I have infrequent seizures: to treat or not to treat? -that is the question

A great question from a concerned sister. My reply follows.

 

Hi Dr Sethi,

Thank you for your very informative site. My brother was recently diagnised with complex partial epilepsy. His seizures (that he is aware of at least) are very few and far between, on average one every two to six months. He says he knows in advance when the sezures are beginning as he starts with loss of vision slowly in one eye and then the other and then his hands go numb.

He feels that the side effects of the medication interfere with his busy schedule and active lifestyle and has opted not to take any medication due to the long periods between seizures. Is this advisable? If his condition is left untreated could it progress or cause any irreversible problems?

Thank you,
K

 

 

Dear K,
you have asked a very valid question and one that I have confronted personally at many times as a neurologist and epileptologist. If seizures are few and far inbetween do they warrant to be treated? There is no consensus on this. Let me explain in my usual simple way.

Argument in favor of not treating them:

1. At times patient’s get an aura and know their seizure is coming and feel they can take precautions such as sitting down if they are standing or pull over to the side of the road if they happen to be behind the wheel of a car when the aura starts. So the patient feels that since he has only infrequent seizures and that too accompanied by a reliable aura, why take an anticonvulsant medication.

2. Moreover every anticonvulsant has its own side-effect profile. Frequently the side-effects are unpleasant and so if possible the patient would like to avoid taking the medication on a regular basis.

3. Anticonvulsants have to be taken on a daily basis, some medicines have a twice daily or three times a day dosing. This interferes with their lifestyle.

4. If the seizures are few and far inbetween (like for example a patient who suffers one seizure every year), does it make sense to take a medicine on a daily basis (at times with unpleasant side-effects)?

 

 

Arguments in favor of treating these infrequent seizures:

1. One of the biggest problems with seizures is their unpredictable nature. A seizure can occur anytime, sometimes out of the blue when the patient least expects it. Moreover one does not want to have a seizure at the wrong place and the wrong time like for example when one is driving or when one is waiting by the side of the rail track or when one is swimming. Seizures can be associated with falls and injuries. Hence it makes sense to treat the seizures and aim for good seizure control no matter how infrequent the seizures may be. Many patients feel more confident when they know they are on an effective anticonvulsant and shall not have a seizure out of the blue.

2. In majority of the countries there are laws with respect to driving if you suffer from epilepsy. A patient may not like to risk loss of his driving privileges and independence if a seizure was to occur. He would rather take an anticonvulsant on a daily basis no matter how infrequent his seizures.

So you can see there are good arguments on both sides. Your brother’s doctor shall be the best person to turn to for advice.

Personal Regards,

Nitin K Sethi, MD

Seizure disorder/ epilepsy: making the diagnosis. The role of an EEG.

 

A question and an answer.

R

Hello Everyone, I am glad to meet you. I am new here.

I noticed that a lot of you are having seizures, as well as your diabetes. Seizures are a complication of diabetes. I am going to give you a link:

I also have epilepsy, diabetes and Alzheimer’s. When I was diagnosed with diabetes, I stuck to my diet. My seizures are under control now.

When you have hypoglyclemia, you can have seizures, coma and death. The same is true of hyperglycemia..When your blood glucose goes to low, you need to have a small snack. i never let my BG goes below 90 or higher than 140.

Take care of your diabetes diet and you should not have any problems.

The reason your hypoglycemia seizure does not show up on the EEG, is because it is a Diabetic Seizure. Only epileptic seizures will show up on an EEG.

Your Friend, R

 

 

 

 

Dear R,

Thank you for writing in. I am glad you are taking such good control of your blood sugar. You say only an epileptic seizure shall show up on an EEG and not a diabetic seizure–that is not quite true. A seizure is a seizure and if you happen to have one while the EEG is running, it shall be recorded on the EEG.

What you are mentioning R is what we neurologists refer to as interictal epileptiform discharges. Think of them as abnormal blips which show up on the EEG when the EEG study is done inbetween the seizures (inbetween means the patient has an EEG study when he or she is not having a seizure at that very moment). Patients who have underlying epilepsy may show interical epileptiform discharges. On the other hand those who have seizures provoked by metabolic factors (low blood sugar–hypoglycemia, low sodium–hyponatremia, low calcium or magnesium) or toxic factors (excessive intake of alcohol or use of a recreational drug such as cocaine) usually do not show interictal epileptiform features and the EEG is frequently reported as normal.

Here I want to emphasize a point. The diagnosis of a seizure disorder/ epilepsy is not made simply based on an abnormal EEG. Put in another way, a normal EEG does not rule out or rule in epilepsy. Many epileptics may have normal EEGs even when the test is repeated many times. Conversely there are people who have abnormal EEGs but no epilepsy. Hence the diagnosis of a seizure disorder (epilepsy) is made based on a thorough history of the patient event (convulsion): what led to the event, what happened during the event, the clinical semiology of the event, whether there were any provoking factors and so forth. The past medical history is explored (any history of significant head trauma, any history of meningitis or encephalitis). The medications the patient was taking at that time are reviewed. Even the birth history is reviewed–was the patient born full term, were there any complications during child birth such as lack of oxygen.

 

 

Nitin Sethi, MD

 

Disclaimer

Please read my disclaimer posted here and on my website http://braindiseases.info. The information presented on this blog is for information and educational purposes only. It is not a substitute to an actual visit to your physician. Also your physician is the best person to answer all your queries.

I again urge all of you who post on this blog to post under a fake name and fake email id. Medical information should always remain private.

 

Nitin Sethi, MD