Epilepsy Treatment in Delhi, India

The most recent International League Against Epilepsy (ILAE) classification of epileptic seizures and epilepsies, published in 2010, revises past types using terminology and concepts appropriate for the modern era. Seizures are divided into three categories: generalised, focal (formerly called partial), and epileptic spasms. 

• Focal seizures originate in neuronal networks limited to part of one cerebral hemisphere.

• Generalised seizures begin in bilateral distributed neuronal networks.

• A seizure can start focally and later generalise. Seizures can originate in the cortex or in subcortical structures.

1. Focal seizures

   When consciousness is impaired during a focal seizure, the patient is unable to respond normally to verbal or tactile stimuli; the seizure is classified as dyscognitive (formerly called complex partial) seizures arising from the temporal lobe are often dyscognitive. Some seizures are preceded by an aura, a focal seizure wherein a patient retains awareness and describes motor, sensory, autonomic, or psychic symptoms. An aura precedes a focal dyscognitive or generalised seizure by seconds or minutes and is most often experienced by patients with temporal lobe epilepsy.

   Focal seizures can further be subclassified as those without loss of consciousness and seizures with altered awareness.

2. Focal seizures with no loss of consciousness

   Also known as simple partial seizures, as the name suggests, there is no loss of consciousness in these focal seizures. However, there may be an alteration in emotions or a change in the way things look, smell, feel, taste or sound. Sometimes there might also be an experience of déjà vu for the patient. Involuntary jerks in body extremities, that is, arms and legs, or spontaneous sensory alterations such as tingling, light flashes, or even dizziness are also known symptoms of focal seizures without loss of consciousness.

3. Focal seizures with altered awareness

   Also known as complex partial seizures, there is a change and/or loss of consciousness and/or awareness reported in these cases. Patients affected by these focal seizures may experience it as a dream. They may stare into space endlessly and not respond to environmental triggers. They may also indulge in repetitive movements, such as hand rubbing, chewing, swallowing, or walking in circles.

   Focal seizure symptoms may mimic other neurological disorders, migraine, narcolepsy, or mental illness, to name a few. A thorough examination and accurate diagnosis are needed to distinguish epilepsy from other disorders.

4. Generalised seizures

   The main subtypes of generalised seizures are absence, generalised tonic-clonic (GTC), myoclonic, and atonic. Absence seizures (formerly called petit mal) involve staring with unresponsiveness to external verbal stimuli, sometimes with eye blinking or head nodding. GTC seizures (formerly called grand mal) consist of bilateral symmetric convulsive movements (stiffening followed by jerking) of all limbs with impairment of consciousness.

   Myoclonic seizures consist of sudden, brief ("lightning-fast") movements that are not associated with any obvious disturbance of consciousness. These brief involuntary muscle contractions may affect one or several muscles; therefore, myoclonic seizures can be generalised or focal. Atonic seizures involve the loss of body tone, often resulting in a head drop or fall.

   Opposite to focal seizures, generalised seizures involve all areas of the brain.

These are further subclassified into six types-

1. Absence seizures

   Historically known as petit mal seizures, absence seizures are typically seen in children. A classical sign of absence seizure is that the patient stares into blank space, which may or may not be accompanied by subtle body movements, for example, eye blinking or lip smacking. These seizures typically last five to ten seconds. Absence seizures tend to occur in clusters. A frequency of as many as 100 times a day can be observed with this seizure, which may cause a brief loss of awareness.

2. Tonic seizures

   Stiffness of muscles and a loss of consciousness are typical signs of a tonic seizure. Muscle groups in the arms, legs, and back are the first to be impacted, leading to a loss of balance and a potential fall to the ground.

3. Atonic seizures

   These seizures cause a loss of muscle control and mostly affect the legs. This causes the patient to collapse suddenly. The seizures, therefore, are also known as drop seizures. 

4. Clonic seizures

   Clonic seizures classically show repeated or rhythmic muscle movements or jerks. The neck, face, and arms are the usual sites affected in clonic seizures.

5. Myoclonic seizures

   Sudden, brief jerks or twitches, usually affecting the upper body, arms, and legs, are termed myoclonic seizures.

6. Tonic-clonic seizures

   It can also be called the most dramatic of all seizures; tonic-clonic seizures were also known as grand mal seizures. Symptoms of this seizure include an abrupt loss of consciousness and body stiffening, twitching, and/or shaking. They may also affect visceral organs causing loss of bladder control or biting one's tongue.

Causes of epilepsy cannot be identified in half the people with the condition. However, the condition may arise due to various factors, including:

• Genetic influence

  Genetics may predispose one to certain types of epilepsy, categorised by the type of seizure experienced or the part of the brain that is affected. In these cases, it's likely that the particular epilepsy type runs in the family. Though genes are only a part of causative factors, researchers have linked certain kinds of epilepsy to specific genes. Some specific genes may predispose a person and make them more sensitive to environmental conditions that trigger seizures.

• Head trauma

  Injury to the head, as seen in road traffic accidents or other traumas, can also be a factor causing epilepsy.

• Brain abnormalities

  Brain abnormalities such as brain tumours or vascular malformations- arteriovenous malformations (AVMs) and cavernous malformations also contribute to epilepsy. In adults, especially over age 35, stroke is a leading cause of epilepsy.

• Infections

  Infections like meningitis, HIV, and viral encephalitis can cause epilepsy.

• Prenatal injury

  Even before birth, babies are sensitive to brain damage, and reasons such as infection in the mother, oxygen deficiency, or poor nutrition can lead to epilepsy or cerebral palsy. 

• Developmental disorders

  Developmental disorders such as autism are also contributing factors to epilepsy.

Other than the aforementioned causes, there are certain risk factors associated with epilepsy, such as:

• Age

  Children and older individuals are more prone to epilepsy. However, the condition can occur at any age.

• Family history

  A family history of epilepsy increases the risk of developing a seizure disorder.

• Lifestyle choices

  Intake of alcohol and smoking cigarettes can lead to vascular disorders that may eventually cause stroke or other blood vessel diseases responsible for epilepsy. Avoiding these triggers and eating a healthy diet and regular exercise can help reduce the chances of developing these diseases.

• Dementia

  Typically seen in older adults, dementia is also associated with epileptic attacks.

• Brain infections

  An inflammation in the brain, as caused by infections such as meningitis, may also increase the chances of developing seizures.

• Seizures in childhood

  Seizures are also seen in children who have had episodes of very high fever. This, however, does not always lead to epilepsy. The risk increases if there have been long-standing fever-associated seizures, an accompanying nervous system disorder, or a family history of epilepsy.

A seizure that starts in a specific part of the brain can cause different symptoms.

• If it starts in the back part of the brain (occipital lobe), it may cause vision changes.
• If it starts in the front part of the brain (precentral gyrus), it may cause rhythmic clonic or tonic motor activity (rhythmic muscle movements).
• If it starts in the middle part of the brain (postcentral gyrus), it may cause abnormal sensory sensations like paresthesia (tingling).

Diagnosis of epilepsy is made based on the symptoms and medical history. Evaluation is further confirmed by various tests, such as:

• Electroencephalogram (EEG)- One of the most common tests used to diagnose epilepsy. Here electrodes are attached to the scalp, which then records the electrical activity of the brain.

• High-density EEG- A variation of an EEG, high-density EEG has the electrodes placed more closely than conventional EEG. This helps in a more precise evaluation of the areas of the brain affected.

• Computerised tomography (CT) scan- structural abnormalities such as tumours, cysts, etc., in the brain can be seen on CT scans.

• Magnetic resonance imaging (MRI)- Similar to CT scans, an MRI gives a detailed picture of abnormalities in the brain.

• Neuropsychological tests- Thinking, memory, and speech skills are assessed using these tests. They help determine which areas of the brain are affected.

Accurate diagnosis is the first step toward effective treatment.

Treatment for epilepsy is usually started conservatively with medication. The choice of medication depends on the type of epilepsy and factors such as age and other existing medical conditions. In an event where medication does not provide relief from symptoms and seizure episodes, surgery may be recommended. Two major prerequisites usually looked into before deciding on the surgery are:

• The seizures should originate in a small, well-defined area of the brain.

• The area to be operated on should not interfere with vital functions such as speech, language, motor function, vision, or hearing.

If managed well, epileptic patients have known to have lived their lives to the full. It is important to have the correct diagnosis and complete treatment. 

There are several options for treating epilepsy, with the most common being anti-epileptic drugs, or AEDs. Up to 70% of people with epilepsy could have their seizures completely controlled with the right treatment.

Max Institute of Neurosciences offers the following options to get the best treatment for epilepsy.

A) Anti-Epileptic Drugs: This is usually the first treatment that the doctor will try to start to control the seizures. The aim is to control seizures as fully as possible, whilst minimising the side effects of the drugs.

B) The Ketogenic Diet: It is usually considered for children when AEDs have not had a good effect on controlling seizures. It involves strict control of fat, protein and carbohydrate levels, and should always be done with the supervision of a specialist dietitian.

C) Vagal Nerve Stimulation (VNS): This involves implanting devices to attempt to suppress the abnormal electrical activity that causes seizures. They can be considered for people when anti- epileptic drugs have failed to give control.

D) Surgery: This option is recommended for people with uncontrolled seizures. About 20 to 30% of people have poorly controlled epilepsy despite trying multiple medications. Surgery can practically cure epilepsy in such patients. The origin of seizures can be located by Video-EEG Monitoring and MRI. The small area of the brain responsible for seizures can be removed easily by surgery. Surgery has been very successful in such cases.

Seizures are not just about bouts of muscular stiffness and involuntary movements; they may also lead to complications that can potentially be fatal. Below mentioned are a few such possibilities:

• Falling- A fall during a seizure may result in head injury or fractures.

• Drowning- A patient with epilepsy is almost 20 times more at risk of drowning while swimming and/or bathing. This happens if the epileptic attack comes while the patient is in water.

• Car accidents- An epileptic patient is always at risk while driving. An attack when on the wheel can lead to loss of awareness and control, risking not just their life but that of others on the road too. A similar risk exists for those dealing with and operating heavy machinery.

• Pregnancy complications- Seizures during pregnancy are some of the trickiest ones. They pose a danger to the mother as well as the baby. What makes it tougher is that certain antiepileptic medications increase the risk of congenital disabilities and are not preferred as treatment. This does not rule out the possibility of a healthy pregnancy for an epileptic patient. A thorough discussion with the doctor, careful monitoring, and adjusted medication doses can help an epileptic patient in their pregnancy journey.

• Emotional health issues- Depression, anxiety, and suicidal thoughts are common mental health concerns seen in patients with epilepsy. These can be due to altered lifestyles and restrictions or also possible side effects of medication.

Other life-threatening complications, though uncommon, include:

• Status epilepticus

  A state of continuous seizure activity for more than five minutes or frequent recurrent seizures with loss of consciousness in between is termed status epilepticus. Patients with status epilepticus are at an increased risk of permanent brain damage, eventually leading to death.

• Sudden unexpected death in epilepsy (SUDEP)

  Certain seizures may impact the heart or respiratory conditions that may lead to sudden death during a seizure. Though the percentage of such cases is low, the possibility cannot be completely ruled out. High-risk groups include patients with tonic-clonic seizures or those patients where seizures are not controlled by medication.

Treatment for epilepsy is usually started conservatively with medication. The choice of medication depends on the type of epilepsy and factors such as age and other existing medical conditions. In an event where medication does not provide relief from symptoms and seizure episodes, surgery may be recommended. Two major prerequisites usually looked into before deciding on the surgery are:

• The seizures should originate in a small, well-defined area of the brain.

• The area to be operated on should not interfere with vital functions such as speech, language, motor function, vision, or hearing.

Max Institute of Neurosciences (MINS) provides comprehensive and compassionate care to adults and children with seizure disorders. Our team of highly experienced doctors and surgeons strive to ensure the best results that eventually bring good quality life to people. We provide super speciality tertiary care for all kinds of neurological disorders. Apart from an array of services like Advanced Brain Tumour Centre, Minimally Invasive Spine Surgery Centre and Stroke Centre, it has India's first BrainSUITE - the most advanced Neuro Operation Theatre.

We have highly-skilled neurosurgeons, neurologists, interventional neurologists, neuro anaesthetists, experts in critical care and specialised nurses who work together to deliver world-class services. They are supported by next-gen facilities such as a dedicated high-end Neuro ICU and HDU with 24x7 neurosurgery and neuro anaesthetist backup. Each member of the team brings expertise from years of experience and skills, all directed towards providing the highest standards of patient care.

The institute provides round-the-clock, comprehensive diagnostic and therapeutic neurology services, according to evidence-based protocols set as per internationally accepted guidelines. Our casualty services are available round-the-clock for diagnosis and early management of a wide range of neurological emergencies, including Status Epilepticus.

At Max Institute of Neurosciences, patients can receive a comprehensive evaluation and neurodiagnostic treatment services such as counselling, education, customised treatment plans, medication, physical evaluations, and psychological reports. It also provides elaborate presurgical evaluation and surgical treatment to those epilepsy patients whose condition cannot be controlled with medical treatment.

60%–70% of patients will see their seizures controlled by medication. In most cases, treatment is deferred until a second seizure occurs. Patients with no identified aetiology have a better outcome than those with structural, metabolic, or genetic aetiology.

Reviewed by Dr. Mukesh Kumar, Associate Director and Head (Parkinson's Disease Unit), Neurosciences, Neurology on 27-Mar-2023.

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What is epilepsy?
Epilepsy is a neurological condition characterized by recurring seizures caused by abnormal electrical activity in the brain.

What are the goals of epilepsy treatment?
The primary goals of epilepsy treatment are to control seizures, minimize side effects of medications, improve quality of life, and prevent injury or complications associated with seizures.

What are the different treatment options available for epilepsy?
Treatment options for epilepsy include medication therapy, ketogenic diet, epilepsy surgery, vagus nerve stimulation (VNS), responsive neurostimulation (RNS), and lifestyle modifications.

Can epilepsy be cured?
While epilepsy cannot always be cured, it can often be effectively managed with appropriate treatment. Some individuals may achieve seizure freedom, while others may experience a significant reduction in seizure frequency.

How is medication used in the treatment of epilepsy?
Medication is the most common treatment for epilepsy. Antiepileptic drugs (AEDs) are prescribed to control seizures by stabilizing abnormal electrical activity in the brain.

Are there any non-medication treatments for epilepsy?
Yes, non-medication treatments for epilepsy include the ketogenic diet (a high-fat, low-carbohydrate diet) that may help reduce seizures and various neurostimulation techniques such as VNS and RNS.

What is the ketogenic diet, and how is it used in epilepsy treatment?
The ketogenic diet is a specialized diet that is high in fat, low in carbohydrates, and adequate in protein. It is used as a treatment option for epilepsy, particularly in children, and may help reduce seizure frequency.

Can surgery be an option for epilepsy treatment?
Yes, epilepsy surgery may be considered when seizures are not well-controlled with medication. The goal is to remove or disconnect the area of the brain where seizures originate or to prevent the spread of abnormal electrical activity.

How is vagus nerve stimulation (VNS) used in epilepsy treatment? VNS is a treatment that involves implanting a device that stimulates the vagus nerve. It can help reduce seizure frequency and severity and is typically used when other treatments have been ineffective.

What is responsive neurostimulation (RNS), and how does it work for epilepsy?
RNS is a treatment that involves the implantation of a device in the brain to detect and respond to abnormal electrical activity, providing electrical stimulation to prevent seizures from occurring or spreading.

Can lifestyle modifications help in managing epilepsy?
Yes, certain lifestyle modifications can complement epilepsy treatment. These include getting enough sleep, managing stress, avoiding seizure triggers, and maintaining a healthy lifestyle overall.

Are there specific considerations for epilepsy treatment in children?
Yes, treatment considerations for children with epilepsy may involve adjusting medication doses based on age and weight, considering the impact on development and learning, and addressing any specific concerns related to childhood epilepsy syndromes.

What are the potential side effects of epilepsy medications?
Epilepsy medications may have side effects, which can vary depending on the specific medication. Common side effects are dizziness, memory issues, drowsiness, coordination problems, and mood changes.

Can epilepsy medication interact with other medications?
Yes, some epilepsy medications can interact with other medications, including over-the-counter drugs and herbal supplements. Inform the medical team about all medications being taken to avoid potential interactions.

How long does epilepsy medication need to be taken?
The duration of epilepsy medication treatment varies depending on the individual and the specific circumstances. In some cases, medication may be taken for a few years, while in others, it may need to be continued long-term.

Can epilepsy medication be stopped once seizures are under control?
The decision to discontinue epilepsy medication should be made in consultation with an epilepsy surgery doctor. It is generally not recommended to stop medication abruptly, as this can lead to a recurrence of seizures.

Can epilepsy treatment affect fertility or pregnancy?
Some epilepsy medications can pose a risk to fertility or pregnancy. It is important for individuals of reproductive age to discuss potential risks and considerations with their healthcare provider to make informed decisions.

What should be done in case of a seizure emergency?
In a seizure emergency, it is important to stay calm and ensure the person's safety. Protect them from injury by clearing the surroundings, placing something soft under their head, and not restraining their movements. Call for medical assistance if necessary.

Are there any alternative or complementary therapies for epilepsy treatment?
Some individuals may explore alternative or complementary therapies such as acupuncture, yoga, or herbal remedies. However, discuss these options with a healthcare professional, as their effectiveness and safety may vary.

Can stress management techniques help in reducing seizures?
Stress management techniques, like relaxation exercises, mindfulness, and counselling, may help reduce the frequency or intensity of seizures in some individuals. Stress reduction is often recommended as part of a comprehensive epilepsy treatment plan.

What is the role of a specialized epilepsy centre in treatment?
Specialized epilepsy centres provide comprehensive evaluation, diagnosis, and treatment of epilepsy. They have expertise in managing complex cases and may offer advanced treatment options and access to clinical trials.

Can epilepsy treatment affect cognitive function or memory?
Some epilepsy medications may have side effects that affect cognitive function or memory. However, not all individuals experience these side effects, and the impact can vary.

Are there any dietary restrictions for individuals with epilepsy?
While specific dietary restrictions may not be necessary for everyone with epilepsy, certain triggers such as alcohol or caffeine may be advised to be avoided in some cases. It is recommended to discuss dietary considerations with a healthcare provider.

Can epilepsy treatment be individualized based on the type of seizures?
Yes, epilepsy treatment can be tailored based on the type of seizures a person experiences. Different medications or treatment approaches may be more effective for certain seizure types.

Can epilepsy treatment be adjusted based on the frequency of seizures?
Yes, treatment plans can be adjusted based on the frequency of seizures. If seizures are not well-controlled, medication dosages may be modified, or additional treatment options may be considered.

Are there any specific considerations for elderly individuals with epilepsy?
Elderly individuals may have unique considerations when it comes to epilepsy treatment. They may be more susceptible to certain side effects of medications and may have coexisting medical conditions that need to be taken into account.

Can epilepsy treatment be affected by other medical conditions or medications?
Yes, other medical conditions or medications can potentially interact with epilepsy treatment. It is important to inform healthcare providers about all existing medical conditions and medications to ensure safe and effective treatment.

Can epilepsy treatment help in reducing the risk of sudden unexpected death in epilepsy (SUDEP)?
While there is no guarantee, effective epilepsy treatment and seizure control may help reduce the risk of SUDEP. Regular medical care, adherence to treatment, and appropriate precautions are important in managing epilepsy and minimizing associated risks.

What is the role of psychological therapy in epilepsy treatment?
Psychological therapy, like cognitive-behavioural therapy (CBT) or counselling, can help individuals with epilepsy manage the emotional and psychological facets of living with the condition. It can also address any mental health concerns that may arise.

Can epilepsy treatment be personalized based on genetic factors?
Genetic testing and personalized medicine approaches are increasingly being utilized to identify specific genetic factors that may influence treatment response. This can help guide the selection of medications and treatment strategies.

Are there any experimental or investigational treatments for epilepsy?
Yes, ongoing research and clinical trials are exploring new and innovative treatments for epilepsy. These may include novel medications, neurostimulation techniques, gene therapies, and other emerging therapies.

Can epilepsy treatment lead to complete seizure freedom?
While the goal of epilepsy treatment is to achieve seizure control, complete seizure freedom is not guaranteed for everyone. The likelihood of achieving seizure freedom depends on various factors, including the underlying cause of epilepsy and individual response to treatment.

Can epilepsy treatment prevent or minimize the long-term effects of seizures?
Effective epilepsy treatment and seizure control can help prevent or minimize the long-term effects of seizures. This includes reducing the risk of cognitive decline, injuries from seizures, and other complications associated with uncontrolled epilepsy.

Can epilepsy treatment help improve quality of life?
Yes, successful management of epilepsy through appropriate treatment can improve the quality of life for those with epilepsy. Seizure control, reduction in medication side effects, and better overall well-being contribute to an improved quality of life.

What should I do if my current epilepsy treatment is not effective?
If your current epilepsy treatment is not effective in controlling seizures, it is important to consult with your healthcare provider. They may consider adjusting medication dosages, exploring alternative treatment options, or referring you to a specialized epilepsy centre for further evaluation and management.

Review

FAQs reviewed by Dr. Vinny Sood - Principal Consultant, Neurosciences, Neurology.