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Epilepsy

INTRODUCTION

Epilepsy is defined as a ‘tendency to recurrence of seizures’. It is a symptom, not a disease. A person should not be labelled ‘epileptic’ until at least two attacks have occurred. Use monotherapy for prescribing if possible. First-line medication is valproate, or carbamazepine. For females of reproductive age, valproate is out and lamotrigine is in.

Types of epilepsy Epileptic seizures are classified in general terms as generalised and partial (Table E6). Partial seizures are about twice as common as generalised seizures and usually due to acquired pathology.

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Table E6 Classification of epileptic seizures

1 Generalised seizures

Motor—convulsive:

  • tonic–clonic (previously called grand mal)

  • clonic

  • myoclonic

  • secondary generalised

Motor—non-convulsive:

  • tonic (drop attacks)

  • atonic (drop attacks)

Non-motor (absence):

  • typical absence—childhood (petit mal) and juvenile

  • atypical absence

  • eyelid myoclonia

2 Focal (partial) seizures

Simple partial (consciousness retained):

  • with motor signs (Jacksonian)

  • with somatosensory symptoms

  • with psychic symptoms

Complex partial (consciousness impaired)

TONIC–CLONIC SEIZURES

Formerly called grand mal seizure, it is the classic convulsive seizure with muscle jerking. Typical features of sequence: AURA–CRY–FALL–FIT (clonic then tonic)—Incontinence–Confusion

  • initial rigid tonic phase (up to 60 secs)

  • convulsion (clonic phase) (seconds to minutes)

  • mild coma or drowsiness (15 mins to several hrs)

Atypical tonic–clonic seizures These variants of tonic–clonic seizures are more common than realised:

  • stiffen and fall = tonic

  • floppy and fall = atonic

  • shaking only = clonic

Diagnosis

  • Check short-term aggravating factors (e.g. lack of sleep, medications, drugs incl. alcohol)

  • Investigate and treat any cause. Usual tests—EEG, CT or MRI (preferable) scan, basic biochemistry and haematology

Management

Note: Do not usually treat on one fit (chance of a further seizure is about 70%); after second seizure when diagnosis confirmed or when 2+ within 6–12 mths. Refer to Figure E6.

Figure E6

Initial management of epileptic seizure

A flowchart represents the initial management of epileptic seizures. The steps are as follows. The single (first ever) seizure. Developmental history in child, investigate the cause and perform EEG (electroencephalography). Treat the cause if possible. Is recurrence risk high? If no, it leads to reassure and observe followed by the second question, has a further seizure occurred? If yes, it leads to the third question, was the seizure partial (focal)? If the answer to the second question is no, it leads to reassure and observe. If the answer is yes, it leads to the third question. The third question has three options: yes, no, and uncertain that lead to starting carbamazepine, starting sodium valproate, and starting sodium valproate.
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  • Profound psychosocial support

  • Education, counselling, advocacy

  • Appropriate referral

Medication

  • Sodium valproate (first choice)

  • Adults: 500 mg (o)/d for 1 wk, then bd for 1 wk, ↑ every 2–4 wks to achieve control (up to 2–3 g/d)

Some prefer carbamazepine or lamotrigine in young women because of risk of teratogenicity with valproate which, however, is less sedating.

  • Carbamazepine (2nd choice)

  • Other choices: phenytoin, lamotrigine, topiramate, levetiracetam (usually added on to achieve optimal control—check interactions)

Continue treatment until fit-free for at least 2 yrs.

Avoid use of prochlorperazine and benzodiazepines. Monitor with annual LFTs and FBE.

ABSENCE SEIZURES

This type of generalised epilepsy typically affects children from 4 yrs up to puberty. It is ...

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