In seizure disorders, the brain's electrical activity is periodically disturbed, resulting in some degree of temporary brain dysfunction.
Normal brain function requires an orderly, organized, coordinated discharge of electrical impulses. Electrical impulses enable the brain to communicate with the spinal cord, nerves, and muscles as well as within itself. Seizures may result when the brain's electrical activity is disrupted.
About 2% of adults have a seizure at some time during their life. Two thirds of these people never have another one. Seizure disorders commonly begin in early childhood or in late adulthood.
Types of seizures
Seizures may be described as follows:
Certain mental disorders can cause symptoms that resemble seizures, called psychogenic nonepileptic seizures.
Which causes are most common depend on when seizures start:
Seizures with no identifiable cause are called idiopathic.
Conditions that irritate the brain—such as injuries, certain drugs, sleep deprivation, infections, fever—or that deprive the brain of oxygen or fuel—such as abnormal heart rhythms, a low level of oxygen in the blood, or a very low level of sugar in the blood—can trigger a single seizure whether a person has a seizure disorder or not. A seizure that results from such a stimulus is called a provoked seizure (and thus is a nonepileptic seizure).
People with a seizure disorder are more likely to have a seizure when they are under excess physical or emotional stress, when they are intoxicated or deprived of sleep, or when they have suddenly stopped drinking or using sedatives. Avoiding these conditions can help prevent seizures.
Rarely, seizures are triggered by repetitive sounds, flashing lights, video games, or even touching certain parts of the body. In such cases, the disorder is called reflex epilepsy.
An aura (unusual sensations) precedes seizures in about 20% of people who have a seizure disorder. An aura may include any of the following:
Almost all seizures are relatively brief, lasting from a few seconds to a few minutes. Most seizures last 1 to 2 minutes.
When a seizure stops, people may have a headache, sore muscles, unusual sensations, confusion, and profound fatigue. These after-effects are called the postictal state. In some people, one side of the body is weak, and the weakness lasts longer than the seizure (a disorder called Todd paralysis).
Most people who have a seizure disorder look and behave normally between seizures.
Symptoms vary depending on which area of the brain is affected by the abnormal electrical discharge, as in the following:
Other possible symptoms include numbness or tingling in a specific body part, brief episodes of unresponsiveness, loss of consciousness, and confusion. People may vomit if they lose consciousness. People may lose control of their muscles, bladder, or bowels. Some people bite their tongue.
Symptoms also vary depending on whether the seizure is
There are several types of partial and generalized seizures.
About 70% of people have only one type of seizure. The rest have two or more types.
Only one side of the brain is affected. Partial seizures may be
In simple partial seizures, abnormal electrical discharges begin in a small area of the brain and remain confined to that area. Because only a small area of the brain is affected, symptoms are related to the function controlled by that area. For example, if the small area of the brain that controls the right arm's movements (in the left frontal lobe) is affected, the right arm may involuntarily be lifted up and the head may turn toward the lifted arm. People are completely conscious and aware of the surroundings. A simple partial seizure may progress to a complex partial seizure.
Jacksonian seizures are a type of simple partial seizures. Symptoms start in one part of the body, then spread to another. Abnormal movements may occur in the hand or foot, then move up the limb as the electrical activity spreads in the brain. People are completely aware of what is occurring during the seizure.
In complex partial seizures, abnormal electrical discharges begin in a small area of the temporal lobe or frontal lobe and quickly spread to other nearby areas. The seizures usually begin with an aura that lasts 1 to 2 minutes. During the aura, people start to lose touch with the surroundings. During the seizure, consciousness is impaired but not completely lost. People may do the following:
Some people can converse, but their conversation lacks spontaneity, and the content is somewhat sparse. They may be confused and disoriented. This state may last for several minutes. Occasionally, people lash out if they are restrained.
Most people do not remember what happened during the seizure (a condition called postictal amnesia).
Some people then recover fully. In others, the abnormal electrical discharge spreads to adjacent areas and to the other side of the brain, resulting in a generalized seizure. Generalized seizures that result from partial seizures are called secondarily generalized seizures.
Epilepsia partialis continua is rare. Seizures occur every few seconds or minutes for days to years at a time. They typically affect an arm, a hand, or one side of the face. These seizures usually result from localized brain damage (such as scarring due to a stroke) in adults or from inflammation of the brain (as occurs in encephalitis and measles) in children.
Large areas on both sides of the brain are affected. Generalized seizures often cause loss of consciousness and abnormal movements, usually immediately. Loss of consciousness may be brief or last a long time.
Generalized seizures include the following:
In generalized tonic-clonic seizures, muscles contract (the tonic part), then rapidly alternate between contracting and relaxing (the clonic part). These seizures may be
In both types, consciousness is temporarily lost and a convulsion occurs when the abnormal discharges spread to both sides of the brain.
Primarily generalized seizures begin with abnormal discharges in a deep, central part of the brain and spread simultaneously to both sides of the brain. There is no aura. The seizure typically begins with an outcry. People then lose consciousness.
During primarily generalized seizures, people may do the following:
The seizures usually last 1 to 2 minutes. Afterward, some people have a headache, are temporarily confused, and feel extremely tired. These symptoms may last from minutes to hours. Most people do not remember what happened during the seizure.
Secondarily generalized tonic-clonic (grand mal) seizures usually begin with an abnormal electrical discharge in a small area of one side of the brain, resulting in a simple or complex partial seizure. The discharge then quickly spreads to both sides of the brain, causing the entire brain to malfunction. Symptoms are similar to those of primarily generalized seizures.
Absence seizures may be
Typical absence seizures usually begin in childhood, usually between the ages of 5 and 15 and do not continue into adulthood. However, adults occasionally have typical absence seizures. Unlike tonic-clonic seizures, absence seizures do not cause convulsions or other dramatic symptoms. People do not fall down, collapse, or move jerkily. Instead, they have episodes of staring with fluttering eyelids and sometimes twitching facial muscles. They typically lose consciousness, becoming completely unaware of their surroundings. These episodes last 10 to 30 seconds. People abruptly stop what they are doing and resume it just as abruptly. They experience no after-effects and do not know that a seizure has occurred. Without treatment, many people have several seizures a day. Seizures often occur when people are sitting quietly. Seizures rarely occur during exercise. Hyperventilation can trigger a seizure.
Atypical absence seizures differ from typical absence seizures as follows:
Most people with atypical absence seizures have neurologic abnormalities or developmental delays. Seizures usually continue into adulthood.
Atonic seizures occur primarily in children. They are characterized by a brief but complete loss of muscle tone and consciousness. They cause children to fall to the ground, sometimes resulting in injury.
Tonic seizures occur commonly during sleep, usually in children. Muscle tone increases abruptly or gradually, causing muscles to stiffen. The seizures typically last only 10 to 15 seconds but can cause people, if standing, to fall to the ground. Most people do not lose consciousness. If seizures last longer, muscles may jerk a few times as the seizure ends.
Atypical absence seizures, atonic seizures, and tonic seizures usually occur as part of a severe form of epilepsy called Lennox-Gastaut syndrome, which begins before children are 4 years old.
Myoclonic seizures are characterized by quick jerks of one or several limbs or the trunk. The seizures are brief and do not cause loss of consciousness, but they may occur repetitively and progress to a tonic-clonic seizure with loss of consciousness.
Juvenile myoclonic epilepsy typically begins during adolescence. Typically, seizures begin with quick jerks of both arms. About 90% of these seizures are followed by tonic-clonic seizures. Some people also have absence seizures. The seizures often occur when people awaken in the morning, especially if they are sleep-deprived. Drinking alcohol also makes these seizures more likely.
Infantile spasms and febrile seizures occur in children.
This disorder is the most serious seizure disorder and is considered a medical emergency because the seizure does not stop. Electrical discharges occur throughout the brain, causing a generalized tonic-clonic seizure.
Status epilepticus is diagnosed when one or both of the following occur:
People have convulsions with intense muscle contractions and often cannot breathe adequately. Body temperature increases. Without rapid treatment, the heart and brain can become overtaxed and permanently damaged, sometimes resulting in death.
Generalized convulsive status epilepticus has many causes, including injuring the head and abruptly stopping an anticonvulsant.
Seizures may have serious consequences. Intense, rapid muscle contractions can cause injuries, including broken bones. Sudden loss of consciousness can cause serious injury due to falls and accidents. People may have numerous seizures without incurring serious brain damage. However, seizures that recur and cause convulsions may eventually impair intelligence.
If seizures are not well-controlled, people may be unable to get a driver's license. They may have difficulty keeping a job or getting insurance. They may be socially stigmatized. As a result, their quality of life may be substantially reduced.
If seizures are not completely controlled, people are twice as likely to die as those who do not have seizures. A few people die suddenly for no apparent reason—a complication called sudden unexpected death in epilepsy.
Doctors diagnose a seizure disorder when people have at least two unprovoked seizures that occur at different times. The diagnosis is based on symptoms and the observations of eyewitnesses. Symptoms that suggest a seizure include loss of consciousness, muscle spasms that shake the body, loss of bladder control, sudden confusion, and inability to pay attention. However, seizures cause such symptoms much less often than most people think. A brief loss of consciousness is more likely to be fainting (syncope) than a seizure.
People are usually evaluated in an emergency department. If a seizure disorder has already been diagnosed and people have completely recovered, they may be evaluated in a doctor's office.
History and physical examination
An eyewitness report of the episode can be very helpful to doctors. An eyewitness can describe exactly what happened, whereas people who have an episode usually cannot. Doctors need to have an accurate description, including the following:
A quick recovery suggests fainting rather than a seizure. Confusion that lasts for many minutes to hours after consciousness is regained suggests a seizure.
Although eyewitnesses may be too frightened during the seizure to remember all details, whatever they can remember can help. If possible, how long a seizure lasts should be timed with a watch or other device. Seizures that last only 1 or 2 minutes can seem to go on forever.
Doctors also need to know what people experienced before the episode: whether they had a premonition or warning that something unusual was about to happen and whether anything, such as certain sounds or flashing lights, seemed to trigger the episode.
Doctors ask people about possible causes of seizures, such as the following:
A thorough physical examination is done. It may provide clues to the cause of the symptoms.
Once a seizure is diagnosed, more tests are usually needed to identify the cause. People known to have a seizure disorder may not need additional tests. In others, blood tests are often done to measure the levels of substances such as sugar, calcium, sodium, and magnesium and to determine whether the liver and kidneys are functioning normally. A sample of urine may be analyzed to check for recreational drugs that may not be reported. Such drugs can trigger a seizure.
Electrocardiography may be done to check for an abnormal heart rhythm. Because an abnormal heart rhythm can greatly reduce blood flow (and therefore oxygen supply) to the brain, it can trigger loss of consciousness and occasionally a seizure or symptoms that resemble a seizure.
Imaging of the brain is usually done promptly to check for bleeding or a stroke. Typically, computed tomography (CT) is done, but magnetic resonance imaging (MRI) may be done. Both tests can identify brain abnormalities that could be causing seizures. MRI provides clearer, more detailed images of the brain tissue, but it is not always readily available.
If doctors suspect a brain infection such as meningitis or encephalitis, a spinal tap is usually done.
Electroencephalography (EEG) can help confirm the diagnosis. EEG is a painless, safe procedure that records electrical activity in the brain. Doctors examine the recording (electroencephalogram) for evidence of abnormal electrical discharges. Because the recording time is limited, EEG can miss abnormalities, and results may be normal, even in people who have a seizure disorder. EEG is sometimes scheduled after people have been deprived of sleep for 18 to 24 hours because lack of sleep makes abnormal discharges more likely to occur.
Brain Activity During a Seizure
An electroencephalogram (an EEG) is a recording of the brain's electrical activity. The procedure is simple and painless. About 20 small adhesive electrodes are placed on the scalp, and the brain's activity is recorded under normal conditions. Then the person is exposed to various stimuli, such as bright or flashing lights, to try to provoke a seizure. During a seizure, electrical activity in the brain accelerates, producing a jagged wave pattern. Such recordings of brain waves help identify a seizure disorder. Different types of seizures have different wave patterns.
EEG may be repeated because when done a second or even a third time, it may detect the cause, which was missed the first time the test was done.
If the diagnosis is still uncertain, specialized tests, such as video-EEG monitoring, can be done at an epilepsy center.
For video-EEG monitoring, people are admitted to a hospital for 2 to 7 days, and EEG is done while they are video-taped. If people are taking an anticonvulsant, it is often stopped to increase the likelihood of a seizure. If a seizure occurs, doctors compare the EEG recording with the video recording of the seizure. They may then be able to identify the type of seizure and the area of the brain where the seizure began.
With treatment, seizures are eliminated in one third of people with epileptic seizures, and the frequency of seizures is reduced by more than50% in another third. About 60% of people whose seizures are well-controlled by drugs can eventually stop the drugs and remain seizure-free.
Epileptic seizures are considered resolved when people have been seizure-free for 10 years and have not taken anticonvulsants for the last 5 years of that time period.
If the cause can be identified and eliminated, no additional treatment is necessary. For example, if a low blood sugar (glucose) level (hypoglycemia) caused the seizure, glucose is given, and the disorder causing the low level is treated. Other treatable causes include an infection, certain tumors, and an abnormal sodium level.
If people have a seizure disorder, general measures plus drugs are usually sufficient. If drugs are ineffective, surgery may be recommended.
Exercise is usually recommended and social activities are encouraged. However, people who have a seizure disorder may have to make some adjustments. For example, they may be advised to do the following:
After seizures are controlled (typically for at least 6 months), they can do these activities if adequate precautions are taken. For example, they should swim only when lifeguards are present.
In most states, laws prohibit people with a seizure disorder from driving until they have been free of seizures for at least 6 months to 1 year.
A family member or close friend and coworkers should be trained to help if a seizure occurs. Attempting to put an object (such as a spoon) in the person's mouth to protect the person's tongue should not be tried. Such efforts can do more harm than good. The teeth may be damaged, or the person may bite the helper unintentionally as the jaw muscles contract. However, helpers should do the following during a seizure:
If a pillow is unavailable, helpers can put their foot or place an item of clothing under the person's head.
People who lose consciousness should be rolled onto one side to ease breathing and help prevent them from inhaling vomit or saliva. Inhaling vomit or saliva can lead to aspiration pneumonia (a lung infection caused by inhaling saliva, stomach contents, or both).
People who have had a seizure should not be left alone until they have awakened completely, are no longer confused, and can move about normally. Usually, their doctor should be notified.
These drugs reduce the risk of having another seizure. Usually, they are prescribed only if people have had more than one seizure and if reversible causes, such as low blood sugar, have been ruled out or completely corrected. Anticonvulsants are usually not prescribed when people have had only one generalized seizure.
Most anticonvulsants are taken by mouth.
Anticonvulsants can completely stop seizures in about one third of people who have them and greatly reduce the frequency of seizures in another third. Almost two thirds of people who respond to anticonvulsants can eventually stop taking them without having a relapse. However, anticonvulsants are ineffective in about 10 to 20% of people with a seizure disorder. These people are referred to a seizure center and evaluated for surgery.
There are many different types of anticonvulsants. Which one is effective depends on the type of seizure and other factors. For most people, taking one anticonvulsant, usually the first or second one tried, controls seizures. If seizures recur, different anticonvulsants are tried. In such cases, determining which anticonvulsant is effective may take several months. Some people have to take several drugs, which increases the risk of side effects. Some anticonvulsants are not used alone but only with other anticonvulsants.
Doctors take care to determine the appropriate dose of an anticonvulsant for each person. The best dose is the smallest dose that stops all seizures while having the fewest side effects. Doctors ask people about side effects, then adjust the dose if needed. Sometimes doctors also measure the level of anticonvulsant in the blood.
Anticonvulsants should be taken just as prescribed. People who take anticonvulsants to control seizures should see a doctor regularly for dose adjustment and should always wear a Medic Alert bracelet inscribed with the type of seizure disorder and the drug being taken.
Anticonvulsants can interfere with the effectiveness of other drugs, and vice versa. Consequently, people should make sure their doctor knows all the drugs they are taking before they start taking anticonvulsants. They should also talk to their doctor and possibly their pharmacist before they start taking any other drugs, including over-the-counter drugs.
After seizures are controlled, people take the anticonvulsant until they have been seizure-free for at least 2 years. Then, the dose of the drug may be decreased gradually, and the drug eventually stopped. If a seizure recurs after the anticonvulsant is stopped, people may have to take an anticonvulsant indefinitely. Seizures usually recur within 2 years if they are going to. A recurrence is more likely in people who have had any of the following:
Anticonvulsants, although very effective, may have side effects. Many cause drowsiness, but some may make children hyperactive. Blood tests are done periodically to determine whether an anticonvulsant is impairing kidney or liver function or reducing the number of blood cells. People taking anticonvulsants should be aware of possible side effects and should consult their doctor at the first sign of side effects.
For women who have a seizure disorder and are pregnant, taking an anticonvulsant increases the risk of miscarrying or of having a baby with a birth defect of the spinal cord, spine, or brain . However, stopping the anticonvulsant may be more harmful to the woman and the baby. Having a generalized seizure during pregnancy can injure or kill the fetus. Consequently, continuing to take an anticonvulsant is usually recommended . All women who are of childbearing age and taking an anticonvulsant should take folate supplements to reduce the risk of having a baby with a birth defect.
Emergency treatment is required for
Large doses of one or more anticonvulsants (often starting with a benzodiazepine, such as lorazepam) are given intravenously as quickly as possible to stop the seizure. The sooner anticonvulsants are started, the better and the more easily seizures are controlled.
Measures to prevent injuries are taken during the prolonged seizure. People are monitored closely to make sure breathing is adequate. If it is not, a tube is inserted to help with breathing—a procedure called intubation. If seizures persist, a general anesthetic is given to stop them.
If people continue to have seizures while taking two or more anticonvulsants or if they cannot tolerate side effects of the anticonvulsants, brain surgery may be done. These people are tested at specialized epilepsy centers to determine whether surgery can help. Tests may include the following:
If a defect in the brain (such as a scar) can be identified as the cause and is confined to a small area, surgically removing that area can eliminate seizures in up to 60% of people, or it may reduce the severity and frequency of seizures.
Surgically cutting the nerve fibers that connect the two sides of the brain (corpus callosum) may help people who have seizures that originate in several areas of the brain or that spread to all parts of the brain very quickly. This procedure usually has no appreciable side effects. However, even if surgery reduces the frequency and severity of seizures, many people need to continue to take anticonvulsants. However, they can usually take lower doses or fewer drugs.
Before and after surgery, a psychologic and neurologic evaluation may be done to determine how well the brain is functioning.
Stimulation of the vagus nerve
Electrical stimulation of the 10th cranial nerve (vagus nerve) can reduce the number of partial seizures by more than one half in about 40% of people who have partial seizures. This treatment is used when seizures continue despite use of anticonvulsants and when surgery is not a possibility.
The vagus nerve is thought to have indirect connections to areas of the brain often involved in causing seizures.
For this procedure, a device that looks like a heart pacemaker (vagus nerve stimulator) is implanted under the left collarbone and is connected to the vagus nerve in the neck with a wire that runs under the skin. The device causes a small bulge under the skin. The operation is done on an outpatient basis and takes about 1 to 2 hours.
The device is programmed to periodically stimulate the vagus nerve. Also, people are given a magnet, which they can use to stimulate the vagus nerve when they sense that a seizure is about to begin. Vagus nerve stimulation is used in addition to anticonvulsants.
Side effects of vagal nerve stimulation include hoarseness, cough, and deepening of the voice when the nerve is stimulated.