How Is Epilepsy Treated?

Epilepsy, an elusive and multifaceted neurological condition, is defined by its hallmark – recurrent, unpredictable seizures that disrupt the brain’s delicate balance. But epilepsy is not one singular entity; it encompasses a range of types, each distinct in its nature. The seizures might occur in isolated pockets of the brain or ripple across its entire expanse, their severity fluctuating, and their symptoms varied. What happens before, during, or after a seizure can also differ dramatically from person to person. Yet, for all its complexity, the treatment of epilepsy often begins with one common thread: antiepileptic drugs (AEDs). These medications, wielded with precision by neurologists—specialists in the brain and spinal cord—are frequently the first line of defense, sometimes requiring a cocktail of drugs to quell the storms of seizures.

However, when the first line fails, the options stretch further. Alternative treatments, though seldom employed unless absolutely necessary, are available, and they hold promise for those for whom conventional therapies fall short.

Treatment by Type of Epilepsy

The vast majority of epilepsy cases are managed with antiepileptic drugs, with over 25 approved drugs currently in circulation. Most require a regimen of two daily doses, though exceptions do exist. Adherence to your prescribing neurologist’s guidance is essential—each dose is part of a carefully orchestrated plan to control the unpredictable nature of epilepsy.

Choosing the right drug is no simple task. Neurologists consider a mosaic of factors—age, sex, and the seizure’s characteristics—when deciding on the most effective treatment. This careful selection isn’t just about efficacy but also about minimizing the potential for adverse side effects, which may vary from person to person.

And, in the most fortunate of circumstances, treatment works wonders. Seizures, once an unrelenting force, begin to diminish, and with time, some patients may find themselves free from medication altogether. Over 70% of children with the common forms of epilepsy are able to stop their treatment after a few years. For adults, the success rate is similarly encouraging, with more than two-thirds of individuals becoming seizure-free after two years of treatment.

Surgical Interventions: A Last Resort

When epilepsy stubbornly persists despite medications, surgery may provide a flicker of hope. For those whose seizures have a clear origin in one focal area of the brain, a surgeon might opt to remove the offending tissue. This approach not only halts seizures in their tracks but also prevents them from cascading throughout the brain.

For generalized seizures—those that sweep across both hemispheres—more novel treatments are on the horizon. Devices such as vagal nerve stimulators, akin to pacemakers for the brain, may offer hope, using electrical pulses to help keep seizures at bay.

Focal Onset Epilepsy: Targeting the Seizure’s Origin

Focal onset epilepsy is deceptive. Seizures may manifest in subtle ways, from strange sensory experiences to involuntary movements or moments of lost consciousness. Here, treatment options diverge, ranging from pharmaceutical interventions to surgical solutions, with emerging research exploring the potential of the ketogenic diet as a supplemental measure.

Medications: A Personalized Approach

Though there are many medications on the market, some are more suitable for specific groups, such as older adults or those who are pregnant or planning to conceive. Commonly prescribed drugs include:

• Lamictal (lamotrigine)
• Keppra (levetiracetam)
• Trileptal (oxcarbazepine)
• Tegretol/Curatil (carbamazepine)
• Vimpat (lacosamide)

For older adults, the preferred options remain:

• Lamictal (lamotrigine)
• Keppra (levetiracetam)
• Vimpat (lacosamide)

And for those who may become pregnant:

• Lamictal (lamotrigine)
• Keppra (levetiracetam)

Surgical Options: When Drugs Aren’t Enough

For those whose seizures resist the pull of medication, surgery becomes an option. The following procedures might be considered:

• Lobectomy or lesionectomy: Removing the brain tissue responsible for seizures.
• Multiple subpial transection (MST): Making cuts in the brain’s outer layers to prevent seizures from spreading.
• Corpus callosotomy: Severing the fibers that connect the brain’s hemispheres, halting seizures’ spread.
• Thermal ablation: A less invasive procedure using lasers to target the offending tissue.
• Hemispherectomy: A drastic measure that involves removing one half of the brain—usually reserved for children, and as a last resort.

The Ketogenic Diet: A Complementary Option

For certain individuals, particularly children, the ketogenic diet—a strict regimen of high fats and low carbohydrates—has shown promise. While the evidence supporting its use is still in flux, it remains a viable consideration for those with treatment-resistant epilepsy. However, more research is necessary before it can be embraced as a primary treatment option.

Side Effects: A Double-Edged Sword

Like all treatments, the road to relief is not without its bumps. Common side effects from antiepileptic drugs include drowsiness, dizziness, and a lack of balance. More severe reactions, though rare, can involve cognitive impairments, hypersensitivity, or changes in weight. Notably, drugs like Depakene or Depakote—valproate-based medications—carry serious risks during pregnancy, including an increased chance of birth defects.

Surgical interventions, too, are not without risk. Despite the precision of modern imaging techniques, surgery may still damage healthy parts of the brain, leading to cognitive challenges, personality shifts, or even physical disabilities.

Generalized Epilepsy: A Complex Battle

Generalized epilepsy is a different beast altogether. Involving seizures that span the entire brain, its treatment hinges on the type of seizure experienced and the underlying genetic predispositions. Seizures may range from the violent and dramatic tonic-clonic variety, with muscle stiffening and twitching, to more subtle myoclonic seizures that simply cause muscle twitches. Absence seizures may manifest as fleeting moments of lost consciousness.

Medications for Generalized Epilepsy

The choice of drug depends on the specific nature of the seizures:

• For tonic-clonic seizures:

  • Lamictal (lamotrigine)
  • Keppra (levetiracetam)
  • Depakene/Depakote (valproate)
  • Topamax (topiramate)
  • Zonegram (zonisamide)

• For myoclonic seizures:

  • Keppra (levetiracetam)
  • Depakene/Depakote (valproate)
  • Zonegram (zonisamide)

• For absence seizures:

  • Zarontin (ethosuximide)
  • Depakene/Depakote (valproate)
  • Lamictal (lamotrigine)

Brain Stimulation: The New Frontier

For those whose seizures do not respond to drugs, brain stimulation presents a cutting-edge alternative. These devices, which work much like pacemakers for the brain, deliver electrical pulses to help control seizures. Two primary approaches are currently in use:

• Deep brain stimulation: Constant stimulation to the anterior nucleus of the thalamus.
• Responsive neurostimulation: Only delivering stimulation when a seizure is imminent.

Living with Epilepsy: Navigating the Daily Challenges

Epilepsy doesn’t just affect the body—it impacts the mind and spirit. Many individuals with epilepsy face cognitive issues, anxiety, or depression. Children, in particular, may experience stigma, bullying, or social isolation. Yet, help is available. Therapy and counseling can go a long way in alleviating these emotional burdens.

For those planning to conceive, managing seizures becomes a critical concern. The risks associated with tonic-clonic seizures during pregnancy are significant, both for the individual and the fetus.

In some places, laws restrict driving until individuals have been seizure-free for a specified period. Nevertheless, many people with epilepsy achieve remission and may go months or even years without experiencing a single seizure. For peace of mind, wearing a medical alert bracelet is strongly recommended, ensuring vital information is readily available in emergencies.

A Quick Review

Epilepsy, though a challenging condition, is manageable. With a variety of treatment options—ranging from medications to surgeries, brain stimulation, and even dietary changes—many people with epilepsy can live relatively seizure-free lives. While treatment success is highly individual, there is hope for long-term relief.