Definition of Epilepsy (per ILAE 2022 & 2014 Updates)
According to the ILAE, epilepsy is a brain disease defined by any of the following conditions:
- At least two unprovoked seizures occurring more than 24 hours apart.
Note: Epilepsy is considered to be resolved if the patient remains seizure-free for 10 years with no treatment for the last 5 years, or if the age-dependent epilepsy syndrome has passed its relevant age range.
Signs and Symptoms of Epilepsy
Seizure symptoms vary depending on the type and the location in the brain. They may include:
Focal seizures (formerly partial seizures):
- Motor symptoms: Jerking or stiffening of a limb or facial muscles
- Sensory symptoms: Tingling, visual flashes, strange smells or sounds
- Autonomic: Sweating, nausea, flushing, heart racing
- Cognitive/emotional: Deja vu, fear, confusion
- May occur with or without awareness
Generalized seizures:
- Tonic-clonic: Sudden loss of consciousness, muscle rigidity, convulsions
- Absence: Sudden staring, often in children, lasts seconds
- Myoclonic: Brief, shock-like jerks of limbs
- Atonic: Sudden drop due to loss of muscle tone
Post-ictal phase:
- Confusion
- Headache
- Fatigue
- Temporary paralysis (Todd’s paresis)
Diagnostic Investigations
A complete evaluation includes:
Electroencephalogram (EEG):
- May be routine or prolonged (video EEG monitoring)
- Epilepsy monitoring unit.
Brain MRI (preferred over CT):
- Detects structural causes: tumors, gliosis, cortical malformations, strokes
- Specific epilepsy protocols improve diagnostic yield
Additional tests:
- Genetic testing: for epilepsy syndromes or early-onset seizures
- Metabolic panels: if inborn errors of metabolism are suspected
- Neuropsychological testing: helpful in presurgical evaluation
- PET scan.
- Ictal SPECT.
- Functional MRI
Management of Epilepsy
Acute Seizure Management:
- Seizure lasting >5 minutes = status epilepticus
- Treat with benzodiazepines (e.g., lorazepam, midazolam)
Long-Term Treatment (Anti-seizure medications - ASMs):
- Chosen based on seizure type, patient age, comorbidities, and reproductive status
Examples:
- Focal epilepsy: carbamazepine, lamotrigine, levetiracetam
- Generalized epilepsy: valproate, topiramate, ethosuximide
- Consider monotherapy first, then polytherapy if uncontrolled
Other Treatment Modalities:
- Epilepsy surgery: for medically refractory focal epilepsy
- Vagal Nerve Stimulation (VNS) or Deep Brain Stimulation (DBS)
- Ketogenic diet: effective in some refractory pediatric epilepsies
- Lifestyle modification
Sleep regulation
- Avoid triggers (flashing lights, missed doses)
- Adherence to medications
When Should a Patient Follow Up in the Clinic?
Patients should attend the neurology clinic:
- After a first seizure, to determine if epilepsy is present
- Every 6–3 months if stable on medications
- Sooner, if:
- Breakthrough seizures occur
- Medication side effects arise
- Pregnancy is planned (ASM review)
- Driving clearance is needed
- For drug level monitoring, especially with phenytoin, valproate, carbamazepine
When Should a Patient Go to the Emergency Room?
The patient should go to the ER immediately if:
- A seizure lasts more than 5 minutes (status epilepticus)
- They have multiple seizures without recovery in between
- They experience their first seizure ever
- The seizure leads to injury, head trauma, or occurs in water
- There is prolonged confusion, weakness, or change in mental status after the seizure
- Seizures occur in pregnancy, diabetes, or cardiac disease
- There is a change in seizure pattern, severity, or frequency
