Complex partial seizures/ temporal lobe epilepsy

One of the most common type of seizures seen in the adult population is what are called complex partial seizures. As the name suggests these are partial seizures  meaning that only a part of the brain has the seizure (remember in generalized seizures the whole brain has the seizure and hence the patient clinically has a convulsion, read my posts on epilepsy and seizures at http://braindiseases.info). Complex partial seizures differ from simple partial seizures. While in simple partial seizures there is no disturbance in the patient’s level of consciousness (the patient is awake and alert), in complex partial seizures there is an impairment in the level of consciousness. The patient may have his or her eyes open but usually is unable to respond or communicate. He may or may not comprehend if you try to speak to him during a seizure episode.

As many of the complex partial seizures arise from the temporal lobes in the brain, epilepsy of this kind is also referred to as temporal lobe epilepsy (TLE). That said and done complex partial seizures may also arise from the frontal lobes. Seizures arising from the frontal lobes can present with bizzare clinical manifestations, patient may become hyperactive during the seizure and have strange bicycling like movements of the legs. Complex partial seizures are at times associated with an aura. A simple way to define aura is what happens usually before the seizure. Prior to the onset of a seizure, the patient may experience gustatory or olfactory auras (smell of burning rubber, metallic taste in the mouth are the different classical auras mentioned in the textbooks of neurology). Other patients may mention they “feel wierd” or “dizzy”. Others mention a rising sensation in the stomach.

During the seizure apart from impairment in the level of consciousness, patients frequently exhibit what we refer to as automatisms. These are semi-purposeful movements. Examples include lip-smacking, chewing movements, tongue protusion, picking at the clothes (semi-purposeful movements of the hands). These patients may or may not have a “convulsion”. If the seizure spreads and becomes generalized then they go into a convulsion (such seizures are referred to as partial with secondary generalization).

If an adult presents with a new onset complex partial seizure, neuroimaging is warranted. This is because a new onset complex partial seizure raises the suspicion for an underlying structural lesion in the brain such as a cyst or a tumor (though I want to emphasize here that the most common cause of new onset seizures in the elderly is vascular, meaning a previous stroke).

Work-up for TLE includes an EEG, if needed a long term EEG recording (we call this a video-EEG study), imaging studies like CT scan (though the study of choice is what is called a MRI scan of the brain done under the epilepsy protocol). Thin slices are taken to look at the temporal lobes and hippocampus to make sure there is no structural lesion there nor is there any evidence for mesial temporal sclerosis (MTS).

There are many effective drugs for complex partial seizures/TLE. The most commonly used are carbamazepine (Tegretol) and oxcarbazepine (trileptal). If the seizures are refractory to medications, these patients can be worked up for epilepsy surgery (see my post on epilepsy surgery at http://braindiseases.info).

Nitin Sethi, MD

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59 thoughts on “Complex partial seizures/ temporal lobe epilepsy

  1. I was just diagnosed with Complex partial seizures and I’m relieved to finally have a name for the unexplained episodes of “passing out” that have been happening for the last several months. I have had two EEGs and and MRI and nothing seemed adnormal, but have had 3 severe concussions since early teens, I am now 53, is this unusual for these to suddenly start happening now. My family does report I have often times over the years just gazed off and gone into my own world and they thought I was just tuning them out. Could this have been early episodes?

  2. Dear Jenny,
    thank you for writing in. Yes it is quite possible that your episodes of fading out (gazed off and gone into your own world) were complex partial seizures all along which were not picked up. As I stated in my post, complex partial seizures are unlike convulsions. You do not shake or have violent jerks, all that might happen is a subtle impairment in the level of consciousness with or without automatisms.
    It is possible that your prior episodes of severe concussions may be the etiology of your seizures (we define a severe concussion as that associated with a loss of consciousness for about 30 minutes or more). Routine 30 minute EEG’s may miss the diagnosis of the seizures and maybe normal. So when the index of suspicion is high based on clinical history we at times do a prolonged video-EEG recording. You are admitted to the hospital and monitored for 5-7 days. MRI too may be normal and that does not take anything away from the diagnosis as the damage may be at a “microscopic level” which cannot be seen with a MRI. Did they look for mesial temporal sclerosis (MTS) on your MRI and for hippocampal atrophy? I would follow up on that.
    Personal Regards,
    Nitin Sethi, MD

  3. Hello, I am glad I found this site, my Father died last month from what we do not know. He was hospitalized for low blood sugar (58), and by the next day he did not know us, four days later he had a seizure, and fell into a semi coma state. Every test came back negative including spinal tap. I am at a loss because no one can tell me what happened to him. I just spoke to a rep at the hospital where he died, and she told me to look up “partial seizure with secondary generalzation” she said that this meant “old stroke” which is what it was thought he had six months ago, while recouporating in a nuring home from pnuemonia but was not confirmed by cat scan, or MRI. The hospital has always said it was not a stroke, because nothing showed up on any test, and he had many! Reading what Jenny above wrote makes me think, what good is MRI & cat csan if they don’t show anything. Sorry for rambling on here, I am devastated over the loss and just can not understand why these dotors can’t give me answers. By the way, my father was in the hospital for a month, so you’d think they could come up with something.

  4. Dear Rose,
    thank you for writing in. I am so sorry for your loss and can only try to understand your pain. It does not help that you do not have an answer to what really happened to your father. Seems from what you tell me he came in with hypoglycemia (low blood sugar) (what was the cause of hypoglycemia? Was he a diabetic?) Seizures can occur in the setting of hypoglycemia. The brain needs sugar to work and when the sugar falls below 60 mg/dl, one may have a seizure (this is usually a convulsion. The whole brain has a seizure). Seizures in the setting of hypoglemia though are rapidly reversible once the blood sugar is corrected and should not recurr if the sugar remains normal. So I am not sure what happened in your father’s case.
    Old strokes are one of the most common causes of seizures in the elderly population. The damaged brain (from the old stroke) acts as the seizure focus. Usually one can see the tell tale signs of an old stroke on a good quality MRI scan. At times though the stroke is very small, we refer to these as lacumar infarcts.
    What would I advise you? All I can say is you should try to get in touch with the physician who took care of your father during the prolonged hospitalization. The best would be the main physician under whom he was admitted (he likely was seen by many other specialists who may or may not have all the details handy). He alone would be able to give you some much needed answers.
    I am sure all was done by you and the physicians who took care of your father. Medicine at times is not all black and white but knowing some of the answers helps the caregivers in understanding and coming to terms with their loss.
    And please you did not ramble, feel free to write in again.

    Personal Regards,
    Nitin Sethi, MD

  5. My child had a head injury (brain hematoma, was in hospital, 2 operations, and ok then) when he was only 6 m. Three years after seizures start. Doctor include tegretol as monotherapy. Seizures don’t stop. It is partial type of seizures, and we use diazepam rectal (klizma) to stop it. Seizures starts in early morning every time (twice a mounth, and going worse). He is on the maximum dose of tegretol. EEG found two focus (on left and right side of TL, injury was on the left side). Diagnose is Post traumatic epilepsy. The child have no other problem, and grow normally (except this) and he is six years old now.

    I have some questions:
    1. Because Tegretol doesn.t work, what is next ? (Lamictal, or something else (some better choice, because Tegretol is an old AED), some combinations ?), is there some new AED for this type of seizure.
    2. Is there ANY kind of therapy which can help to my child (akupunktura, or any), to try to stay sezurez under control?

    best regards
    M.

  6. Dear M,
    thank you for writing in. Let me try to shed some light on the questions that you have asked. Tegretol is a good drug for focal/ partial seizures (the kind your child is having since you mention EEG showed two seizure foci in the temporal lobes). Sometimes temporal lobe seizures are hard to control and good seizure control is not achieved inspite of maximum tolerated dose of an anti-epileptic drug (in your child’s case Tegretol). When this happens there are a couple of options. We can add on a second anti-epileptic drug (we usually choose one that has a different mechanism of action as compared to the first drug which is already been used, in your child’s case that is Tegretol). I would not like to suggest a particular drug since I have not examined your child nor do I have all the relevant information in my hands. But your doctor shall be the best person to add a second anti-epileptic drug and see the response.
    If for some reason the seizures still remain poorly controlled, other drugs can be tried. At times we have patients on polytherapy ( as many as 3 to 4 drugs. You have to understand though, as the number of drugs are increased so are the side-effects and drug-drug interactions).
    Apart from medicines there are other options like vagus nerve stimulator (VNS) and surgery.
    You should discuss them with your child’s doctor.
    Personal Regards,
    Nitin Sethi, MD

  7. Thank you for your reply. This is the problem I am having, I get conflicting information from the physicians. I was told the other day he could have had a stroke, than they said no, if he had a prior stroke, it would have shown up on the MRI. I am so confused, is this true?
    Could he have had a stroke while he was in the nursing home for rehab in Dec. , and by the time he got to the hospital it didn’t show on the cat csan? The nurse swore to me she thought he was having a stroke, (in Dec.) but nothing showed up, how can this be? Remember this was back in Dec. 07, he was hospitalized a lot from that point with pnuemonia. He died in June, the official cause was listed as: Anoxic brain injury, secondary, pnuemonia. The coroner evan called me to ask why this was. I know his blood pressure dropped the day before he died, than rebounded somewhat, the next evening it dropped again and he had a nose bleed, than died. Is this not strange??
    Thanks for your support.
    Sincerely,
    R

  8. Dear Rose,
    it is indeed difficult for me to figure out what happened since I do not have all the information. Seizures and strokes at times can mimic each other in their presentation (by that I mean, one may feel a patient is having a stroke but actually it turns out to be a seizure. In a case like this the brain MRI of course shall show no evidence of a stroke since a stroke never happened. Seizures unless they are prolonged usually do not leave behind any signs on the MRI).
    Personal Regards,
    Nitin Sethi, MD

  9. Thank you Dr. Sethi,
    This really does shed some new light on the situation. Very interesting!
    So it is possible back in Dec. 07, the nurse could have witnessed him actually having a seizure not a stroke? ( remember that was never documented, this is what SHE thought he was having )
    My next question, Could he than have been having seizures all along, and we never knew it, could they have been so mild at first, and intermitenly we just thought he was having events from low blood sugar? He lived alone for a long time not near me, and he told me he had passed out a couple of times, but he of course thought it was from heat. When he moved coser to me in Nov. 07, We witnessed some odd behavior of forgetfullness, and confusion at times, would this also be from seizures? Thanks again

  10. Dr. Sethi, I forgot to answer your previous question, yes, my Father did have type 2 diabetes, his blood sugar came back up in the ER, and he knew who my sister & I were when we left him, the next day & there after until he died, he did not. After the seizure, 4 days after his ER admittance, he was unable to communicate with us again.

  11. Dear Rose,
    complex partial seizures are characterized by impairment in the level of consciousness which may manifest clinically as confusion or odd/ alerted behavior and personality. Usually seizures are brief episodic events and patients should revert to their previous “normal” self once the seizure is over. In complex partial seizures usually complete loss of consciousness does not occur, that is seeing more commonly in generalized seizures.
    Personal Regards,
    Nitin Sethi, MD

  12. I have had epsiodes of partial loss of consciousness with metallis taste in my mouth and nausea prior to the episode; some dizziness; very tired once back around; no ability to speak or respond but can hear. My EEG had spikes of Theta and Delta waves but the docs said it was “normal.” Now I have a venous angioma in right temporal lobe-parietal region; hypometabolism in right temporal lobe; and previous long term EEG showed mild slowing and some slight spike in Beta and doc attribited to Klonopin which I had tapered to .25mg per day (alomst nothing); new doc wants new long term EEG; he is thinking TLE, CPS; is it possible the EEG is just not really showing the epileptiform activity or am I just making these up? By the way, MTBI in 1997 and syptoms started in 1998. What do you think? Thank you.

  13. Dear Lisa,
    your history does sound very suspicious for complex partial seizures of temporal lobe origin. At times a routine EEG may not show the epileptiform activity. In these cases a longer EEG study usually an in-patient video-EEG study helps (you come into the hospital for a few days, your doctor shall take you off Klonopin and then monitor you to characterize your events). Your MRI brain and PET too fit into the picture, so I think your doctor is quite right in his assessment.
    Personal Regards,
    Nitin Sethi, MD

  14. Dr. Sethi,

    I am wondering your opinion. I am still having problems from mild traum braininjury from dec 2007. This is around the 5th or 6th concussion in past 6 years. I have been experiencing, mostly at night. Sharp electric like pains in head on right side and then a clicking sound on left side of head then my face will twich and jerk on left side and eyes will roll. i feel paralysed while this happens but am still aware. the jerky/twitching is going into my arm and chest left side lately. and my leg and arm can feel numb or tingly. sometimes before this happens i have a wave of paranioa or a strange feeling of floating and usually hear some ringing or buzzing before hand as well. I tend to get this at night before i sleep or in the middle of the night. has happened at work and after MRI. I also have period where i space out, seem to loss time and things seems to move. I still have balance issues since the fall as well. Someone told me this could be partial seizure? What do you think?

  15. Dear Andrea,
    thank you for writing in. From what you mention it seems you have had multiple concussions. Cerebral concussions especially if significant can lead to a seizure disorder. We refer to this type of epilepsy as post traumatic epilepsy. The catch though is that the concussion should be a significant one to cause a seizure disorder. What constitutes a significant concussion is not well defined, we assume a concussion associated wih loss of consciousness as being significant. The period of unconsciousness may vary.
    Your history does have some points which raise the suspicion for complex partial (focal) seizures. You can read more about complex partial seizures on my website http://braindiseases.info.
    I would advise you to see a neurologist. He would likely order a MRI looking closely at the temporal lobes of the brain. Such a MRI is commonly referred to as a MRI done under epilepsy protocol. Your doctor may also order a routine EEG study and at times a more prolonged EEG monitoring study to look for any epileptogenic brain waves. This shall help in characterization of the clinical events which you have been having. Another differential diagnosis which comes to mind is post-concussive syndrome (you can read more about it again on my website http://braindiseases.info).

    Personal Regards,
    Nitin Sethi, MD

  16. Thank you Dr. Sethi
    I have been told i have PCS and because i’ve had multiple concussions maybe that is why my sypmtoms are worse this time. have had nueropsch test with problems in attention, concentration and communication. I will call nuerologist for appt. as the things i’ve been experiencing do not seem right. Thanx for your help.

  17. Hello, my grandson was 16 months old when he started having seizures. This was May 26, 2008, he was hospitalized and had many tests. The Doctors couldn’t find no known cause, so they called his seizurea Epilepsey. The thing is during May and June he had seizures, with convulsions. Then the end of June his hands would go up in the air, his head would drop and that would be it to his seizures. Now his head drops and what ever is in his hands, flys right out of them. He can have as many as 20 seizures a day. But he dosent go into convulsions, he’s on his fourth medication. It’s beginning to be frustrating, because nothing seems to work. We my daughter and I even wondered if when the Doctors gave him four spinal taps on the first day, trying to get fluid could they have hit a nerve. Have you ever heard of these kind of syptoms for seizures?

  18. Dear Jerri,
    thank you for writing in. Seizures in small children frequently look different from seizures in adults. One type of seizures seen in infants is what are called infantile spasms wherein the infant does something similar to what you describe in your grandson. Children can also have atonic seizures (these seizures are characterized by loss of body tone, at times they may have head drops).
    From what you say your grandson’s seizures are poorly controlled inspite of being on multiple seizure medications.
    It may help to have your grandson be seen by a pediatric epileptologist in a comprehensive epilepsy center. A good EEG (at times a prolonged EEG study) shall help in characterizing all his seizures and depending upon that further treatment recommendations can be made. A MRI of the brain shall be worthwhile if not done already.
    Personal Regards,
    Nitin Sethi, MD

  19. Dr. Sethi-

    Well the long term EEG was normal with a few events. I am on a calcium-channel blocker as now they are saying migraine variant. It is not working. I am at a loss. Any ideas. Is it possible the EEG is normal and yet I do have TLE? They also did a SPECT which showed hypoperfusion in lfet temporal lobe. They tell me they do not now why. What about a MEG? I am frsutrated after ten years of this!

    Lisa

  20. Dear Lisa,
    I understand your frustation. The ideal thing is that you have a typical event while you are on the EEG monitor. If the EEG at that time changes and shows epileptiform activity then more than likely your events are epileptic in nature.
    I am not sure what the yield for a MEG would be by itself. My advise to you would be to request your doctor for a second opinion, let someone reassess you with a fresh pair of eyes and let them make the call for further investigations.

    Personal Regards,
    Nitin Sethi, MD

  21. hello, i have suffered from “staring spells” since i was in my teens, im 39 now and still “staring off into space” i guess what i would like to know is, is this dangerous? it usually happens to me when im standing still, lasts about 30 secs to 2 min. when it happens i do not lose consciousness . i could hold a conversation while it goes on..i just wait for it to pass and go on with my buisness.

    thanks

    1. Dear Paul,
      thank you for writing in. While it is possible that you may have complex partial seizures which have remained undiagnosed since childhood, I want to add there are other more benign conditions which may resemble complex partial seizures in their clinical semiology.
      My advise to you would be to ask your doctor to refer you to a neurologist. Depending upon your detailed history and examination, your doctor may order further diagnostic testing such as an EEG study to rule out or rule in complex partial seizure disorder.
      Personal Regards,
      Nitin Sethi, MD

  22. I’ve been reading some of the comments on this website. My husband who is 55 started having some episodes this past year. He describes it as a metal taste in his mouth and then he gets very confused and doesn’t know where what day it is, wouldn’t know someone’s name, or what he was doing, etc. He has timed this and it lasts for about 10 minutes and then he starts coming out of it. He will talk to me while this is happening telling me he’s having one of his spells. He’s had about 6 in the past year that I know of — the last two were a day apart and then seem to last a little longer. After his last one is said he was very tired. He went to the doctor last summer and they told him it was probably nothing but to keep track of it. My daughter has epilepsy which started when she was 20 and she has grandmal seizures. Could my husband be having a complex partial seizure disorder?

    1. Dear Pam,
      thank you for writing in. Your husband’s episodes do sound suspicious for complex partial seizures of temporal lobe origin. I would advise you to ask his doctor to evaluate him for the same or to refer him to a neurologist for a second opinion. Some relatively simple tests–a good history and an electroencephalogram (EEG) study can help to rule in or rule out seizures.

      Personal Regards,
      Nitin Sethi, MD

  23. Dear dr.Nitin,
    I am a parent of 2 lovely boys. Ill start with my younger one. Hes 4 1/2 yrs. as a 13month old, he had a febrile convulsion and then again in 6 mts another one. Ever since aug 07 he started doing something funny with his mouth.. almost like a chewing action. When i showed the video of what he does to the neurologists they diagnosed it as complex partial seizure. He has been on meds since jan 08. Currently, hes on oleptal, encorate, lamez and 2.5mg of frisium. But still he gets an episode every week. The attacks are usually 15sec. He is also PDD-NOS, which doesnt make life easier for him. After an attack he looks so exhausted and generally sleeps for 2 hrs after. Can u suggest what we shd do??? Now, my older one was diagnosed with auditory processing difficulties. the neurologist just to be safe asked to get his eeg and mri done considering his brothers history. His eeg is abnormal and the mri shows something known as venous angioma which according to the technician is nothing to be worried about. I have heard him munching away in the night which till recently i didnt worry about, since all kids make some noise while changing sides, etc. Can u pls advice on our next course of action.

    1. Dear Archana,
      thank you for writing in. My experience with seizures in children is that it is worth the time and effort to characterize their seizures. From that I mean, trying to determine what kind of seizures do they actually have. Is it a generalized seizure disorder or is it focal epilepsy (focal epilepsy comes from one side of the brain). If it is generalized then is it primary generalized or is it secondary generalized due to some intracranial lesion. How is the background of the EEG–is it slow and disorganized? All this helps to determine the right anti-seizure medication. Also in children with PDD-NOS, not all atypical events represent seizures, some of these might just be behavioral and may not warrant treatment with anti-epileptic medications.
      With that in mind an inpatient Video-EEG study may be invaluable. I would recommend an attempt to capture some of these atypical events of “munching in the night” on Video-EEG to determine are they actually seizures or not.
      Personal Regards,
      Nitin Sethi, MD

  24. Dr. Sethi,

    My wife was diagnosed with a right frontal angioma and less developed vessels on the right side of her brain a year ago after having experienced many symptoms. The angioma is less than 1cm. The greater concern that was initially raised was the seizure symptoms. The symptoms have included exhaustion, feelings of head pressure, headaches, nausea, night time feeling of burning in her mouth and tongue, night time feelings of significant confusion and fear, and occasional sand like feelings in the back of her neck. She has also had a few incidents of aphasia. There have been multiple attempts to catch seizures on the EEG without success, though focal slowness in the area of the angioma was found. She is taking 400 mg of Topamax, which seems to partially control the symptoms. However. these symptoms become worse about two days after exercise, which no one has been able to explain. MRI and MRAs of her head and neck have been done.

    Her neurologist has indicated that he is not sure that all the symptoms correlate to seizures, such as the delayed response from exercise, and cannot explain all of the symptoms.

    I had a couple of questions:

    Should we be concerned that some of these symptoms have not been explained? I specifically have concern that there may be concurrent issues going on, such as some form of vascular problem, TIAs, or problems with intercranial pressure? The symptoms that I do not understand to correlate directly to seizures would be the delayed response to exercise, the sand-like feeling, and possibly the aphasia.

    The only medication she has been tried on has been Topamax. Is there any reason to think that if she is only getting partial control using Topamax that she should be tried on a medication such as Tegretol?

    Thank you for having this posting and your willingness to respond to questions that are posed. It is really appreciated.

    1. Dear Steve,
      thank you for writing in. You ask some specific questions regarding your wife’s condition and I shall attempt to answer them here. As I have not had the privilege of examining her or taking her history, please note that the best person to answer these questions remains her treating doctor.
      1. Some of her symptoms specially the confusion, fear, burning sensation in the mouth and aphasia may indeed be a part and parcel of her clinical seizure semiology. Patients who have extratemporal (frontal lobe) seizures have at times unusual seizure semiology (meaning that the seizures look strange and may be missed unless a high index of clinical suspicion is maintained). The ideal would be to capture all her “typical events” on Video-EEG to rule out or rule in seizures. Despite our best efforts sometimes this is not possible (as it seems to have happened in your wife’s case). Could some other process like vascular steal explain her semiology shall need further evaluation.
      2. Your other question is well taken and something which you should discuss with your wife’s doctor. She is currently on a relatively good dose of Topamax . Would a further increase in dose or the addition of a second anti-seizure medication help is something worth considering.

      Personal Regards,
      Nitin Sethi, MD

      1. Dr. Sethi,

        I wanted to follow up to let you know how things went, and to inquire about concurrent medical conditions complicating epilepsy. For my wife, things got worse before they got better… significant heart rate disturbances with her seizures, fairly constant seizures, sleeping majority of every day, feeling flu like, relatively low blood pressure and more. She was admitted to the hospital after a significant incident with low blood pressure and heart rate disturbances. They finally determined (after initally thinking vasopressin level issues) that it was actually low cortisol (secondary or tertiary adrenal insufficiency). Her seizures have gone from practically every day to maybe once per month, and with less severity and no longer heart rate disturbances. None of the doctors seem to have experience with low cortisol triggering the breakthrough of seizures, but at the same time, as her low cortisol puts additional stress on her body, wouldn’t one think it made her much more succeptible to breakthrough seizures? I would be interested to hear what you have seen with other concurrent conditions that complicate epilepsy, and whether you have seen seizure activity disturbing endocrine or pituitary functions.

        Thank you.

  25. John was diagnosed with autism at the age of two. At the age of 12, he suffered a head injury. John did not have seizures prior to the head injury. One week after the head injury, John started experiencing complex partial seizures that start from the right temporal lobe. John has been having at least one seizure every month since he suffered the head injury four years ago. Was John’s seizure caused by the head injury or was it a product of the autism.

    Thank you.

    1. Dear Ugo,
      thank you for writing in. It is hard to say what is the underlying etiology of John’s seizure disorder. Seizures do occur in patients with autistic spectrum disorder. Seizures can also occur after a head injury. We call this post-traumatic epilepsy. I shall write a post on this soon I promise.

      Personal Regards,
      Nitin Sethi, MD

  26. Dear Dr. Sethi,
    My husband was diagnosed with mesial temporal sclerosis almost a year ago. After suffering a generalized seizure, it was determined from an MRI that he had a lesion in his left temporal lobe. At that time, we also realized that his “spells” that he thought were panic attacks and had been left untreated for almost 2 years were actually complex partial seizures. In the past year, he has been taking a medley of seizure medications, including maximum doses of Keppra and Lamatrogine, along with some anxiety medications. With the medication, it seems that he suffers fewer complex partial seizures, but they seem to be much worse in how they affect him. Before the medicine, he would have more seizures per month but he would recover fairly quickly. Now, he only has a few each month, but he is totally knocked out for 4-8 hours each time. The medicine seems to work for a few weeks and then the seizures begin again. It is as if he becomes immune to the medication. I am worried that the MTS is progressing and that the medications will not be effective in controlling his seizures. He is also developing additional symptoms like slurred speech, falling on occasion for no apparent reason, and some minor facial numbing/paralysis. Does Mesial Temporal Sclerosis get progressively worse for some people, and, if so, should he be continually monitored through MRI’s or other tests to make sure the lesion is not growing? When and how is it determined if someone’s seizures are intractable? My concern is that the medications are ineffective and the disease is getting worse as we wait.
    Thank you for your help.

    1. Dear Kelli,
      thank you for writing in. Usually patients who have mesial temporal scleorsis (MTS) have hard to control epilepsy (that said and done there are some patients with MTS who get excellent seizure control with anti-epileptic drugs).
      The general thinking among epileptologists is that patients with MTS should be given a trial of an effective anti-epileptic medication. If that does not adequately control the seizures, other anti-epileptic drugs can be tried. But if they too are ineffective, these patients should be worked up for epilepsy surgery. Patients with MTS frequently have a gratifying response to epilepsy surgery and 60-70% of carefully selected patients may become seizure free with epilepsy surgery.
      So nowdays we think about epilepsy surgery sooner rather than later in these patients. Ongoing temporal lobe seizures cause memory problems and other neurocognitive impairments in these patients.

      Personal Regards,
      Nitin Sethi, MD

  27. I have a 3 year old who has been diagnosed with severe epilepsy. It started just 7 months ago with a random grand mal seizure and has since progressed to multiple grand mals in one day and also the head-drop type of seizure. He has the head drop seizures more frequently than the grand mals. He has up to 60 head drop seizures a day.

    We have had an MRI which was normal, two CTs, two EEGs and a Video EEG. They were able to determine that seizures are coming from all over the brain, not one focal area. He has been on 7 different medications. Currently he is on Depakote and Keppra. They make him crazy, agitaged and give him insomnia. Those side effects wouldn’t seem so bad if they actually stopped the seizures, but they are not. I’ve been told he is not a candidate for surgery and I think we’ve almost run out of options for medication. He’s been on Trileptal, Lamictal, Zonegram, Chlorizapam, Depakote and Keppra; sometimes up to four different medications at once. My question is what are our options? Isn’t there some kind of surgical procedure out there?

    1. Dear Angela,
      thank you for writing in. It seems your son has medically refractory epilepsy. Multiple anti-epileptic drugs have failed to control his seizures. My advise would be to have him evaluated in a comprehensive epilepsy center. Some options still on the table might be a limited resective surgery and/ or vagal nerve stimulator (VNS).

      Personal Regards,
      Nitin Sethi, MD

  28. Dear Annie,
    thank you for writing in. Your boyfriend warrants an evaluation for his seizure disorder. Oxcarbazepine (Trileptal) is a good drug for patients with focal seizures arising from the temporal lobe (also called as temporal lobe epilepsy). The laws with respect to driving vary from country to country and here in the United States from state to state. He should not drive till his seizures are well controlled (in accordance with the country and state laws). After he is started on oxcarbazepine his physician shall gradually titrate the medication up (this is done based on blood level of the drug). The goal is good seizure control (meaning no further seizures) at side-effects which are acceptable to him as the patient.

    Please feel free to write in to me again. I wish both of you my very best.

    Personal Regards,

    Nitin Sethi, MD

  29. I’ve been having these episodes, that I pass off as a dizzy spell to anyone who witnesses, for about 8 years now. They’re so hard to describe that I just say I felt dizzy even though I’m not dizzy during them at all. They start as a really intense feeling a deja vu. I feel like I know I’ve been there before, and I know exactly what’s going to happen next. If someone’s talking to me they sound like the teacher in the Charlie Brown cartoons, I can’t understand a thing they’re saying. My daughter says I will ask her to repeat herself three or four times, and watch her mouth while she does like I’m concentrating really hard. And then, I stop talking to her at all. I open my mouth like I’m about to say something to her, but nothing comes out, I look frustrated, close my mouth, swallow and then open my mouth like I’m trying to talk again, but nothing, close mouth, swallow and repeat. I feel her observations are accurate, because I know I want to to tell her I’m fine, I know the worlds I want to say, but they seem to get lost somewhere between my brain and my mouth. Very frustrating. Afterwards, I’m so tired, I feel drained like I ran a marathon, and need a two to three hour nap. Sometimes, I go straight from the deja vu, to the trouble understanding what people are saying and talking back to them, and then the nap. But, sometimes, right between the deja vu and the talking thing, I have a blank period. Like, I’ll start the episode while I’m thinking of grabbing something upstairs, and I’ll end up where I wanted to go, but I won’t remember climbing the stairs, and how I got there. Or even more disturbing, picking my daughter up from school, I’m heading home, my daughter is on the phone with my husband, she tells me he’s having lunch at McDonalds, and instead of driving home, I drive to McDonalds, but can’t remember anything in between pulling out of the school parking lot and parking at McDonalds. I’ve had many of these episodes, (not too many driving, but enough to scare me). Sometimes, I have them every few months, and then out of nowhere I’ll have several within a few days of each other. They make me feel like I’m going crazy, which is partly why I haven’t had them checked out. But I noticed that some of my symptoms touch on what you’ve been saying about temporal lobe seizures, and I was wondering if you thought that might be what’s going on. I’m also curious about the effects of not having these treated, and your opinion on what I should do now?

  30. I was diagnoseed with left temp. lobe partial complex seizure disorder in 1996. My life was hell for a long time. I had all the usual workup by Dr.L. Romaine…a leader in the field at the time. I had all the usual work ups of 24 hr EEGs which he,himself studied..had it 3 times over a year, had MRIs Cat scans,Pet scans,Mylograms, Spinal Taps, lots of blood work. and more. My symptoms, which has all but ruined my relationships with adult children were phone calls to them with full amnesia, my speaking vulgar language to a violent attack on own home breaking dishes and anything else before I saw my neurologist. After about 2 years of testing and drug experiments I resonably responded to Nuerontin and Lamictal. Dr. Romaine was responsible for getting lamicital thru /fda from /france. By this time my adult children were feeding off each other on how crazy I was and amnesia was no excuse. Tho 15 years have passed ,I know they love me, but love to hold on to how badly my foul language hurt them forever. They just could never get over it. My dauhghterinlaw calls me dangerous to my one and only grandchild, age 3, but I have been trouble free for many years. even tho my husband trusts me, these adult kids break my heart. She for bids me to be alone with the child even after a dozen years,and these kids like tohold it against me as tho I asked for amnesia, alesion in my brain, and somehow they hurt more than me for the amnesiac behaviors I had in the 90’s. Myheart is broken. My family was raised in a loving safe environment and were in college by the time of the first seizure.M y 35 year career as anLCSW and RN. ended in disability and poverty.They are nice enough but always this hidden tension. Whatever can I do to feel loved again. I feel all alone. By the way the doc. thought it may be genetic, tho most all my family is dead.I now have breast cancer and live all alone at age 65 with no one alive but these 3 edgey grown professionbal kids..I mean lawyers and professors, but no hearts or brains. Help me find a way to reclaim my life.

    1. Helene, my wife has epilepsy and I am so sorry to hear what you have been through and are going through. Epilepsy seems to have far reaching effects beyond just the physical. You did everything you can for them – apologized, explained, and got help for your seizures. Many people seek counseling to help us through, and if you would choose to, it does help though make sure it is someone who works well with you. Please hang in there, take some steps for your benefit, it can turn around pretty quickly even when it doesn’t seem possible. My heart goes out to you and the many other people who go through this at times in their lives.

    2. Dear HP,
      I am sorry to hear that you find yourself in such troubling and tough times. My advice to you would be to seek the help of your primary care physician. Bring to his or her attention all of this so that the social and psychological issues can be addressed as soon as possible. I send you my very best.

      Personal Regards,

      Nitin Sethi, MD

  31. I have been suffering with these symptoms for about 2/3 years now and I have been to doctors about it but they have not found anything wrong. These are the symptoms I have been getting.
    Flushing, sweating, going very pale, having a churning feeling in your stomach
    Seeing things as smaller or bigger than they really are
    Seeing or hearing something that is not actually happening
    Smelling non-existent smells
    Chewing, smacking your lips, swallowing or scratching your head
    If you can help me at all I would be grateful!

  32. 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,
    Kerri

    1. Dear Kerri,
      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

  33. Hello,
    My husband started having seizures about 3 weeks ago. He is 23 years old and does not have a past history of seizures. At first he thought he was passing out or blacking out. When he would wake up, he would not know how long he had been unconscious, he is confused and sometimes doesn’t know what time of day it is. He also gets a bad stomach ache and feels scared. He can feel them coming on, he says it feels like deja vu. He has had about 15 of these since April 11th, sometimes as many as 3 per day. He does not lose consciousness in all of them, sometimes he just gets deja vu and then ‘feels wierd’.

    His neurologist has told us that he is having complex partial seizures, probably originating in the temporal lobe. Our concern now is about the medication.

    They perscribed him phenytoin. We are concerned with the side effects of this medicine. After rsearching it extensively online, we have heard lots of complaints and bad reviews. My questions is, just how harmful is this drug? How exactly does it stop your brain from having seizures without effecting regular brain activity? Will he still be able to think critically while on the drug? We have read blogs about people going into comas while on this drug, is this common and why? Also, since he is only 23, we are concerned about long term effects. What are the long term side effects: neuropathy, gum disease, liver damage? Please tell me eveything you can about this drug, I am very curious about it.

    Thanks,
    Kyra

    1. Kyra,

      I forgot to mention, but if the neuro has not yet, you may want to ask them to start with MRI imaging – with new onset seizures I would personally very much want to know if there is something going on structurally that is causing his new issues. Maybe nothing but rather safe than wrong. I’d ask about whether they have ruled out lesions and AVMs. And make sure it is not a condition that the neuro is less familiar with but could result in seizures for example, uncontrolled diabetes, etc. My experience is that I needed to be my wife’s best advocate and make sure that all basis are covered (or at least rule out things). -Steve

  34. Hello, my mom has a venous malformation in her right temporal lobe that causes her complex partial seizures. Most of the time, she is fine. Occaisionally, she has small ones, where she is out of it. (I’ve found that getting her to eat more frequently helps a lot) She does take an anti-seizure medication for it. I don’t mind helping her at all. My concern is that sometimes, she has seizures where she’s confused, screams (things that don’t make sense) throws things and can get violent. (it’s only happened a few times) But, I don’t know if there’s anything else I can do for her. Is it common for complex partial seizures to be violent? Today, (she has been VERY stressed lately) she tried to leave the house, and I had to get the keys from her, so she wouldn’t hurt herself. She hit me several times in the process, but was so confused about EVERYTHING. it is very difficult. I know she won’t remember later, but is there anything I can do to help her? (besides call her doctor…) How do I help her, without getting hurt myself?

    1. Dear Ashley,
      thank you for writing in to me. I am sorry to hear the tough times you find yourself in. Epilepsy is a chronic disease at times disabling if seizure control is poor and can cause a lot of stress and caregiver burnout. It is unusual for patients to become violent during an ictal episode (meaning that during a seizure a patient usually does not have goal directed behavior. He/she shall not start hitting someone deliberately. That said if they are having a convulsion and you are trying to help, it is possible that you may get hit in the process). The patient during a complex partial seizure has impaired level of consciousness. He/she is agitated, confused and disoriented. Some partial seizures of frontal lobe origin are quite hyperkinetic and the patient may be extremely agitated and at times display violent psychotic like behavior.

      Her seizures need to be better controlled and you should explore options such as epilepsy surgery. Talk to her doctor. He shall be the best person to help you further.

      Stay strong!

      Personal Regards,

      Nitin K Sethi, MD

  35. Dr. Sethi,
    I am 36, had a stroke at 30 in the right frontal lobe. I have simpal partial seizures. Before medications my Seizures prsented an anxious feeling, then almost floating sensation;my mouth would then water like crazy, I would get strange sensation of smell and then throw up. After a 5 day EEG with video telemetry in 2009 the “feeling” were confirmed as seizures and I was put on meds for S.P.S. I record every seizure and the average occurance is about 25 a month. it eems the seizure are less in strength now. I no longer throw up just gag and only occasionally get the strange smell. These seizures have displayed in 2 other ways over a 2 year span. Every 3 months I would have the “normal” PS anxious feeling, mouth watering ect.. followed directly with a brief memory loss ( the approx the last 4 hours) I knew basic questions, how old I was , who the President was but could not recall anything from the last 4-6 hours including how I got to where my present location. After talking it out with my wife 15-20 mins later Everything would come back in full detail. My meds were increased and these “memory losses” were controlled for a year until i had one last year. Currently I have been experienceing something similar except my memory is not completely gone. I am more confused and can not recall certain details. Nothing really ever “comes back” except remembering the initial feeling that something was “not right”. I’m on 4 grams keppra, 600mg lamictal, 400 mg vimpat a day. There is a suspicion of overdosing because of recent extreme dizzyness not able to walk on my own. This dizzyness on four occasions has led to tonic clonic type convulsions but I was awear and could almost control the seizing. I do know that memory is sometimes affected with SP seizures but it would be very difficult to capture these moments during an eeg video test. Is it possible that these two memory issues are an actual seizure? Is it possible the dizzyness and convulsons are a type of SP or is it more likely a dosing issue? A nurologist has been controlling my meds for the past 4 years. are these anxious, strange smell, nauseous SPs possible to control? For 3 years on medication I have not had a single month clear of a Seizure
    -CAMERON

  36. Hi, I am writing because i have temporal lobe epilepsy starting 3 years ago with catemenial exacerbation. Have been controlled for almost 6 months with Keppra XR, 40 mg progesterone cream on days 12 thru 27 of cycle and modified ketogenic diet. 3 weeks ago I suffered a mild concussion.Followed by seizures that day. Negative CT scan.My neuro stated I was suffering from PCS. As of yesterday, had more breakthrough. Both times were tonic clonic which I haven’t had in a long time. Is this normal? the breakthrough seizures? I was so close to returning to work as RN and driving again. Will it continue?
    Thank you, D

    1. Dear Donna,
      thank you for writing in to me. In my experience I have not seen break through seizures occurring after a minor concussion (minor meaning that the loss of consciousness if any was exceedingly brief). That said every epilepsy patient is unique and if you have hard to control temporal lobe epilepsy, all bets are off,
      Sending you my very best.

      Nitin K Sethi, MD

  37. My son is 14, has Autism and has had siezures since 2006. He has been on Trileptal up until 3 weeks ago. He was having 1 siezure a year on Trileptal until he started puberty about a year ago. He had 4 siezures in the past year and every time the Neurologist kept upping his dose. He started having a severe headache once a month, than a couple times a month and then a couple times a week over the past six months. He has some verbal skills and also uses a communication device. But when he has a headache he pokes the space between his left eye and the bone of his eye socket really hard. It’s alway the left side. After the 4th siezure this year and the more frequent headaches I brought him in to see his Neurologist. She said we could try a new drug since he is at his max with Trileptal and it clearly isn’t working. We got an MRI done which came back clean. We decided to try Topamax. We started weaning him off the Trileptal and slowing putting him on Topamax for the past 3 weeks. He has had decreased appetite, no interest in reading (he is obsessed with dictionaries and reads them all day) and more headaches. He seemed to be feeling better this week (he is at 1 1/2 tabs 2 x a day for Topamax and 4 Trileptal 2x a day) and then had a siezure this morning. When I spoke to the Neurologist’s nurse she said that the Neurologist wanted us to give him Lamictal and take him off the Topamax and keep weaning him off the Trileptal. This made no sense to me. We hadn’t gotten him off Trileptal completely and also hadn’t given him JUST Topamax to see whether or not it would work. I told her we wanted to continue to increase the Topamax and keep weaning him off the Trileptal and see what happens. I’m wondering if what we want to do is the best choice or if we should have stopped the Topamax and tried Lamictal. I have heard bad things about Lamictal and look at it as a last resort. Are his loss of appetite and interest in preferred activities normal side effects of Topomax? He also has Echolalia and was repeating this phrase a few times in the morning and at night, “You can’t see what you are doing.” Could he be having vision problems from the Topomax. The doctor didn’t seem alarmed by all the side effects he seems to be experiencing.

    1. Dear Beth,
      thank you for writing in to me. Topamax is a good drug but does have a few side-effects. It causes weight loss and also at times cognitive side-effects mainly problems with naming and other word finding difficulties. It is certainly possible that your son’s symptoms are side-effects of Topamax. Lamictal too is a widely used and highly effective drug for both generalized and focal epilepsies. It has a risk of rash and hence is started at a low dose and slowly titrated up. Lamictal has a favorable effect on mood and cognition. You should maintain follow up with your son’s neurologist. She shall be the best person to help make further treatment decisions.

      Personal Regards,

      Nitin K Sethi, MD

  38. I have been diagnosed with L-temporal lobe partial complex seizures. I have tried several AED’s and currently taking Lamictal – 100mg a.m. and 250 mg evening. My seizures are usually 3-hours after retiring (regardless of when I retire) and about 2-weeks apart. I hesitate to go to another Neurologist because all they want to do is add another drug. Shouldn’t they figure out why I am having them B4 pushing the drugs? I have thought about trying to get an appointment at the Mayo but uncomfortable with what the cost may be. What do you suggest?
    Thank you,

    1. Dear Joan,
      I am sorry to hear that your seizures remain uncontrolled. I recommend that you follow up with your doctor or seek a second opinion for these “medically refractory” seizures. At times polypharmacy that is two or more drugs which are synergistic are needed to control the seizures.

      Nitin K Sethi, MD

  39. I do agree.. I was using 175mg bid but continued having seizures several times weekly. My neurologists had to increase my dose of lamictaI. He then put me on 200 mg of Lamictal bid, in addition to clobazam 10mg each evening. Unfortunately, I needed to change medications again. Lamictal does have a tendency of working well with another medication, but efficacy may not be long term in preventing future seizures. Side effects are not as bad with lamictal as with other medications, so he did his best to keep me on this medication.. but between side effects with increased doses, and continued seizures, he is weaning me off lamictal and has introduced tobiramate. Best of luck.. I am sure by now, you have gotten everything looked after! 🙂

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