences. Mental relaxation exercises can help to reduce the frequency of seizures, especially because these can help to reduce the child’s fear of his condition. Sometimes too a patient will learn over time how to use his medications in the best way so that their effectiveness is increased.
A course of general psychotherapy for the child is advisable if:
- there are indications that seizures can be triggered by especially stressful situations,
- the stresses caused by the seizures and their consequences are leading to emotional distress, such as increased anxieties, depression, aggression or psychosomatic complaints such as headaches or sleep disorders,
- if in addition to the epileptic seizures, the child also suffers disassociative seizures (or "non-epileptic attacks") which may be seen as being the result of an emotional conflict or stress.
If a child undergoes any form of psychotherapy the parents will generally be invited to take part in regular supplementary discussions with the therapists. This generally applies to teenagers too. When the problems arise more in the family's life together or if one family member is finding the situation particularly stressful, the emphasis of the child's therapy may be adjusted accordingly. When very young or severely disabled children are treated for epilepsy advice and counselling for the child's parents is usually a core component of the therapy. The sooner treatment begins, the greater the chances of a successful outcome.
Unfortunately there are not enough psychotherapists who have experience of counselling children with epilepsy and their parents.
The precondition for a successful course of psychotherapy is the willingness and ability of both child and parents to cooperate with the therapists. Unfortunately there are not enough psychotherapists who have experience of counselling children with epilepsy and their parents. If the doctors and psychotherapists cooperate closely with each other they will be able to overcome this difficulty. In Germany the statutory health insurance companies will pay for a psychotherapy course when the doctor says that this is necessary for clinical reasons.
These clinics are specialized in the treatment of epilepsy and epileptic seizures.