The brain normally functions by sending microscopic electric charges through and between your nerves. In a seizure, that electricity is discharged in unusual ways, as if an area of the brain got “overexcited” electrically. These discharges cause behaviors that have been what have been called spells or fits and are known medically as a seizure. What behaviors occur depend on where in the brain the discharges occur.
When someone is having a seizure, they may stare blankly off into space and be unresponsive or they may faint, fall, or have twitching and other uncontrolled movements. The most obvious of these are when a person’s entire body, arms, and legs jerk and flail uncontrollably.
Having a single seizure does is not the same as having epilepsy. A seizure can be provoked—caused by another illness, a drug, or a toxin. A seizure can also happen for unknown reasons—an unprovoked seizure. It is common to have a seizure (1 out of every 10 people will have a seizure at some time in their lives). It is much less common to have epilepsy (1 out of 1,00 people).
Even though a person who had a seizure may be disoriented afterward and might not remember what happened, a single seizure usually stops by itself and usually isn’t dangerous. The exception is when a seizure makes a person lose consciousness during an activity like driving or swimming, in which a loss of consciousness can be deadly. Multiple, repeated, or prolonged seizures can be dangerous and may cause brain damage over time.
Epilepsy is defined as having 2 or more unprovoked seizures. Because multiple, repeated, or prolonged seizures may be dangerous for the brain, people with epilepsy need treatment to control seizure activity.
There are many different kinds of epilepsy, which is why some people refer to “the epilepsies.” Sometimes epilepsy is caused by a genetic mutation, that is, it runs in the family. There are more than 400 genes that are known to cause epilepsy when they carry a mutation but most of these genetic epilepsies are very rare. Unfortunately, for most epilepsies, we still do not understand the exact cause.
Anyone who has even a single seizure should see a doctor to make sure she or he doesn’t have a serious unknown illness, drug reaction, or toxic exposure.
After a first seizure, the doctor will first talk with you about what happened and try to find out if the seizure was provoked or unprovoked. The doctor will want to know how long the seizure lasted and where it happened. They may ask if the person who had the seizure:
Typically, the doctor will order blood tests, an EEG to measure electric activity in the brain, and brain imaging with MRI to find and treat any problems that might have caused the seizure.
Anyone who has had more than 1 seizure should see a neurologist, who will ask many of the same questions. They will also repeat some tests and do others to continue ensuring no other problem is causing the seizure and try to learn more about the seizures. Sometimes genetic tests will be ordered, especially if other family members have epilepsy or the person with seizures has trouble thinking or behaves strangely after seizures. Evaluation with EEG to measure brain electric activity and patterns may have to last 24 to 48 hours or more. Usually, but not always, this is done in the hospital. Sometimes it is necessary to monitor a person’s brain during sleep or after they have gone without sleep.
There is no cure for epilepsy yet. The goal of treatment is to prevent seizure activity. The first step is usually to use an antiepileptic medication. There are many available. The doctor will discuss which is best to try first depending on a person’s type of seizure, cause of epilepsy, age, sex, side-effects, other health problems, and cost. If the first drug tried doesn’t decrease the seizure activity after 3 months, another will be tried. Sometimes multiple drugs can be used together.
Most people find a drug that works for them. When 3 or more different drugs have been tried by a person with epilepsy and none have worked, the epilepsy is considered medication- or drug-resistant. People with medication-resistant epilepsy should be seen by a neurologist who specializes in epilepsy, called an epileptologist, preferably at a comprehensive epilepsy center. When drug-resistant epilepsy occurs, there are other treatment options, including electric nerve stimulation or even surgery.
Recently a chemical derived from marijuana was approved for treating 2 rare types of drug-resistant epilepsy. The use of medical marijuana is still being researched for treatment of epilepsies, and we don’t know yet how effective it may or may not be.
For some patients with drug-resistant epilepsy a very specific high-fat, high-protein, and low carbohydrate diet called the ketogenic diet has proven helpful. This can be a difficult diet to follow and should not be used as treatment without the involvement of a doctor and a nutritionist. It is typically used only with drug treatments are not effective.
A doctor will also be able to talk with the patient and their family about the risk of sudden unexplained death in epilepsy, known as SUDEP. This cause of death is rare (1 out of 1000 people with epilepsy), especially in people whose epilepsy has just started or who have seizures controlled well with medicine. It is important to understand this risk by talking about SUDEP and how to lower it with the health care team. Taking medicine as prescribed and partnering with the health care team to lower the number of seizures a person has are among the best ways to prevent SUDEP.
The most important thing a person with epilepsy can do is to work with their doctor to develop a treatment plan they can follow and then stick to that plan. Sometimes drugs take time to work, and it can take time to find the right dose and the right drug for each person. Taking medications that decrease seizure activity is the best way to lower the risk of SUDEP. It is important not to stop taking or change how a seizure medication is taken without consulting the doctor who prescribed it.
Having a person who can be there to help after a seizure occurs can also reduce risk of SUDEP and other problems that might result from a seizure. This can also help people with seizures, their caregivers, and their health care team informed about what seizures are happening.
Another critical safety measure for people with epilepsy is not to drive a motor vehicle during a period of active seizures or during the 6 months after a seizure last occurred. Laws regulating driving by people with epilepsy vary from state to state.
Sleeping well—7 to 8 hours per night—regularly can also diminish seizure risk. Chronic loss of sleep or poor sleep can increase seizures. Stress can trigger seizures. Although exercise and strong social support networks are not known to improve epilepsy, both promote brain health and are recommended as good ways of reducing stress.
Other than the highly specialized ketogenic diet that should be used only with medical and nutritionist supervision, there is no known effect of diet on epilepsy. Eating a heart-healthy diet will make exercise, socialization, and good sleep more possible and is a good idea, however.
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Healthy Cognitive Aging
There are evidence-based tools for staying sharp throughout the lifespan.
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Guiding patients through contraceptive choices, prepregnancy planning, and pregnancy improves pregnancy outcomes.
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A. G. Christina Bergqvist, MD
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