What is epilepsy?

Epilepsy is a brain disorder associated with recurrent seizures, and it can occur at any age. A seizure is an episode of brain overactivity wherein an abnormally high number of electrical signals are sent from the brain cells (neurons). This can lead to involuntary movement involving either twitching of some muscles or convulsions of the whole body causing the person to lose consciousness. Epilepsy affects more than 50 million people globally and approximately 5 million people are diagnosed with epilepsy each year.

Importance of epilepsy treatment

As epileptic seizures occur owing to overactive neurons, anti-epileptic drugs (AEDs) either completely stop the seizures from recurring or reduce the frequency and severity by lowering this neuronal activity. However, seizures cannot always be prevented by medication. In such cases, other treatment options such as surgery or vagus nerve stimulation should be considered. This article discusses the various treatment options available for epilepsy.

Treatment of epilepsy

Pharmacological treatment 

AEDs

Usually after the first seizure, diagnostic tests can determine if the frequency of seizures will increase via an electroencephalogram (EEG), magnetic resonance imaging (MRI) scan or cerebrospinal fluid examination for brain infection or glucose transporter 1 deficiency syndrome.

AEDs reduce the activity of nerve cells, thereby preventing or lowering the frequency of seizures. The mechanism of action of AEDs is by changing the electrical activity in nerve cells by affecting the ion channels or by changing the chemical transmission between nerve cells by affecting the neurotransmitter receptors. AEDs prevent seizures in 7 out of 10 people. Medications can be in the form of tablets, syrups or capsules. The most common medications approved are carbamazepine, valproic acid, gabapentin, levetiracetam, lamotrigine and pregabalin. 

Medications are prescribed based on the type of epilepsy, frequency of seizures, effectiveness and side effects of the medication, and the person’s tolerance to the drugs. The treatment usually starts at a low dose and if no improvement is seen, the dosage is increased. People try different medications to determine the one that is most effective and with the least side effects. Some people do not have seizures for several years and may be advised to stop AEDs, whereas others have to continue with AEDs life-long.

Side effects of AEDs

AEDs have no side effects at low doses. However, an increase in dose may cause tiredness, difficulty in thinking, dizziness, nausea, and rashes on the skin. These short-term side effects tend to subside after a while; however, long-term effects may include mental health problems, excessive weight gain or loss, sexual dysfunction or osteoporosis.

Precautions

• Take your medication on time and as directed by the physician
• Never miss a dose or stop or change the medicine without consulting your doctor
• If you are pregnant or trying to conceive, talk to your doctor as AEDs can cause birth defects.

Cannabidiol (CBD, medical cannabis)

The U.S. Food and Drug Administration (FDA) approved CBD oral solution for treating seizures in Dravet syndrome and Lennox-Gastaut syndrome in children ≥ 2 years after several studies showed its positive effect in reducing seizures.

Non-pharmacological treatment

Surgery

Epilepsy surgery is a brain surgery that removes the part of the tissue where seizures occur to stop or reduce the frequency of seizures. The risks include memory problems, vision loss, depression, and mood problems, which vary among individuals and may be temporary. Patients can resume normal daily activities in about 6 weeks and the success of the surgery can be assessed after 2 years. In temporal lobe surgery, 70% of patients become seizure-free, and in 20% of the cases, the frequency of seizures is reduced.

Surgery is considered under the following conditions:

• Failure of AEDs to reduce the frequency or stop seizures
• Identification of the region of the brain where seizures occur and where surgery can be performed

Pre-surgical assessment

Several pre-surgical tests (EEG and MRI scans to identify the origin of the seizure, and tests to assess memory, mental health and learning abilities) are performed to decide whether surgery is an option, including its risks and benefits.

These tests will guide the neurosurgeon in the following aspects:

• Whether the lesion can be safely removed without causing new issues
• Other parts of the brain controlling speech, movement, vision, hearing and memory are unaffected
• High chances of a successful surgery, which will completely stop the seizures
• Any other medical condition that can prevent the surgery

Surgery types

Resective surgery

A common type of surgery in which the neurosurgeon removes the part of the brain tissue, usually in the temporal lobe, which controls your emotions, understanding of language and memory storage and retrieval, where the seizure occurs. 

Corpus callosotomy

The neurosurgeon cuts the nerve fibres connecting the two cerebral hemispheres (the corpus callosum).

Multiple subpial transections (MST)

In the brain tissue, the fibres responsible for critical brain function are vertically arranged, whereas the seizure activity spreads through fibres that are horizontally arranged. MST is performed by making shallow cuts in the horizontal fibres to stop the spread of seizure activity while maintaining key brain functions. MST does not stop the seizures completely but prevents them from escalating. Thus, it is usually performed in combination with resective surgery on non-critical regions of the brain and in children with Landau-Kleffner syndrome, which is difficult to cure with AEDs.¹

Laser interstitial thermal therapy (LITT)

A laser beam is used to destroy the specific part of the brain responsible for the seizures. It is performed in an MRI scanner. The surgical wound is minimal, and the patient is discharged the following day.²

Vagus nerve stimulation (VNS)

VNS is recommended in adults and children (≥ 4 years) with drug-resistant epilepsy. A device is implanted under the skin on the left side of the chest area. A wire attached to the device connects to the vagus nerve and sends mild electrical impulses at regular intervals to the brain. This approach reduces the seizure frequency by increasing the blood flow to the brain, elevating the levels of neurotransmitters required for controlling seizures or changing the EEG pattern.

The side effects of VNS include hoarseness in voice, difficulty swallowing, shortness of breath, difficulty sleeping, cough, and headaches. Patients with breathing problems, sleep apnea and abnormal or low heart rate should avoid undergoing VNS. The treatment does not eliminate seizures; it only reduces their severity or frequency. Therefore, AEDs are usually used in combination with VNS.³

Responsive neurostimulation (RNS)

RNS involves a device that is placed in the skull. Small wires are placed on top of the brain at several places where seizures may originate and are connected to the device. Whenever unusual electrical activity is detected, it sends out short bursts of electrical stimulation in milliseconds that can curtail the seizure, possibly by acting on inhibitory neurotransmitters that stop the neuronal activity.

It is used in adults along with seizure medications and is commonly used for individuals who are drug-resistant or are ineligible for surgery. Bleeding or infection are possible risks associated with the procedure.⁴

Deep brain stimulation (DBS)

DBS involves a device that is placed in the chest and connected to the brain via small wires. The device is programmed to deliver bursts of electrical impulses that can reduce the severity and frequency of seizures. It is used along with seizure medication and in patients who are drugs-resistant or are ineligible for surgery.⁵

Ketogenic diet

Ketogenic diet includes four parts of fat to one part of a combination of protein and carbohydrate. This diet may alter the chemical levels in the brain, reducing seizures. It is commonly recommended for children with epilepsy where seizures cannot be controlled with AEDs. A ketogenic diet is not recommended for adults as it increases the risk of diabetes and cardiovascular diseases due to the high proportion of fat in the diet.

A study showed that seizures completely stopped in 16% of the patients and reduced by >90%  in 32%. Improved attention and mood have been observed in children. The mechanism of action possibly involves the leptin hormone produced by the ketogenic diet, which has been shown to reduce seizures in a rodent model.⁶

Complementary therapy

Yoga

Yoga is a modern therapeutic approach towards epilepsy, which restores balance in the body and its metabolism. Controlled deep diaphragmatic breathing (Pranayama) alters the blood flow, metabolism and blood oxygen levels. Yoga poses improve respiration, circulation and concentration. Moreover, practising meditation can improve blood circulation to the brain, reduce the production of stress hormones (stress is a known seizure trigger) and increase serotonin release, which calms the nervous system. Thus, yoga may reduce seizure activity. Practising Sahaja yoga for 6 months has been shown to reduce seizure frequency by 86%.⁶

Ayurveda and botanicals

Ayurveda, the traditional medical system of India, involves unclogging the channels of the mind and heart that have been blocked by doshas. Medicines can be given orally, via external application, massages and baths. The prescription of ayurvedic medicine is patient-dependent. Siddharthaka ghrita, aswagandharistam and saraswata rishta are ayurvedic medications used for epilepsy. Although not scientifically proven to be effective against epilepsy, it is based on the individual’s trust in alternative medicine.

Many botanicals, such as Valerian (European traditional botanical), Kava kava (Pacific native botanical) and Passiflora incarnata (native North and South American botanical), have been traditionally used for epilepsy; however, scientific proof is limited.⁶ 

Summary

Epilepsy is a condition where a seizure occurs more than once, indicating abnormal electrical activity of the brain. Treatment starts with a pharmacological approach (AEDs). In cases where AEDs are ineffective, surgery can be performed to remove the part of the brain from where the seizure originates. When neither AEDs alone are effective nor surgery is possible, VNS, RNS and DBS can be considered.

Lifestyle changes, such as a ketone diet, adequate sleep, stress management and reduced alcohol consumption, can also help in controlling seizures. Complementary therapies, including yoga, ayurveda or botanicals can also be used with medications. As no treatment cures all types of epilepsy, clinical advice is recommended to discuss the best treatment suitable in each case to improve the quality of life.