Buy the Book

Print This Topic Email This Topic

Pronunciations amphetamines aplastic anemia buspirone carbamazepine cerebrum chlorpromazine computed tomography cyclosporine divalproex eclampsia edema electrocardiography electroencephalography encephalitis encephalography encephalopathy ethosuximide gabapentin hemorrhage hirsutism hydrocephalus idiopathic imipenem indomethacin intracranial hemorrhage lamotrigine malaria meningitis meperidine neurologic occipital lobe phenobarbital phenylketonuria phenytoin primidone psychogenic status epilepticus syncope theophylline thrombocytopenia toxoplasmosis valproate vasculitis

In seizure disorders, the brain's electrical activity is periodically disturbed, resulting in some degree of temporary brain dysfunction.

• Many people have unusual sensations just before a seizure starts.
• Some seizures cause uncontrollable shaking and loss of consciousness, but more often, people simply stop moving or become unaware of what is happening.
• Doctors suspect the diagnosis based on symptoms, but imaging of the brain, blood tests, and electroencephalography (to record the brain's electrical activity) are usually needed to identify the cause.
• If needed, drugs can usually prevent seizures.

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.

There are two basic types of seizures:

• Epileptic: These seizures have no apparent cause (or trigger) and occur repeatedly. These seizures are called a “seizure disorder” or “epilepsy.”
• Nonepileptic: These seizures are triggered (provoked) by a disorder or another condition that irritates the brain. In children, a fever can trigger a nonepileptic seizure.

Certain mental disorders can cause symptoms that resemble seizures, called psychogenic nonepileptic seizures.

About 2% of adults have a seizure at some time during their life. Two thirds of these people never have another one. Most commonly, seizure disorders begin in early childhood or in late adulthood.

Causes

Which causes are most common depend on when seizures start:

• Before age 2: High fevers or temporary metabolic abnormalities, such as abnormal blood levels of sugar (glucose), calcium, magnesium, vitamin B₆, or sodium, can trigger one or more seizures. Seizures do not occur once the fever or abnormality resolves. If the seizures recur without such triggers, the cause is likely to be an injury during birth, a birth defect, or a hereditary metabolic abnormality or brain disorder.
• 2 to 14 years: Often, the cause is unknown.
• After age 25: A head injury, stroke, or tumor may damage the brain, causing a seizure. Alcohol withdrawal (caused by suddenly stopping drinking) is a common cause of seizures. However, in about half of people in this age group, the cause is unknown.

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 single 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 or deprived of sleep. 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.

Causes of Seizures Cause Examples High fever Heatstroke Infections Brain infections Abscess AIDS Malaria Meningitis Rabies Syphilis Tetanus Toxoplasmosis Viral encephalitis Metabolic disorders High blood levels of sugar or sodium Kidney or liver failure Low blood levels of sugar, calcium, magnesium, or sodium Underactive parathyroid gland Vitamin B6 deficiency (in newborns) Inadequate oxygen supply to the brain Abnormal heart rhythms Carbon monoxide poisoning Near drowning Near suffocation Stroke Vasculitis Structural damage to the brain Brain tumor (noncancerous or cancerous) Head injury Hydrocephalus Intracranial hemorrhage Stroke Abnormalities present or occurring at birth Birth defect Hereditary metabolic disorders, such as Tay-Sachs disease or phenylketonuria Injury during birth Fluid accumulation in the brain (cerebral edema) Eclampsia Hypertensive encephalopathy Prescription drugs* Buspirone Some Trade Names BUSPAR (used to treat anxiety disorders) Camphor Ceftazidime Some Trade Names FORTAZ TAZICEF TAZIDIME (an antibiotic) Chlorpromazine Some Trade Names THORAZINE (used to treat schizophrenia) Ciprofloxacin Some Trade Names CILOXAN CIPRO (an antibiotic) Chloroquine Some Trade Names ARALEN (used to treat malaria) Cyclosporine Some Trade Names SANDIMMUNE NEORAL (used to prevent and treat rejection of organ transplants) Imipenem (an antibiotic) Indomethacin Some Trade Names INDOCIN (used to relieve pain and reduce inflammation) Meperidine Some Trade Names DEMEROL (used to relieve pain) Phenytoin Some Trade Names DILANTIN † Theophylline Some Trade Names BRONKODYL THEOLAIR (used to treat asthma and other airway disorders) Tricyclic antidepressants (overdose) Recreational drugs Amphetamines Cocaine (overdose) Withdrawal of a drug after heavy use Alcohol General anesthetics (used during surgery) Sedatives, including sleep aids Exposure to toxins Lead Strychnine *Various drugs can cause seizures if too much is taken. † Phenytoin Some Trade Names DILANTIN , used to treat seizure disorders, can cause seizures if too much is taken.

Symptoms

In about 20% of people who have a seizure disorder, seizures are preceded by unusual sensations (called aura), such as the following:

• Abnormal smells or tastes
• Butterflies in the stomach
• A feeling of déjà vu
• An intense feeling that a seizure is about to begin

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's 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 (see Biology of the Nervous System: Brain and Brain Dysfunction: Dysfunction by Location) as in the following:

• An intensely pleasant or unpleasant taste if the part of the cerebrum called the insula is affected
• Visual hallucinations (seeing unformed images) if the occipital lobe is affected
• Inability to speak if the area that controls speech (located in the frontal lobe) is affected
• A convulsion (jerking and spasms of muscles throughout the body) if large areas on both sides of the brain are affected

Other possible symptoms include numbness or tingling in a specific body part, brief episodes of unresponsiveness, loss of consciousness, confusion, and loss of muscle or bladder control.

Symptoms also vary depending on whether the seizure is partial or generalized. About 70% of people have only one type of seizure. The rest have two or more types.

Partial Seizures: Only one side of the brain is affected. Partial seizures may be simple or complex.

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 begin to shake and jerk. 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:

• Stare
• Chew or smack the lips involuntarily
• Move the hands, arms, and legs in strange, purposeless ways
• Utter meaningless sounds
• Not understand what other people are saying
• Resist help

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. 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 tonic-clonic 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.

Generalized Seizures: 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 tonic-clonic seizures may be primary or secondary. Primary generalized seizures begin with abnormal discharges in a deep, central part of the brain and spread simultaneously to both sides of the brain. Secondary 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 complex partial seizure. The discharge then quickly spreads to both sides of the brain, causing the entire brain to malfunction. In both types, consciousness is temporarily lost and a convulsion occurs when the abnormal discharges spread to both sides of the brain. In primary generalized seizures, there is no aura. During the seizure, people may do the following:

• Have severe muscle spasms and jerking throughout the body
• Fall down
• Forcefully turn their head to one side
• Clench their teeth
• Bite their tongue (often occurs)
• Drool or froth at the mouth
• Lose bladder control

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.

Absence seizures may be typical (petit mal) or atypical. 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 are 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 are less common. They last longer that typical absence seizures, jerking and other movements are more pronounced, and people are more aware of their surroundings. 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. 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.

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, resulting in a tonic-clonic seizure with loss of consciousness.

Infantile spasms and febrile seizures occur in children (see Childhood Cancers: Prognosis and Treatment).

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 of juvenile myoclonic epilepsy often occur when people awaken in the morning, especially if they are sleep-deprived. Drinking alcohol also makes these seizures more likely.

Status epilepticus is the most serious seizure disorder and 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 a seizure lasts more than 5 minutes or when people do not completely regain consciousness between seizures. People have convulsions with intense muscle contractions and cannot breathe adequately. Body temperature increases. Without rapid treatment, the heart and brain can become overtaxed and permanently damaged, sometimes resulting in death.

Complications: 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 unexplained death in epilepsy.

Did You Know... Many types of seizures do not cause convulsions and loss of consciousness. Putting a spoon in the mouth of someone having a convulsion can do more harm than good.

Diagnosis

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—see Low Blood Pressure: Fainting) than a seizure.

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:

• How fast the episode started
• Whether it involved abnormal muscle movements (such as spasms of the head, neck, or facial muscles), tongue biting, drooling, loss of bladder control, or muscle stiffening
• How long it lasted
• How quickly the person recovered

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 whether people have had a disorder that can cause seizures (such as a brain infection) or a head injury. Doctors also ask about which drugs (including alcohol) people are taking or have recently stopped. A thorough physical examination is done. It may provide clues to the cause of the symptoms.

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.

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 (see Symptoms and Diagnosis of Heart and Blood Vessel Disorders: 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.

Computed tomography (CT) is usually done promptly to check for bleeding, tumors, and other structural damage to brain tissue (for example, by a stroke). If results are negative, magnetic resonance imaging (MRI) is usually done later. It provides detailed images of abnormalities and can detect most neurologic disorders.

If doctors suspect a brain infection such as meningitis or encephalitis, a spinal tap (lumbar puncture—see Diagnosis of Brain, Spinal Cord, and Nerve Disorders: How a Spinal Tap Is Done) is usually done.

Electroencephalography (EEG) can help confirm the diagnosis. EEG is a painless, safe procedure that records electrical activity in the brain (see Diagnosis of Brain, Spinal Cord, and Nerve Disorders: Electroencephalography). 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.

If these tests do not identify a cause, other tests may be done. 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 this test, 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.

Treatment

If the cause can be identified and eliminated, no additional treatment is necessary. For example, if a low blood sugar (glucose) level (hypoglycemia—see 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.

General Measures: Exercise is recommended and social activities are encouraged. However, people who have a seizure disorder may have to make some adjustments. For example, they should eliminate or limit their consumption of alcoholic beverages and should not use recreational drugs. They should refrain from activities in which a sudden loss of consciousness could result in serious injury. For example, they should not bathe in a bathtub, climb, swim, or operate power tools. 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 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:

• Protect the person from falling
• Loosen clothing around the neck
• Place a pillow under the head

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. 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.

Anticonvulsants: These drugs reduce the risk of having another seizure. Usually, they are prescribed only for people who have had more than one seizure, unless the cause has been identified and completely eliminated. They are usually not prescribed when people have had only one generalized seizure. Most anticonvulsants are taken by mouth.

Anticonvulsants can completely prevent generalized 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 the response to it. For most people, taking one anticonvulsant, usually the first or second one tried, controls seizures. If seizures recur, different anticonvulsants are tried. 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:

• A seizure disorder since childhood
• The need to take more than one anticonvulsant to be seizure-free
• Seizures while taking an anticonvulsant
• Partial or myoclonic seizures
• Abnormal EEG results within the previous year

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 (see Drug Use During Pregnancy: Categories of Risk for Drugs During Pregnancy). 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. All women who are of childbearing age and take an anticonvulsant should take folate supplements to reduce the risk of having a baby with a birth defect.

Emergency Treatment: Emergency treatment is required for status epilepticus and seizures that last more than 5 minutes. Large doses of one or more anticonvulsants are given intravenously as quickly as possible. 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.

Drugs Used to Treat Seizures Drug Use Possible Side Effects Acetazolamide Some Trade Names DIAMOX Absence seizures when other anticonvulsants are ineffective Kidney stones, dehydration, and chemical imbalances in the blood Carbamazepine Some Trade Names TEGRETOL Generalized seizures Partial seizures A low white blood cell count (granulocytopenia), production of too few blood cells (aplastic anemia, which can be fatal disorder), a low platelet count (thrombocytopenia), digestive upset, inability to articulate words, lethargy, dizziness, and visual disturbances Clonazepam Some Trade Names KLONOPIN Atonic seizuresAtypical absence seizures Infantile spasms Myoclonic seizures Drowsiness, abnormal behavior, loss of coordination, and lost effectiveness of the drug after 1 to 6 months Divalproex Some Trade Names DEPAKOTE Absence seizures Febrile seizures Generalized tonic-clonic seizures Infantile spasms Juvenile myoclonic epilepsy Myoclonic seizures Partial seizures Nausea, vomiting, abdominal pain, diarrhea, temporary drowsiness, dizziness, shaking (tremor), reversible hair loss, weight gain, and liver damage Ethosuximide Some Trade Names ZARONTIN Absence seizures Nausea, lethargy, dizziness, headache, a low white blood cell count, and a low red blood cell count Felbamate Some Trade Names FELBATOL Atypical absence seizuresPartial seizures Headache, fatigue, liver failure, and, rarely, aplastic anemia (which can be fatal) Fosphenytoin Some Trade Names CEREBYX Status epilepticus Loss of coordination, drowsiness, dizziness, headache, rash, and tingling sensations Gabapentin Some Trade Names NEURONTIN Partial seizures Drowsiness, dizziness, weight gain, and headache In children, aggressive behavior, mood swings, and hyperactivity Lamotrigine Some Trade Names LAMICTAL Generalized seizures Partial seizures Nausea, vomiting, indigestion, headache, drowsiness, dizziness, insomnia, fatigue, loss of coordination, double vision, tremor, rash, and abnormal menstrual periods Levetiracetam Some Trade Names KEPPRA Juvenile myoclonic epilepsy Myoclonic seizures Partial seizures Primary generalized tonic-clonic seizures Dizziness, weakness, fatigue, loss of coordination, changes in mood and behavior, and increased risk of infection Oxcarbazepine Some Trade Names TRILEPTAL Partial seizures Headache, abdominal pain, double vision, drowsiness, dizziness, fatigue, nausea, low sodium levels in the blood, and a low white blood cell count Phenobarbital Some Trade Names LUMINAL Generalized tonic-clonic seizures Partial seizures Status epilepticus Drowsiness, abnormal eye movements (nystagmus), and loss of coordination In children, hyperactivity and learning difficulties Phenytoin Some Trade Names DILANTIN Complex partial seizures Generalized tonic-clonic seizures Swollen gums, a low red blood cell count, loss of bone density, excessive hairiness (hirsutism), and swollen glands   Status epilepticus when phenytoin Some Trade Names DILANTIN is given intravenously   Pregabalin Partial seizures Dizziness, drowsiness, loss of coordination, blurred vision, double vision, tremor, and weight gain Primidone Some Trade Names MYSOLINE Generalized tonic-clonic seizures Partial seizures Drowsiness, abnormal eye movements (nystagmus), and loss of coordination In children, hyperactivity and learning difficulties Tiagabine Some Trade Names GABITRIL Partial seizures Drowsiness, dizziness, confusion, abdominal pain, fatigue, nausea, abdominal pain, and tremor Topiramate Some Trade Names TOPAMAX Atypical absence seizures Partial seizures Primarily generalized tonic-clonic seizures Confusion, reduced concentration, difficulty finding words, fatigue, loss of appetite and weight, numbness or tingling, reduced sweating, and kidney stones Valproate Some Trade Names DEPARENE Absence seizures Febrile seizures Generalized tonic-clonic seizures Infantile spasms Juvenile myoclonic epilepsy Myoclonic seizures Partial seizures Nausea, vomiting, abdominal pain, diarrhea, weight gain, reversible hair loss, temporary drowsiness, shaking (tremor), and, rarely, liver damage Zonisamide Some Trade Names ZONEGRAN Partial seizures Drowsiness, fatigue, dizziness, confusion, difficulty finding words, loss of coordination, kidney stones, loss of appetite and weight, and nausea

Surgery: 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:

• Functional MRI: To determine which areas in the brain are causing seizures
• Single-photon emission CT (SPECT): To check for areas with decreased blood flow around the time of a seizure, which may indicate which areas in the brain are causing seizures
• EEG combined with magnets used for imaging (magnetic source imaging): Also to help determine which areas in the brain are causing seizures

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 80% 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 (see Diagnosis of Brain, Spinal Cord, and Nerve Disorders: Physical Examination) 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 some people. 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. 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.

When people sense that a seizure is about to begin, they turn the device on with a magnet. Or, the device may be left on all the time to intermittently stimulate the vagus nerve. Vagus nerve stimulation is used in addition to anticonvulsants. Side effects include hoarseness, cough, and deepening of the voice when the nerve is stimulated.

Last full review/revision March 2008 by Bola Adamolekun, MD