Epilepsy
Morgan Feely
Consultant Physician
Target Meeting
Tong, November 2006
Epilepsy
A person is said to have ‘epilepsy’ when they have
exhibited a tendency to have recurring seizures
It is not a single disease
Manifest by underlying brain dysfunction from many
known or unknown causes
Single seizures should not be diagnosed as epilepsy
A patient could be said to have ‘one of the epilepsies’ as
there are a number of seizure types and causes.
Epidemiology
Bimodal incidence
440,000 active cases in UK
Typical practice: 15 patients per 2000
Age-specific prevalence of treated epilepsy per 1000 persons
Source: Wallace, Shorvon, Tallis, Lancet
9.5
9
8.5
8
7.5
7
6.5
Prevalence/100 0
6
5.5
5
4.5
4
3.5
3
2.5
2
1.5
1
0.5
0
5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85+
Age
Age-specific incidence of treated epilepsy per 100,000 persons
(Source: Wallace, Shorvon, Tallis: The Lancet, 1998 Dec 19–26;352
(9145):1952-3)
210
200
190
180
170
Incidence/100,000
160
150
140
130
120
110
100
90
80
70
60
50
40
30
20
10
0
5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85+
Age
The epilepsies
Generalised epilepsies Location related
(mostly idiopathic) epilepsies
(mostly symptomatic)
tonic-clonic (T-C)
and/or absences partial seizures
and/or myoclonic partial +/- secondary
seizures (T-C) generalisation
Over 200 epilepsy syndromes described - mostly of
relevance to young people
Seizures across the ages
Teens/early 20’s Late 20’s – 50’s Late 50’s – 80+
JME Alcohol / drugs Cerebrovascular
disease
Primary Brain tumours Dementias
generalised (T-C)
SAH Brain tumours
Partial +/- Head injury
secondary T-C
Metabolic disorders eg low Na
Late presentation
of earlier types
Continuation of childhood/earlier epilepsy
Making the diagnosis 1
History
History and / or
Eye witness or…
First tonic-clonic seizure in an adult
Clinical scenario
You are asked to see a patient who collapsed and
appeared to have a ‘fit’ within the last few days and is
now back to normal
What are the key issues?
Seizure versus (convulsive) syncope
Provocation (late nights and alcohol, drugs) ?
Is there any evidence of previous unrecognised seizures
What is the patient’s occupation / driving status?
Differences between seizures and syncope
Seizures Syncope
Any posture (e.g. in bed at night) Occurs standing (or sitting if elderly)
Blue lips during attack Pale and clammy
Stiffness and tonic-clonic movements Brief jerking movements may occur
coincide with loss of consciousness and after loss of consciousness
often last for several minutes
Patient is rigid as falls to ground Patient loses tone then falls to ground
Urinary incontinence common Urinary incontinence can occur
Disorientated or headache afterwards
Tongue biting and serious injuries are Quick recovery
common
Seizures arising from secondary
generalisation may be preceded by an Tongue biting rarely; serious injuries
aura or recognisable partial seizure occur in 5% of cases
Often preceded by feeling warm and
light headed
Case 1
18 year old female law student attends your surgery after
suffering a ‘blackout’ following breakfast. Her housemate
had said to her she had a ‘grand mal convulsion’.
Seizure versus syncope
features to support syncope or convulsive syncope…WITNESS / TELEPHONE
Provocation
Studying for exams, started drinking at university, no illicit drugs
Is there any evidence of previous unrecognised seizures
Since the age of 16 occasionally ‘daydreams’, jerks in the morning, cup of tea
What is the patient’s occupation / driving status
Student, drives a car, NB. OCP
Diagnosis: JME
Case 2
42 year old businessman attends surgery following a
generalised seizure. On record he has a heavy alcohol
consumption (>50 units per week), but has recently cut
down.
Seizure versus syncope
No clear witness account, any eye witnesses?
Provocation
Alcohol (ab)use and cut down
Is there any evidence of previous unrecognised seizures
‘Has had a fit before’ after binge drinking
What is the patient’s occupation / driving status
Driver. DVLA issues. Provoked seizure?
Case 3
42 year old businessman attends surgery with his wife who
is concerned he is behaving oddly at times, repeatedly
saying things over and over. On record he has a heavy
alcohol consumption (>50 units per week)
Seizure versus syncope
History from wife ‘Golf-traps! Golf-traps!’ , detached : complex partial seizure(s)
Provocation
Alcohol use, but not in keeping with focal seizure
Is there any evidence of previous unrecognised seizures
No
What is the patient’s occupation / driving status
Driver. Urgent investigations
Diagnosis:
Glioblastoma
Case 4
A 69 year old male attends with seven attacks of speech
disturbance lasting 3 minutes over the last 4 months. He
has been investigated previously for TIA / stroke.
Seizure versus syncope
No evidence of syncope. Recurrent stereotypical focal neurology. Clean stroke tests.
Provocation
No evidence. Not situational. Without warning.
Is there evidence of unrecognised seizures?
No
What is the patient’s occupation / driving status?
Driver. DVLA issues
Case 5
You are asked to see a 73 year old lady in her RH. She had a
previous Left hemi-paresis. The staff think that she has ‘had
another stroke.’
Seizure versus syncope?
Speak to RH witness. ‘Vacant’ at onset with ‘jerking movements’ of left upper limb.
Provocation
Recently started antidepressant for low mood, recent UTI and ‘antibiotics’
Is their evidence of unrecognised seizures?
RH staff say she occasionally ‘switches off’ and ‘stares into space’. Recurrent ‘strokes’
Occupation / driving status
Less relevant, ‘lifestyle issues’. Avoid unnecessary tests?
Making the diagnosis 2
Making the diagnosis 3
Management
Management
Starting AED treatment in newly diagnosed epilepsy
AIMS PRINCIPALS
Prevention of seizures Appropriate drug for
patient’s seizure(s)
Minimal side effects
Appropriate drug for
Optimise QOL individual patient
Through trial and error
Antiepileptic drug development
AEDS More
20
Levetiracetam
Oxcarbazepine
Tiagabine
15 Fosphenytoin
Topiramate
Gabapentin
Felbamate
Lamotrigine
10 Zonisamide
Sodium valproate Vigabatrin
Carbamazepine
Ethosuximide Benzodiazepines
5
Phenobarbital Primidone
Bromide
Phenytoin
0
1840 1860 1880 1900 1920 1940 1960 1980 2000
Year
Choice of drug
Seizure type
Women of childbearing age
Pregnancy
Breastfeeding
Children
Elderly
Learning disability
Treatment options by seizure type
GENERALISED-ONSET SEIZURES PARTIAL-ONSET SEIZURES
Absence myoclonic tonic / atonic primary T-C simple complex-partial
secondary generalisation
Ethosuxamide CARBAMAZEPINE
Phenytoin
Vigabatrin
Gabapentin
Oxcarbazepine
VALPROATE
LAMOTRIGINE
Levetiracetam
Topiramate
Phenobarbital
Benzodiazepines
Initial (first line) treatment
Drugs for generalised seizures Drugs for partial seizures (+/-
secondary generalisation)
Valproate (Epilim Chrono) Carbemazepine (Tegretol
Retard)
Lamotrigine
Lamotrigine
[Topiramate]
Valproate (Epilim Chrono)
Levetiracetam
[Topiramate ]
Sodium valproate (Epilim Chrono)
Useful for location related Can cause tiredness,
and generalised epilepsy tremor, weight gain,
alopecia
Can be brought up to
therapeutic dose quickly Teratogenic (spina bifida)
Low(er) doses tolerated
and possibly drug of
choice for elderly patients
Carbamazepine (Tegratol)
Good drug for partial seizures in young(er) adults
Needs gradual build up to a therapeutic dose
Enzyme-inducer, therefore interactions/oestoporisis
Most specialists use MR (Tegretol Retard)
Lamotrigine (Lamictal)
Broad spectrum
Needs to build up
slowly (months) to
Good tolerability as reduce AEs
monotherapy
Rash common,
Well tolerated by the sometimes severe and
elderly associated with Steven-
Johnson’s syndrome
Synergistic effect with
sodium valproate Blood dyscrasias
Least teratogenic
Newer second line agents - Levetiracetam
(Keppra)
Relatively new but appears Sedation common,
well tolerated and though tends to resolve
efficacious
Long-term experience
Monotherapy licence
still lacking
Licensed for partial
seizures +/- secondary
generalisation (may be
effective in other seizure
types)
Can be started at close to
therapeutic range
Newer second line agents - Topiramate
Potent anticonvulsant Often not tolerated due to
activity side effects: confusion,
word-finding difficulties,
Useful for most forms of weight loss
epilepsy
Needs slow induction
When to start treatment
What is the cause?
What is the risk of recurrence?
First Vs second seizure?
What does the patient / carer think?
Poor control
• Concurrent pro-convulsant drugs Alcohol
prescription
• Lifestyle Sleep
Stress
• Concordance / compliance Why?
ADR
other drugs
Social aspects
Treatment errors
• Incorrect / incomplete detection of seizure(s) resulting
in inappropriate drug choice.
• Appropriate drug for the seizure(s), but not the
patient.
• Wrong dose (high or low)
• Seizures are controlled, but intolerance / SE are a
problem.
• The occurrence of a progressive neurological
condition
Prognosis
• 70 – 80% prolonged remission
• Poor control Structural lesion
EEG abnormality
Associated neuropsychiatric disorder
More than one drug ?
• SUDEP
AED withdrawal
• Seizure free (remission) > 3 (2?) years
• Overall risk of recurrence is 40%
• Most relapses occur within the first year off treatment
• Factors increasing relapse; syndrome, structural
abnormality, severe epilepsy before remission, age.
• Discussion risk versus continued therapy
DVLA – 6 month suspension
Leisure pursuits
Contraception / pregnancy etc
Service Level
Primary Care Secondary care
GMS Establish diagnosis
Referral First seizure initiate treatment
Poor control
Special cases Follow up
AED withdrawal Difficult control
Follow-up if stable Tertiary referral
Re-refer
Neuro-oncology
Obstetrics
Elderly
Epilepsy Nurse specialists