Childhood Epilepsy: Treatment

In the aftermath of a child's first seizure, parents naturally want to learn all that they can about what caused the episode, as well as what they can do to prevent a recurrence. Fortunately, many effective treatments do exist, and most individuals with epilepsy can expect to lead normal lives in which their seizures are well controlled, if not completely eliminated. Early diagnosis and treatment offer the best opportunity for the long-term well-being of a child with epilepsy.

Early Intervention

Identifying an effective course of treatment typically requires patience and persistence. Compared with established treatments for many other medical conditions—the use of antibiotics to fight bacterial infections, for example—epilepsy treatments must be tailored to fit the needs of each individual patient. This is because the cause behind the seizures often varies from person to person. Furthermore, while many treatments are effective in treating or preventing seizures, different individuals may respond differently to the same treatment. Fortunately, treatments do work, and in most cases, through collaboration between doctors, patients, and families, it is possible to treat seizures effectively.

It is important that patients and families understand all of the treatment options available to them. A physician can explain how various treatments work, which treatments might be most effective, and the possible side effects associated with each.

To Treat or Not to Treat

If a child demonstrates any behaviors that parents find particularly unusual, such as staring, fainting, strange movements, sleep problems, or other concerning features, experts recommend that parents have the child evaluated by a doctor as soon as possible. In practice, doctors often do not treat a single seizure because approximately 60 to 70 percent of individuals who have one seizure never have a second. Even so, doctors often obtain an EEG, a test that measures the brain's electrical activity and often reveals abnormal patterns associated with seizures, and recommend that parents watch a child for signs of seizure recurrence. In some specific situations where there is a higher- than-normal risk of recurrence after a single seizure, physicians may begin epilepsy treatment immediately, rather than waiting for a second seizure to occur.

Recurrent seizures can have important consequences on a child's overall health and development and require medical attention. To determine an appropriate course of treatment, physicians must first determine whether an individual's seizures are partial or generalized in origin. To do this they typically use a series of diagnostic tests and tools. The most important of these are eyewitness accounts by family members and by the individual who experiences the seizures. These accounts, along with medical records and EEG recordings, may provide clues as to the seizure type, which will then help to identify treatment options.

About diagnosing epilepsy

Medications

The list of epilepsy treatment options is varied. It includes medications, nutritional therapies, surgery, and technologies such as the vagus nerve stimulator. The largest category, and the first and most effective line of treatment for nearly all cases, is that of anticonvulsant medications. As a group, these drugs have proven highly effective. For approximately half of all individuals diagnosed with epilepsy, seizures are controlled or eliminated with a single medication—often the first medication prescribed. Such successes, however, require that medications be chosen carefully with respect to the specific seizure type.

Physicians choose anticonvulsant medications based on their demonstrated effectiveness in treating particular types of seizures, as well as the potential risk of side effects they pose. However, the response to any given medication can vary from person to person. The right medication and dosage for every patient is the one that controls that particular individual's seizures without causing significant side effects. Often identifying the right combination requires a process of trial and error.

Today, there are a dozen or so medications that doctors can prescribe—about twice as many as were available a decade ago. Not only are these drugs helping people with seizures that are hard to control, but many of the newer drugs are better tolerated than the older ones, with fewer side effects.

Physicians typically begin treating a patient with a single medication, starting with a low dosage and gradually increasing the dose until the amount of medication reaches the therapeutic dosage range and seizures are controlled. Some older anticonvulsants have a predetermined therapeutic range, and physicians may have to regularly check an individual's blood levels of these medications to determine if safe, therapeutic levels have been achieved.

Newer medications are also prescribed at dosage ranges, and physicians use this range as a guide as they begin to hone in on the proper dose for a specific patient. However, one individual may experience side effects at doses much higher or lower than those taken by another individual, or might have seizures controlled at doses higher or lower than those of someone else. The goal is always to find the lowest dose at which seizures are controlled.

In some cases, medications do cause significant side effects, such as skin rash, dizziness, headache, nausea, blurred vision, and fatigue. Medications may cause more serious side effects, as well, including liver failure, life-threatening cases of anemia, and other blood problems. Anticonvulsant drugs may also impair cognitive function and/or negatively impact attention, mood, or motivation. Doctors take these side effects very seriously and make medication recommendations on a case-by-case basis.

Whenever an anticonvulsant drug proves ineffective over a reasonable trial period, doctors typically prescribe a replacement medication, introduced in the same gradual fashion as the first medication was until a therapeutic level is reached. The original drug may then be either continued or tapered off. In some cases, physicians treat seizures with a multi-drug regimen. This approach is more complex than single-drug therapies, given that many drugs interact with each other and may increase or decrease blood levels of partnered drugs. However, a combination of medications can be highly effective at controlling seizures.

Additional medications may also be required to stop seizures that last several minutes. For example, there are medications available that can be administered at home if a child experiences a seizure lasting more than 5 minutes. It is considered a medical emergency if a child enters a state of status epilepticus, defined as a seizure lasting more than 15 minutes, and he or she should be treated immediately by a medical professional to stop the seizure as soon as possible.

Development of highly sophisticated target drugs, which seek to deliver medication to specific rather than generalized areas of the brain, is one notable trend in drug research. While existing anticonvulsants act on the same handful of molecular targets, many potential new targets are being sought and identified in the research laboratory. Advanced diagnostic and monitoring technologies along with animal studies are helping researchers identify, among other things, chemical abnormalities in the brains of people with epilepsy. The goal of this type of research is to develop anticonvulsant drugs that act on more precise targets and thus provide more effective seizure control with fewer side effects.

Unfortunately, seizures are said to be intractable in approximately 35 percent of individuals with epilepsy. This means that two or more appropriate medications have failed to adequately control seizures. After two so-called "first line" medications have failed, many physicians consider it appropriate to explore other treatment options. Several alternative therapies have already been shown to be effective, and research continues across a wide spectrum of new, non-medicinal therapeutic approaches.

Download a list of common medications (PDF)

Dietary Therapies

Dietary therapies are an important alternative for some children with intractable seizures. Importantly, they can be effective in the treatment of both generalized and partial seizures. Mass General researchers have been instrumental in the development of dietary treatment plans that effective but also flexible and easy to follow.

Learn about dietary therapies

Technologies

Vagus Nerve Stimulator (VNS)

The vagus nerve is a cranial nerve within the autonomic nervous system that influences the brain in addition to motor functions in the larynx, diaphragm, stomach, and heart. Neurologists have found that electrical stimulation of this nerve can help to treat patients whose seizures have been unresponsive to drug therapy. This technique uses a pacemaker-like device called a vagus nerve stimulator (VNS). The VNS is implanted under the skin of the chest and supplies intermittent electrical impulses to the vagus nerve. This therapy is most often used in conjunction with medications.

Technologies in Development

Scientists are hopeful that in the coming years they will be able to develop much more selective and specific treatments for epilepsy. In addition to the VNS, there are several other devices currently under development, some of which attempt to directly stimulate the seizure focus.

One such design modifies the brain stimulation therapy occasionally used for individuals with Parkinson's disease. Another utilizes the technology from cardiac defibrillators to respond to electrical activity in the brain. In this model, electrodes are placed where seizures are expected to originate and connected to a recording device that samples brain activity. The device then fires an electrical pulse to disrupt abnormal patterns when they are detected. Similar devices may help to warn an individual with epilepsy that a seizure is imminent.

The unpredictability of seizures is one of their most challenging aspects. Studies demonstrating that the brain undergoes subtle changes prior to a seizure have led several groups of researchers to engineer an implantable device that may be able to predict seizures and warn an individual of their approach up to three minutes before they begin. Given advance warning, individuals prone to falls and injuries could prepare accordingly.

Researchers are continually improving magnetic resonance imaging (MRI) and other brain imaging technologies as well. Pre-surgical brain imaging can better identify abnormal brain tissue, and brain scans, such as magnetoencephalograms (MEGs), magnetic resonance spectroscopy (MRS), and other technologies, are being developed to better understand brain function. Research findings may lead to a better understanding of epilepsy and thereby improve treatments.

Seizure Surgery

For some people, medications and other therapies have little or no effect on seizure activity. For others, treatment options are effective but cause intolerable side effects. In these cases, or in other cases in which the seizure cause is readily identifiable and considered surgically treatable, physicians may recommend epilepsy surgery. As with any epilepsy treatment, epilepsy surgery requires that patients, families, and doctors accurately weigh the benefits and risks of treatment. For some individuals, the benefits of long-term seizure control that surgery may provide outweigh the risks that the procedure might pose.

Although surgical therapy for epilepsy has been used for more than a century, it has become far more common in the last decade. Today, physicians may consider surgery after just a few trials of other treatments, whereas in the past they may have considered this option only after exhaustive attempts at other alternatives. This shift is, in part, the result of advances in imaging technologies that make identification of lesions responsible for the seizure focus and surgery itself far more precise and safe.

Just as seizure types vary, so do seizure surgeries. This is because particular seizure types originate in particular regions of the brain—sometimes confined regions, sometimes regions that are more widespread. As a result, there are two main types of seizure surgery. The first and most common, called resective surgery, removes the portion of the brain where seizures are thought to originate. This approach is used in cases of partial epilepsy, wherein seizures originate from an identifiable location.

Another, less common, type of surgery interrupts critical neural networks that connect large portions of the brain with one another. For example, neurosurgeons may interrupt abnormal signals between the brain's right and left hemispheres by cutting the corpus callosum, the bundle of nerves that connects these regions. This treatment is often used in cases of intractable epilepsy that result in atonic seizures, or drop attacks.

Prior to surgery, physicians are careful to characterize and understand the seizure types that are typical to an individual, considering both their clinical manifestations and their localization within the brain. They conduct this preoperative assessment using tools such as EEG monitoring, to characterize the electrical patterns of the seizures, and MRI, to generate detailed images of brain anatomy. Both of these tools help physicians pinpoint a single source of seizure activity if possible. Other imaging procedures may also be part of a preoperative assessment. The positron emission tomography (PET), which analyzes brain metabolism, and single-photon emission computed tomography (SPECT), which analyzes blood flow in the brain, may both be used to identify seizure focus. WADA testing and functional MRI (fMRI) can help physicians identify regions of the brain involved in language and memory.

The notion of epilepsy surgery may raise many questions, concerns, and fears for patients and their families. However, with surgery, seizure reduction can be significant for patients who otherwise would have little hope of controlling their seizures. Depending on the type of surgery, from 25 percent to more than 80 percent of patients experience either a significant decrease in or elimination of seizures. These potential benefits will likely continue to improve as researchers develop new technologies and surgical therapies.

Beyond Seizure Control

The future of epilepsy research, as with that for many other human disorders, may lie in our DNA. Identifying genes associated with epilepsy can help reveal the underlying molecular processes that influence the disorder and thus point to new treatments.

Scientists have already identified the gene mutations responsible for some types of epilepsy. For most types, however, they have not yet identified genetic abnormalities. One goal of genetic research is to develop drugs that specifically target the abnormal proteins resulting from these abnormal genes. Studying the genetics of the disease could also provide the information necessary for doctors to more accurately diagnose and treat individual patients. Another long-term target of genetic research involves the actual modification of DNA. In gene replacement therapy, abnormal genes are spliced out and replaced with normal ones.

The goal of modern epilepsy treatment is to both control seizures and minimize negative side effects. Within the population of people with epilepsy whose seizures are controlled using prescribed medications, dietary therapies, and surgery, many—but not all—have reached that goal. However, with a greater understanding of the underlying mechanisms behind seizures and with research directed to obtain this information, an increasing number of children and adults should be able to achieve a seizure- free life.

It Is Important to Remember

• Even when epilepsy diagnosis is relatively simple, identifying an effective treatment may require a great deal of patience and persistence.
• Anticonvulsant medications are typically the first line in epilepsy treatment.
• There is no absolute, correct epilepsy medication for all patients or seizure types, nor is there one correct dose for any given medication.
• Treatment options for seizures include medications, specialized diets, vagus nerve stimulation, and surgery.

Relevant Specialists

Dietitian

A dietitian is a medical professional who specializes in diet and metabolism. A dietitian who is knowledgeable about epilepsy and has had specialized training in administering the ketogenic diet and other dietary therapies can instruct patients on how to implement this therapy.

EEG Technologist

An EEG technologist is a person who administers the EEG test and who is trained to recognize the abnormal patterns that are characteristic of epileptic seizures.

Neurologist

A neurologist and a pediatric neurologist are physicians who care for people affected by disorders of the nervous system. An epileptologist is a neurologist or a pediatric neurologist who specializes in the treatment of epilepsy.

Neuroradiologist

A neuroradiologist is a physician who interprets images, including x-rays, ultrasounds, CT scans, and MRIs of the central nervous system, including the brain. A neuroradiologist is trained to recognize abnormalities in brain structure.

Neurosurgeon

A neurosurgeon is a surgeon who specializes in performing surgery on the nervous system, including the brain. A neurosurgeon who treats people with epilepsy is trained in the identification and resection (surgical removal) of brain regions where seizures originate. These neurosurgeons are often also qualified to treat epilepsy with implants such as the vagus nerve stimulator (VNS).