Seizures in adults

Patient information: Seizures in adults

Author
Steven C Schachter, MD
Section Editor
Timothy A Pedley, MD
Deputy Editors
Constanza Villalba, PhD
Janet L Wilterdink, MD

Disclosures

WHAT IS A SEIZURE? — The brain contains billions of neurons (nerve cells) that create and receive electrical impulses. Electrical impulses allow neurons to communicate with one another. During a seizure, there is abnormal and excessive electrical activity in the brain. This can cause changes in awareness, behavior, and/or abnormal movements. This activity usually lasts only a few seconds to minutes.

Epilepsy refers to a condition in which a person has a risk of recurring epileptic seizures. Not everyone who has had a seizure has epilepsy. Nonepileptic seizures can be caused by other conditions such as low blood sugar, a fainting spell, or an anxiety attack.

SEIZURE SYMPTOMS

Seizure types — One of the most common seizure types is a convulsion. This may be called a “tonic clonic” or “grand mal” seizure. In this type of seizure, a person may stiffen and have jerking muscle movements; during the muscle-jerking, the person may bite their tongue, causing bleeding or frothing at the mouth.

Other seizure types are less dramatic. Shaking movements may be isolated to one arm or part of the face. Alternatively, the person may suddenly stop responding and stare for a few seconds, sometimes with chewing motions or smacking the lips.

Seizures may also cause “sensations” that only the patient feels. As an example, one type of seizure can cause stomach discomfort, fear, or an unpleasant smell. Such subjective feelings are commonly referred to as auras. A person usually experiences the same symptoms with each seizure aura. Sometimes, a seizure aura can occur before a convulsive seizure.

Seizure triggers — A minority of people have seizure triggers, such as strong emotions, intense exercise, loud music, or flashing lights. When these triggers are at play, they usually immediately precede the seizure.

Although they are more difficult to link to a seizure, other factors can also increase the likelihood that a seizure will happen. As an example, fever, menstrual periods, a lack of sleep, and stress can all increase the risk of seizures in some people.

After a seizure (postictal state) — For many seizure types, you may be unaware during the seizure. When you are told about your behavior during the seizure, you may not believe it because you have no memory of the event.

The period following a seizure is called the postictal state. During this time, you may be confused and tired, and you may develop a throbbing headache. This period usually lasts several minutes, although it can last for hours or even days.

In some people, the postictal period comes with certain symptoms. For example, you may experience mild to severe weakness in a hand, arm, or leg. Other people have difficulty speaking or experience temporary (partial) vision loss or other types of sensory loss. These can be important clues about the type of seizure and the part of the brain that was affected during the seizure.

SEIZURE CAUSES — As noted earlier, all seizures are not caused by epilepsy. There are three broad categories of seizure causes:

Epileptic seizures — People with epilepsy have a type of brain dysfunction that intermittently causes episodes of abnormal electrical activity. This can be caused by any type of brain injury, such as trauma, stroke, brain infection, or a brain tumor. In some individuals, epilepsy is an inherited condition. In many cases, the cause of epileptic seizures is not clear.
Provoked seizures — A similar type of abnormal electrical activity in the brain can be caused by certain drugs, alcohol withdrawal, and other imbalances, such as a low blood sugar. Seizures that are caused by problems like these are called “provoked” seizures, and they do not usually occur again once the problem is remedied. People with provoked seizures are not said to have epilepsy.
Nonepileptic seizures — Nonepileptic seizures look like seizures, but are not caused by abnormal brain activity. These seizures may be due to fainting spell, a muscle disorder, or a psychological condition.
SEIZURE DIAGNOSIS — If you have a seizure and have never had one before, your healthcare provider will want to get as much information about the seizure as possible. He or she will want to know a detailed description of the episode, if you lost consciousness, stared blankly, or twitched and jerked violently. The more information your healthcare provider has about your seizure, the better able he or she will be to make the right diagnosis.

If a witness to the seizure is available and can come to the appointment or be contacted later, this can be very helpful to the physician.

Tests and procedures — Depending on the circumstances of your seizure, your age, and your individual situation, your healthcare provider may order one or more tests, including:

Blood tests may be done to check for problems (such as low or high blood sugar) that may have caused your seizure, and to check for markers in the blood that could point to the type of seizure you had.
Lumbar puncture (spinal tap) may be done after a seizure to check for signs of infection. This is usually done in an emergency room, if the individual does not seem to be recovering normally from the seizure, or if the person has a fever or other signs of brain infection.

During this test, a needle is inserted into the space surrounding the spinal cord and a fluid sample is taken. The sample is checked for bacteria or other signs of signs of infection, such as an abundance of white blood cells.
Electroencephalography (EEG) may be done to check for abnormal electrical activity in the brain. During this test, electrode pads are placed on your scalp. The clinician may try to provoke a seizure using flashing lights or by asking you to hyperventilate. Both of these maneuvers may produce abnormalities in your brain waves, which could be helpful in determining your diagnosis.
Brain imaging studies, such as MRI or CT scans, may be done to check for tumors, strokes, or other structural problems in the brain. However, these tests are often normal in people with epilepsy.
SEIZURE TREATMENT — The appropriate treatment of your seizure will depend upon what type of seizure you had and whether the seizure was caused by epilepsy or another factor.

As an example, if your seizure was caused by an infection affecting the brain, treatment of the infection should prevent you from having more seizures. Likewise, if your seizure was caused by a psychological problem, such as anxiety, treatment of the psychological problem should remedy the seizures.

Seizure medications — If you have epilepsy or if your seizure was caused by a stroke, tumor, or some type of permanent brain injury, you may to take one or more anti-seizure medications, referred to as antiepileptic drugs (AEDs). (See “Initial treatment of epilepsy in adults”.)

Anti-seizure medications prevent or reduce the number or severity of a person’s seizures. Healthcare providers may not recommend starting these drugs until you have had at least two seizures, in part to make sure that the first seizure was not an isolated incident.

However, your healthcare provider may recommend an anti-seizure medication after a single seizure if you are at high risk of having a second seizure or if you are at high risk of injury related to the seizure.

Starting anti-seizure medication therapy early reduces the risk of another seizure and is generally safe. However, many people dislike taking medications every day, and anti-seizure medications can cause side effects and carry certain risks. Discuss the options for starting an anti-seizure medication with your healthcare provider.

Choosing a seizure medication — In selecting a medication, your healthcare provider will consider your seizure type as well as other medical conditions that you might have and medications you may be taking. Finding the right anti-seizure medication may require a number of adjustments in medications and dosages.

You will meet regularly with your healthcare provider when you are first trying a new medication, and will start with a low dose and slowly increase it, so that you can find the lowest effective dose.

Only about half of the people with a new diagnosis of epilepsy stop having seizures with the first anti-seizure medication [1,2]. That means that most people have to try more than one medication before they find one that works well. The best medication is one that offers the most protection from seizures with the fewest possible side effects.

The good news is that there are many anti-seizure medications to choose from, so the chances are good that you will find one that works without too many side effects.

If you take an anti-seizure medication that causes uncomfortable side effects, such as a skin rash, tell your healthcare provider. In some cases, side effects will go away once you have been taking the medication for a while. In other cases, your healthcare provider may lower your dose or switch you to another medication that is less likely to cause side effects.

If a single anti-seizure medication is not effective, your provider may suggest combining two anti-seizure medications. Although this is a sound strategy, combinations of anti-seizure medications are not usually recommended until you have tried at least two anti-seizure medications.

Generic anti-seizure medications — Several anti-seizure medications are available as generic formulations, which can help you to save money on the cost of your prescriptions. Most generic medications are as effective as the brand name drug.

However, if your clinician has determined that you need a specific brand or form of medication to control your seizures, be sure that your prescription includes the statement “no interchange” or “no substitution”. This lets your pharmacist and insurance company know that the generic drug should not be substituted for the brand name drug.

Side effects — Each anti-seizure medication can cause side effects, which can affect each person differently. Anyone taking an anti-seizure medication should be aware of some side-effects. These include the following:

An increased risk of becoming suicidal. If you start to become depressed or have thoughts of harming yourself or others while taking an anti-seizure medication, speak to your healthcare provider right away. (See ‘Psychological and social issues’ below.)
A rare but serious skin disorder called Stevens-Johnson syndrome, which can cause fever and a painful, sometimes blistering, rash that eventually kills the top layer of skin. This side effect is most likely to happen in people taking carbamazepine, oxcarbazepine, phenytoin, and lamotrigine, and it is mostly likely to occur within the first two months of use. If you notice a severe rash while taking an anti-seizure medication, call your healthcare provider right away.
A weakening of the bones (osteoporosis). This can occur after long-term use of anti-seizure medications. There are steps you can take to protect and strengthen your bones. If you are concerned about your bone health, or are at risk for osteoporosis, ask your healthcare provider what you can do to keep your bones as healthy as possible. (See “Patient information: Osteoporosis prevention and treatment” and “Patient information: Calcium and vitamin D for bone health” and “Pharmacology of antiepileptic drugs”.)
Seizures that persist despite medication — Although anti-seizure medications work for many people with seizure disorders, some people continue to have seizures even after trying several medications. For them, other treatments may be an option.

For example, surgery to remove the portion of the brain causing the seizures or severing the connection between the two halves of the brain can reduce or eliminate seizures in some people. (See “Surgical therapy of epilepsy in adults”.)

Others may benefit from treatment with an implanted electrical device (vagal nerve stimulator). (See “Vagus nerve stimulation therapy”.)

What’s more, several experimental treatments are in development. If you cannot adequately control your seizures with medication, ask your healthcare provider if any other treatment strategies might be appropriate for you.

Increasing your chance for success — The things you do can have a big impact on how well your anti-seizure medication works.

Take your medication exactly as directed, at the right times, and at the right doses. Ask your healthcare provider to write down any special instructions.
Ask what side effects you can expect and what to do about them. Even if you develop uncomfortable side effects, don’t stop taking your anti-seizure medication without first speaking to your healthcare provider.
Be careful not to let your prescription run out. Stopping anti-seizure medication abruptly can put you at risk of seizure.
While taking an anti-seizure medication, do not start taking any other medications including over-the-counter medications and herbal supplements without first checking with your healthcare provider. Anti-seizure medication can interact with prescriptions, over-the-counter medications, and herbal supplements, so mixing them can be dangerous.
LIVING WITH SEIZURES

Seizure calendar — Especially when you first start taking a new medication, it’s a good idea to keep a record of seizures as they occur. On a calendar, note any seizures you may have had, and ask those around you to help you keep track. Note, too, any seizure triggers, such as days when you were sleep-deprived, stressed, drank alcohol, or (if you are a woman) had your period.

If medication side effects are a problem for you, use the calendar to record them as well. Then bring this calendar with you when you see your healthcare provider. That way, the two of you can work together to understand the factors that contribute to your seizures.

Keep appointments — Your healthcare provider may ask to see you on a regular basis, especially soon after you start taking anti-seizure medication. These visits are important because they allow your healthcare provider to:

Check how well your medication is working
Find out whether you are having troubling side effects
Make sure that your kidneys and liver are working properly (anti-seizure medications can sometimes strain these organs)
Monitor the level of medication in your blood
Use the check-up visits to alert your healthcare provider to any problems you may be having, either with your medication or overall health. Having a seizure disorder can be trying, but your healthcare provider can provide insight or solutions if your seizures are presenting obstacles.

Pregnancy — Women who may become pregnant and who require anti-seizure medications should talk to their healthcare provider about their plans for pregnancy.

Anti-seizure medications can affect the health of a developing fetus, and they can interfere with the effects of certain birth control methods, so this discussion is important for women regardless of whether or not you want to get pregnant. (See “Patient information: Birth control; which method is right for me?” and “Management of epilepsy and pregnancy” and “Risks associated with epilepsy and pregnancy”.)

Psychological and social issues — Having a seizure disorder can be emotionally difficult for a number of reasons.

For starters, seizures can be frightening for you and for your friends and loved ones. Depending on their frequency and severity, seizures can also interfere with your ability to drive or even work.

Plus, the medications used to control seizures can sometimes cause you to feel depressed or suicidal. If you become depressed or suicidal, or are just having a hard time with your condition, speak to your healthcare provider about your concerns. There may be treatments, services, or strategies that can help you overcome the hurdles you are facing. You may even decide to seek out a support group for people with epilepsy. If nothing else, this will give you a forum in which to discuss issues that affect people like you.

Driving restrictions — States vary widely in driver licensing requirements for people with epilepsy. The most common requirements are that you be free of seizures for a specified period of time and that you submit a doctor’s evaluation of your ability to drive safely. (See “Driving restrictions for patients with seizures and epilepsy”.)

A listing of individual state driving requirements can be found on the Epilepsy Foundation Website at www.epilepsyfoundation.org/resources/drivingandtravel.cfm.

Alcohol — If your seizures are well controlled, it may be acceptable to drink small amounts of alcohol (no more than one to two drinks per day). But drinking excessively (three or more drinks per day) increases the risk of seizures, particularly in the hours and days after you drink. What’s more, alcohol can interfere with the efficacy of anti-seizure medications.

For these reasons, you should limit the amount of alcohol you drink and use caution if you do drink.

SUMMARY — After you have had a seizure, your healthcare provider’s first priority will be to determine what type of seizure you had and whether it was caused by a problem unrelated to epilepsy that can be corrected. He or she will likely ask you a series of questions, examine you, and order several tests. If you need to begin treatment with an anti-seizure medication, it’s important that you and your healthcare provider come up with a plan together about how you will take your medication and what you will do if you develop side effects or continue to have seizures.

Remember, if one medication does not work for you, either because you cannot tolerate the side effects or because you continue to have seizures, your healthcare provider can suggest alternate medications or alternate methods of taking the medication.

WHERE TO GET MORE INFORMATION — Your healthcare provider is the best source of information for questions and concerns related to your medical problem.

 

Related topics for patients, as well as selected articles written for healthcare professionals, are also available. Some of the most relevant are listed below.

Patient Level Information:

Patient information: Osteoporosis prevention and treatment
Patient information: Calcium and vitamin D for bone health
Patient information: Birth control; which method is right for me?

Professional Level Information:

Clinical neurophysiology
Driving restrictions for patients with seizures and epilepsy
Electroencephalography (EEG) in the diagnosis of seizures and epilepsy
Evaluation of the first seizure in adults
Initial treatment of epilepsy in adults
Localization-related (partial) epilepsy: Causes and clinical features
Magnetic resonance imaging changes related to acute seizure activity
Management of epilepsy and pregnancy
Seizures in patients with primary and metastatic brain tumors
Neuroimaging in the evaluation of seizures and epilepsy
Nonepileptic paroxysmal disorders in adolescents and adults
Overview of the management of epilepsy in adults
Pathophysiology of seizures and epilepsy
Pharmacology of antiepileptic drugs
Risks associated with epilepsy and pregnancy
Treatment of seizures and epilepsy in the elderly patient
Seizures and epilepsy in the elderly patient: Etiology, clinical presentation, and diagnosis
Seizures in patients undergoing hemodialysis
Status epilepticus in adults
Surgical therapy of epilepsy in adults
Video and ambulatory EEG monitoring in the diagnosis of seizures and epilepsy
Vagus nerve stimulation therapy

The following organizations also provide reliable health information.

The Epilepsy Foundation
(www.epilepsyfoundation.org)

National Institute of Neurological Disorders and Stroke
(www.ninds.nih.gov/disorders/epilepsy/detail_epilepsy.htm)

National Library of Medicine
(www.nlm.nih.gov/medlineplus/epilepsy.html)

Epilepsy Therapy Development Project
(www.epilepsy.com)

International League Against Epilepsy and the International Bureau for Epilepsy
(www.epilepsy.org)

REFERENCES
Kwan P, Brodie MJ. Effectiveness of first antiepileptic drug. Epilepsia 2001; 42:1255.
Brodie MJ, Perucca E, Ryvlin P, et al. Comparison of levetiracetam and controlled-release carbamazepine in newly diagnosed epilepsy. Neurology 2007; 68:402.
Krumholz A, Wiebe S, Gronseth G, et al. Practice Parameter: evaluating an apparent unprovoked first seizure in adults (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology and the American Epilepsy Society. Neurology 2007; 69:1996.
Krauss GL, Ampaw L, Krumholz A. Individual state driving restrictions for people with epilepsy in the US. Neurology 2001; 57:1780.
Jacoby A, Gamble C, Doughty J, et al. Quality of life outcomes of immediate or delayed treatment of early epilepsy and single seizures. Neurology 2007; 68:1188.
Glauser T, Ben-Menachem E, Bourgeois B, et al. ILAE treatment guidelines: evidence-based analysis of antiepileptic drug efficacy and effectiveness as initial monotherapy for epileptic seizures and syndromes. Epilepsia 2006; 47:1094.