Approximately 600,000 people in the UK are living with
epilepsy, and to this day, the cause in the majority of sufferers cannot be
established. Fortunately, there are a whole host of treatments that can greatly
assist in the management of this debilitating condition. (1)
What is epilepsy?
Epilepsy means that a person is prone to experiencing
epileptic seizures (fits). A seizure occurs when there is a sudden surge in
electrical activity in the brain and its electrical signals, which are vital
for normal biological processes, become muddled. Seizures manifest themselves
in various ways depending on the area of the brain in which these surges occur
and the signalling pathways affected. (1,2)
Focal seizures begin
on one side of the brain. Usually, they only last for up to two minutes.
Symptoms can vary greatly and a person may experience one or more symptoms,
including but not limited to stiffness, rhythmic movements, limpness or jerking
in part of the body, changes in senses or hallucinations, a sense that the body
is distorted, déjà vu and confusion. (3)
Tonic-clonic seizures
are the ‘typical’ jerky seizures that people are generally familiar with.
They can be focal or bilateral, meaning they may start on one or both sides of
the brain. They are characterised by two phases – the ‘tonic’ phase, when the
person may cry out and bite the inside of their mouth, then become stiff, unconscious
and fall if standing; and the ‘clonic’ phase, involving rhythmic jerking,
breathing difficulties and sometimes soiling oneself. They usually last no
longer than three minutes. If they exceed five minutes, call 999 for an
ambulance, unless you know for definite that seizures of this length which end
by themselves are normal for the particular person. (4)
Tonic seizures follow
the same course as the ‘tonic’ part of the aforementioned tonic-clonic seizure.
They generally last no longer than one minute. (5)
Atonic seizures
are the opposite of tonic seizures, with the body going limp instead of stiff.
The affected person may fall or their head or knees may slump. They are
normally up to two seconds long. (6)
Absence seizures begin
on both sides of the brain and are split into typical and atypical forms. Typical
absence seizures feature sudden abandonment of current activities, a very short
loss of consciousness (but no falling) and then the appearance of daydreaming.
There may also be fluttering of the eyelids, minor body jerking or repetitive
movements. During a typical absence seizure, the affected person is unaware of
what is going on around them and other people will be unable to interact with
them. These seizures are short, lasting approximately 10 seconds, but can occur
in hundreds in a single day. Atypical absence seizures have a greater duration of
around 30 seconds, and tend to come on and wear off gradually. Movement is
possible, but this will be clumsy in appearance due to limpness of the muscles.
It may also be possible for other people to interact with the affected person.
(7)
When is medical
assistance needed?
As mentioned previously, a seizure exceeding five minutes in
length warrants urgent medical attention, unless you know for a fact that the
person regularly experiences seizures this long that subside on their own. (2,
4)
Other instances when you will need to call 999 and ask for
an ambulance are as follows:
How is epilepsy
treated?
The mainstay of treatment for epilepsy is antiepileptic drug
therapy, of which there are a vast range of options. Antiepileptics alter the
amount of certain chemicals within the brain, having a knock-on effect on
electrical activity. The specific antiepileptic drug prescribed for a person
will be determined by the seizures experienced, their age and whether they are
likely to become pregnant in the near future, amongst other factors.
Clonazepam
and valproate can be used to
treat any form of epilepsy. Clonazepam works by potentiating a specific
inhibitory signalling chemical in the brain known as gamma-aminobutyric acid
(GABA). This in turn reduces electrical activity. Valproate raises GABA levels
and blocks chemical transport channels in the brain. Due to the risk of serious
harm to unborn babies if taken in pregnancy, valproate is avoided in women of
childbearing potential unless other medicines have failed to control the
epilepsy.
Tonic-clonic seizures can be treated withclonazepam, valproate, carbamazepine, lamotrigine, oxcarbazepine,
phenobarbital, phenytoin, primidone and topiramate. Most block movement of chemicals through transport
channels in the brain, with topiramate and lamotrigine also blocking receptors
and enzymes associated with electrical activity. Phenobarbital enhances the
effects of GABA. Phenytoin has many side effects, including depression, brittle
bones and lupus, and has many interactions with other medicines including
antacids and warfarin.
Clonazepam, valproate, carbamazepine, gabapentin, lamotrigine, levetiracetam, oxcarbazepine,
phenytoin, topiramate and zonisamide
can be used for focal seizures. The ways in which gabapentin, levetiracetam and
zonisamide work are less clear, but most likely involve blocking of chemical
channels.
Clonazepam, valproate and ethosuximide can be given to treat absence seizures. Ethosuximide is
a chemical channel blocker.
There are several antiepileptic drugs which are
used as adjuncts, meaning that they are not used as treatments alone, but
rather to improve the effects of other antiepileptics. Such drugs include clobazam, brivaracetam, eslicarbazepine,
perampanel, pregabalin, tiagabine and vigabatrin.
(8)
If treatment is unsuccessful, brain surgery may be
considered. If safe, the part of the brain responsible for seizures is removed.
(9)
If brain surgery is unsuitable, vagus nerve stimulation
(VNS) is another option. An electrical device is implanted in the chest and
wired up to the vagus nerve. Electrical activity from this device overrides
that of the brain, reducing the likelihood of developing a seizure. (9)
Deep brain stimulation, like VNS, uses an electrical
implant, but wired up to the brain. Like VNS it is designed to override the
faulty electrical activity of the brain, but carries more risks so is usually a
last resort. (9)
Can anything else be
done to prevent seizures?
As well as making sure you stick to taking your
antiepileptic drugs as prescribed, you may also be able to identify certain
triggers for your seizures. You can then try to avoid these triggers with the
aim of reducing your seizure frequency. You may find it helpful to keep a diary
of the time and place where you experience each seizure and any activities you
undertake in the lead up to them to assist you in the identification of such
triggers. (10)
Also, ensure you keep up to date with your medical reviews
so that you and your doctor can address any problems and determine whether
you’re getting the best treatment for your needs. (10)
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References
Epilepsy action. What is epilepsy? [cited 16
November 2017]. Available from: https://www.epilepsy.org.uk/info/what-is-epilepsy
NHS Choices. Overview [cited 16 November 2017].
Available from: https://www.nhs.uk/conditions/epilepsy/
Epilepsy action. Focal seizures [cited 16
November 2017]. Available from: https://www.epilepsy.org.uk/info/seizures/focal-seizures
Epilepsy action. Tonic-clonic seizures
[cited 16 November 2017]. Available from: https://www.epilepsy.org.uk/info/seizures/tonic-clonic
Epilepsy action. Tonic seizures [cited 16
November 2017]. Available from: https://www.epilepsy.org.uk/info/seizures/tonic-seizures
Epilepsy action. Atonic seizures [cited 16
November 2017]. Available from: https://www.epilepsy.org.uk/info/seizures/atonic-seizures
Epilepsy action. Absence seizures [cited 16
November 2017]. Available from: https://www.epilepsy.org.uk/info/seizures/absence-seizures
Epilepsy action. Epilepsy medicines available in
the United Kingdom [cited 20 November 2017]. Available from: https://www.epilepsy.org.uk/info/treatment/uk-anti-epileptic-drugs-list
NHS Choices. Treatment [cited 20 November 2017].
Available from: https://www.nhs.uk/conditions/epilepsy/treatment/
NHS Choices. Living with [cited 21 November
2017]. Available from: https://www.nhs.uk/conditions/epilepsy/living-with/
Author: Gabby Gallagher MPharm
Medically reviewed by: Superintendent pharmacist Margaret Hudson BSc(Hons)MRPharmS 27/11/17