Dr. Madhuri Khilari Neurologist and Epileptologist, Apollo Hospitals, Jubilee Hills.
Dr. Madhuri Khilari Neurologist and Epileptologist, Apollo Hospitals, Jubilee hills.

~ International Epilepsy Day – February 11th 2019 ~

How significant is this
problem of epilepsy in our country?

There are more than 12 million persons with epilepsy (PWE) in India.
These constitute around 17% of the 70 million PWE worldwide.  Despite availability of antiepileptic drugs
(AEDs), there is a large treatment gap varying from 50 to 70% among PWE. The
overall incidence (0.2-0.6 per 1000 population) and prevalence is (3.0-11.9 per
1000 population) in India. For treatable epilepsy, this gap can be attributed
to poor education, poverty, cultural beliefs, stigma, and poor healthcare
infrastructure; whereas for chronic epilepsy, this gap can be attributed to
lack of proper diagnosis and treatment.

The burden of epilepsy, as estimated using the disability-adjusted life
years (DALYs), accounts for 1% of the total burden of disease in the world.
This does not consider the morbidity caused by social stigma and isolation,
which PWE in our country face; thereby intensifying the magnitude of problem in

What is epilepsy? Does it mean that a person
who has had a seizure once has epilepsy?

Seizures and epilepsy are not the same.

An epileptic seizure is a transient occurrence of signs and/or symptoms
due to abnormal excessive or synchronous neuronal activity in the brain.

IALE defines Epilepsy as a disease characterized by an enduring
predisposition to generate epileptic seizures and by the neurobiological,
cognitive, psychological, and social consequences of this condition.

In simple words, a seizure is an event and epilepsy is the disease
involving recurrent unprovoked seizures and consequences thereof.

A commonly used definition of epilepsy heretofore has been two
unprovoked seizures more than 24 hours apart.

What precautions are important for people
with seizures and epilepsy:

A risk
assessment should be done for such people. It includes assessment for performing
following activities and for following conditions:

Bathing and showering, preparing food, using electrical equipment, managing
prolonged or serial seizures, the impact of epilepsy in social settings, SUDEP
(sudden unexpected death in Epilepsy), the suitability of independent living,
where the rights of the child, young person or adult are balanced with the role
of the carer.

For patients who throw acute full-blown generalized seizure, it is
important for the bystanders to not panic. It is important that patient’s oral
cavity is free and not occluded by cloth/ fingers/ any other material. If
feasible, a patient actively seizing should be always made to lie down in a
sideways position, in a safe place. If a doctor has prescribed nasal midazolam,
it can be administered in prescribed doses. An immediate medical attention
should be sought while attending to a patient with active seizures.

Can seizures Be

With a good compliance of medications, we can
ensure that the seizures are maximally controlled.

Per se, it is difficult to predict who could
develop epilepsy.

In developing countries, maintaining hygiene
of food consumption may help preventing neurocysticercosis, one of the
commonest causes of epilepsy in our country.

For expecting parents, approaching birth can
be an ideal opportunity to review and consider the best and most helpful
measures to start to ensure maximum safety for both mother and baby. 

What are the causes of Epilepsy?

Epilepsy can be caused by different conditions that affect a person’s
brain. Some known causes include:

  • Stroke.
    • Brain tumor.
    • Brain infection from parasites (cerebral malaria, neurocysticercosis),
      viruses (Herpes simplex), and bacteria, tuberculosis
    • Loss of oxygen to the brain (for example,
      during birth).
    • Other neurologic diseases (hereditary
      dementias, ataxias).

For 2 in 3 people, the cause of epilepsy is unknown. This type of
epilepsy is called cryptogenic  or idiopathic. However, most
of the so-called idiopathic causes now we do have genetic basis, which can be
discovered only after a detailed genetic analysis.

All said, there are very few epilepsies that are transmitted from one
generation to another. Most of them are acquired, although genetic and environmental
factors may result in the condition manifesting in a person.

What are the types of seizures, are all
seizures similar?

The clinical presentation depends on a number of factors, chiefly: the
parts of the brain affected, the pattern of spread of epileptic discharges
through the brain, the cause of the epilepsy and the age of the individual. The
classification of the epilepsies is controversial and has tended to focus on
both the clinical presentation (type of epileptic seizure) and on the
underlying neurological disorder (epilepsies and epilepsy syndromes).

As a general awareness regarding seizures, there are partial and
generalized seizures. Children may have other kinds like absence seizures and
Epileptic spasms.

What tests are needed in
People with epilepsy?

In general, a physician often needs basic evaluation to find the cause
of epilepsy. This may include neuroimaging and an electroencephalogram (EEG).
Of children a battery of tests including neurometabolic workup, genetic
analysis and neuropsychiatric assessment may be needed. The latter two also
help in assessment of epilepsy presenting de novo at any age and refractory
epilepsies. For people who already are on medications, a physician may advice
drug levels to guide the treatment and evaluate side effects.

Is epilepsy treatable? How long should be
treatment for epilepsy be? When can AEDs be tapered?

Treatment decisions are often individualized between a person with
epilepsy and a physician. A physician often considers the patient profile and
tailors the treatment offering the most suitable drugs in the armamentarium of
epilepsy drugs.

At times, an
incomplete description of seizure that went unwitnessed may mar the diagnosis.
In such instances, clinicians use their best judgement in order to treat the

In any case
you consider yourself as an epileptic or not, it is paramount to consult a doctor
and decide upon medications accordingly.

It is
difficult to decide the duration of treatment a patient needs at the offset. A
physician often considers medical issues, associated risks and comorbidities,
electrodiagnostics and response to treatment before deciding if medications
could be tapered.

characteristics physicians consider characteristics like focal, myoclonic ,
tonic-clonic seizures  and seizures that
persist after treatment or need more than one drug to get controlled as
indicators for prolonged treatment. Even in children, learning disabilities,
epileptiform abnormalities and history of focal seizures are poor prognostic
markers for treatment withdrawal.

We know of
some good prognostic markers in childhood epilepsy. And children having a
particular subset of epilepsy like typical absence seizures, Rolandic seizures,
benign occipital seizures definitely outgrow the condition with age.

When to start medications
for seizures?

The available literature demonstrates that although early AED treatment
robustly reduces seizure recurrence risk in the short-term, the prognosis for
the development of epilepsy is unchanged. The indication for early
AED treatment depends on the presence of key risk factors such as epileptiform
abnormalities on EEG, a remote symptomatic
etiology, a significant abnormality on neuroimaging, abnormal neurological exam, and a nocturnal seizure among others.

Its more or
less akin to people with diabetes or hypertension or high BP, wherein, the
risen sugars and BP levels are taken care of as long as a patient is on medications;
while off medications, they stand increased risks of uncontrolled sugars and
blood pressure respectively. This also means regular and monitored intake can
control the condition extremely well.

Can seizures persist even after medications
have been started?

This depends
on several factors. A poor compliance or inappropriate or insufficient trial of
medications can result in poorly controlled seizures even after starting
medications. Starting medications does not mean that the underlying cause for
seizures is eradicated. More often than not, medications started for PWE are
for preventing the abnormal excessive electrical discharge in brain that
culminates into seizures than addressing the underlying etiology. This is
because, the underlying brain damage may not always be treatable.

What is refractory

Out of 3 epilepsy patients, one can have uncontrolled seizures despite receiving
an adequate trial of more than two anti-epileptic medications

What is the treatment for
refractory epilepsy?

A physician often tries to control the seizures by changing and
titrating the drugs. Epilepsy surgery is available at many centers, including ours
for a certain subset of epilepsies. Vagal nerve stimulation and a bit expensive
procedure – the responsive nerve stimulation are available for the inoperable
conditions. For children, modalities like ketogenic diet have also helped in
some metabolic conditions with seizures as well as other refractory epilepsies.

Can people with epilepsy participate in

In general, if a person is free from seizures he/she and is on
antiepileptic drugs, most of the sports and leisure activities can be undertaken.
The problem arises when the seizures are frequent and poorly controlled. For
them, any type of activities, which may endanger their life or that of others
due to an accident resulting from a seizure, should be avoided.

Can people with epilepsy
get married?

Today a person with epilepsy can have a legally valid marriage and
epilepsy is no more an illness to claim for divorce. A woman who is in the
reproductive age group gets appropriate counselling from the treating
physician. The latter adjusts medications suitable to this age group. Women
with difficult to control epilepsy should have periodic assessments and
medications may be adjusted/ changed before they conceive.

PWE have right to live as normal individuals and can have highly
successful carriers and family lives. People who have created history like
Theodre Roosevelt, Olympic athlete Dai Greene, Prince an American singer and
writer, author who is a legend Agatha Christie, Olympian Florence Griffith Joyner,composer
George Gershwin, Alexander the Great who conquered the world. The list is
really exhaustive—all faced epilepsy- and created wonders this world has witnessed.
Socrates, Julius Caeser, Napolean I of France all were said to suffer from
epilepsy. World still remembers them for their greatness, not for their

Concluding, epilepsy is a condition that if properly attended, treated and cared may result in a perfectly normal lifestyle. There is no reason why a person with epilepsy that is well controlled should not be able to do something a normal person does. There is always a ray of hope with newer treatment modalities for the patients with hitherto uncontrolled seizures despite proper medications. Epilepsy is a condition, like any other medical condition- be it diabetes or hypertension. It should not be stigmatized upon. Both these conditions need precautions and meticulous treatment, which are easy to follow and need lifestyle adaptation. Small wonder if people with epilepsy can live an absolutely normal healthy lifestyle, have blooming families and carriers, if all the things are taken care of!

Dr. Madhuri Khilari

Neurologist and Epileptologist,

Apollo Hospitals, Jubilee Hills.

Apollo Hospitals, Jubilee Hills.

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