QuestionSBA
QuestionChoice
Ethosuximide is usually used for generalised absence seizures, rather than tonic-clonic seizures.
10015782
b
Ethosuximide
QuestionChoice
Carbamazepine is not a first-line drug for any seizure type. It is a second-line option for focal seizures not well controlled on lamotrigine/levetiracetam.
10015784
d
Carbamazepine
QuestionChoice
While sodium valproate is the first line choice in generalised tonic-clonic seizures, it should not be used in women of child bearing potential due to extreme teratogenicity. It can be used in girls under the age of 10, and in women who are unable to have children (e.g. those who have had a hysterectomy). Lamotrigine/levetiracetam are the preferred options.
10015785
e
Sodium valproate
QuestionChoice
As this patient is experiencing generalised tonic-clonic seizures and are starting treatment, they require a broad-spectrum antiepileptic. Valproate (the first line drug in this situation) is contraindicated due to its teratogenicity; it should not be prescribed to females of child-bearing age. Lamotrigine or levetiracetam are good alternatives.
10015781
a
Levetiracetam
QuestionChoice
Clobazam is a second-line drug for generalised tonic-clonic seizures, if the patient is not well controlled on first line options. Other second-line drugs include perampanel and topiramate.
10015783
c
Clobazam
QuestionComment
Why would a seizure at work be high risk? I'd argue being in a hospital to have a seizure is possible the best place to have one?
33809
QuestionComment
Imagine having a seizure during a procedure 
33885
User
subscriber
Serotonin Complement
QuestionComment
Yeah talking more about the risk of a seizure occurring and impacting on what is going on i.e in surgery or when doing procedures
34456
User
subscriber
Camiodarone
QuestionComment
that must be a joke and it is funny!
36152
User
subscriber
Epidermis Flutter
User
subscriber
Migraine Body
QuestionComment
As a group, we have terrible chat 
40470
User
subscriber
QED
QuestionComment
Surely you would ask if they wish to start a family 

42093
QuestionComment
doesn't matter if she's childbearing age = no sodium valproate
44951
User
subscriber
Emma
User
subscriber
Twisted Tezzy
QuestionComment
What if it was a woman who did not want to have children but is of child bearing age

47260
QuestionComment
its the fact it can cause teratogenicity, just cos they dont want kids they can still get pregnant
58184
User
subscriber
 Nightshift Hematoma
User
subscriber
MadHatter09
QuestionComment
Why did I read it as male 💀
54044
QuestionComment
we're all a bit sexist :/
59706
User
subscriber
Positive Whiff Test
QuestionComment
Talking bout oui a lot, oh you speak French now 
60086
User
subscriber
Humerus H
User
subscriber
Serotonin Abdomen
QuestionComment
resident**
59035
User
subscriber
Fever Relapse
Concept
Chapter
# Summary

Epilepsy is a neurological disorder characterised by an enduring predispotion to generate epileptic seizures. Affecting around 50 million people globally, it is one of the most common neurological conditions. Seizures can be either focal or generalised, with various triggers and symptoms. Differential diagnoses include syncope, transient ischemic attacks (TIA), migraines, panic disorder, and non-epileptic attack disorder (NEAD). Treatment primarily involves antiseizure medications (ASMs), tailored to the type of epilepsy, with surgery and psychological support as additional options in refractory cases. Complications include status epilepticus, psychiatric issues, and Sudden unexpected death in epilepsy (SUDEP).

# Definition

Epilepsy is a neurological disorder characterised by an enduring predisposition to generate epileptic seizures and the neurobiological, cognitive, psychological, and social consequences of this condition. 

Seizures are transient occurrences of signs and/or symptoms due to abnormal excessive or synchronous neuronal activity in the brain. 

# Epidemiology

Epilepsy affects approximately 50 million people worldwide, making it one of the most common neurological disorders.

It has a lifetime prevalence of 7.6 per 100 people.  

Incidence rates vary depending on age, with higher rates in the very young and the elderly. Both males and females are affected equally.

# Aetiology

There is a strong debate amongst epileptologists regarding the classification of epilepsy syndromes by aetiology. 

Broadly, epilepsy syndromes can be classified into:

1. Idiopathic Generalised Epilepsies (IGEs):

- Childhood Absence Epilepsy
- Juvenile Absence Epilepsy
- Juvenile Mycolonic Epilspy
- Generalised Tonic Clonic Seizures Alone

2. Structural aetiology:

- Acquired
	- Stroke
	- Trauma
- Genetic
	- Malformations of cortical development 

3. Genetic aetiology
4. Infectious aetiology
4. Metabolic aetiology
5. Immune aetiology
6. Unknown aetiology


# Signs and symptoms

Signs and symptoms vary between focal and generalized seizures:

- **Focal seizures**: 
  - *With impaired consciousness ('complex')*: patients lose consciousness, usually post an aura or at seizure onset. Commonly originate from the temporal lobe, and post-ictal symptoms such as confusion are common.
  - *Without impaired consciousness ('simple')*: patients retain consciousness, experiencing only focal symptoms. Post-ictal symptoms are absent.
  - *Evolving to a bilateral, convulsive seizure ('secondary generalised')*: patients first experience a focal seizure that evolves into a generalized seizure, typically tonic-clonic.

- **Generalized seizures**:
  - *Absence seizures*: brief pauses for less than 10 seconds.
  - *Tonic-clonic seizures*: characterized by loss of consciousness, stiffening (tonic), and jerking (clonic) of limbs. Post-ictal confusion is common.
  - *Myoclonic seizures*: sudden jerks of a limb, trunk, or face.
  - *Atonic seizures*: sudden loss of muscle tone, causing the patient to fall, with consciousness retained.

Specific epilepsy syndromes to note:

- Temporal lobe epilepsy
 - Associated with complex partial seizures
 - Can present with initial sensory auras e.g. smelling burnt toast, feelings of deja vu or jamai vu (feeling unfamiliar in familiar surroundings), automatisms such as lip smacking
 - Patients often exhibit postictal confusion after each episode
- Jacksonian March
	- A type of focal motor seizure that progressively 'marches' through adjacent areas of the brain
	-  Typically starts in the hand or face then gradually spreads to other muscle groups following the smatotopic organisation of the motor cortex (starting from hand and spreading to arm, shoulder and face)
	-  The seizure may progress into a generalised tonic clonic seizure
	-  Often associated with structural brain lesions
- Todd's Paresis
	- Refers to temporary postictal weakness or paralysis following a seizure
	- Usually lasts minutes to hours but can last up to 48 hours 
	- Usually unilateral but can be bilateral
	- It is transient so the patient will reover following resolution of the postictal state



# Differential diagnosis

The differential diagnosis for seizures includes:

- **Syncope**: characterized by a sudden, transient loss of consciousness and postural tone followed by spontaneous recovery. Triggered by low blood flow to the brain.
- **Transient Ischemic Attack (TIA)**: brief episodes of focal neurologic dysfunction caused by ischemia that does not cause lasting brain injury. Symptoms depend on the brain area affected.
- **Migraines**: characterized by recurrent headaches often accompanied by a variety of symptoms such as visual disturbances (auras), nausea, vomiting, dizziness, extreme sensitivity to sound, light, touch and smell, and tingling or numbness in the extremities or face.
- **Panic Disorder**: sudden periods of intense fear that may include palpitations, sweating, shaking, shortness of breath, numbness, or a feeling that something terrible is going to happen.
- **Non-Epileptic Attach Disorder (NEAD)**: characterized by episodes that resemble epileptic seizures but occur without abnormal electrical activity in the brain. NEAD is often associated with psychological or emotional stress, and symptoms may include convulsions, loss of consciousness, or other seizure-like movements. Diagnosis is confirmed by video EEG monitoring, showing no seizure activity during an episode.

# Investigations

Diagnostic workup of epilepsy includes:

- Detailed history and neurological examination
- Collateral history and, if present, reviewing any videos of previous episodes (with the patient's consent)
- Imaging such as CT or MRI
- Electroencephalogram (EEG)
	- Video-EEG telemetry can also be considered in select cases
- Other investigations can be considered to investigate contributory causes which include blood tests, lumbar puncture and more advanced imaging investigations.


# Management

The goal of epilepsy treatment is to minimize seizures and optimise the patient's quality of life via a biopsychosocial model.

Antiseizure medications (ASMs) remain the mainstay of treatment, with the specific drug chosen based on seizure type, patient age, comorbidities, potential side effects, and the patient's personal considerations. 

Principles of epilepsy ASM management include:

- Aim for optimum quality of life through seizure control, balanced against potential side effects, particularly teratogenesis in women of childbearing age.
- Initiation of medication may not always be appropriate after a "provoked" first seizure; discuss such cases with a specialist.
- The choice of antiepileptic drugs involves complexity due to the lack of head-to-head trials comparing different medications.
- Interactions with other medications, particularly with phenytoin and carbamazepine, should be considered.
- Issues regarding teratogenicity, particularly with valproate, which carries a high risk of neural tube defects, should be considered. Lamotrigine is a better choice for women of childbearing age.

Specific ASMs:

- According to [NICE Guidelines](https://bnf.nice.org.uk/treatment-summaries/epilepsy/#focal-seizures-with-or-without-secondary-generalisation), Lamotrigine or Levetiracetam should be considered as first-line for focal seizures.  
- Sodium valproate can be offered as first-line for myoclonic seizures in males.
- Ethosuximide is the drug of choice for absence seizures.
- Carbamazepine may worsen myoclonic seizures.

Surgical intervention may be an option in cases where AEDs are ineffective. 

Psychological support is a vital part of comprehensive epilepsy management.

Specific guidance on patients presenting with a 'first fit':

- Usual protocols will advise to refer to outpatient neurology following a patient's first seizure
- Most neurologists would start an ASM after a second seizure, unless there is a specific structural cause or a second fit would be unacceptable to the patient. 
- Following a discussion regarding the risks and benefits of starting an ASM, patients are given information on reducing risks e.g. driving advice or taking showers rather than baths. 
- Patient education via leaflets or online websites are utilised heavily as part of the initial discussions and further follow up or advice is usually relayed via a dedicated epilepsy nurse

# Complications

Complications of epilepsy include:

- **Status epilepticus**: Seizures lasting more than 5 minutes, necessitating immediate medical intervention OR more than 2 seizures within 5 minutes without returning to normal between each seizure.
- **Psychiatric complications**: Increased risk of depression and suicide.
- **Sudden unexpected death in epilepsy (SUDEP)**: Thought to occur due to excessive electrical activity inducing a cardiac arrhythmia and subsequent death.

# Side Effects of Anti-Epileptic Drugs

Side effects of common anti-epileptic drugs include:

- **Topiramate**: Abdominal pain, cognitive impairment, confusion, mood changes, muscle spasm, nausea and vomiting, nephrolithiasis, tremor, weight loss.
- **Lamotrigine**: Blurred vision, arthralgia, ataxia, diarrhoea, dizziness, headache, insomnia, rash, tremor.
- **Carbamazepine**: Ataxia, blood disorders, blurring of vision, fatigue, hyponatraemia, skin problems.
- **Sodium Valproate**: Ataxia, Anaemia, confusion, gastric irritation, haemorrhage, hyponatraemia, tremor, weight gain.
- **Phenytoin**: Acne, anorexia, constipation, dizziness, gingival hypertrophy, hirsutism, insomnia, rash, tremor.

# Driving Guidance

The DVLA has issued guidelines on driving with medical conditions, including epilepsy:

- For car/motorbike licence: reapply after 6 months for a one-off seizure, or after 1 year for more than one seizure. After a seizure following a change in anti-epileptic medications, reapply to drive if the seizure was more than 6 months ago or you've been back on the previous medication for 6 months.
- For bus/coach/lorry licence: reapply after 5 years for a one-off seizure if no anti-epileptic medications have been taken during this period. For more than one seizure, reapply after 10 seizure-free years during which no anti-epileptic medication has been taken.

The DVLA's complete guidelines for epilepsy and driving can be found [here](https://www.gov.uk/epilepsy-and-driving).

# References

[ILAE Guidelines](https://www.ilae.org/guidelines)

[NICE Guidelines](https://www.nice.org.uk/guidance/ng217)

[Driving Guidance on Gov.uk](https://www.gov.uk/epilepsy-and-driving)

194
195
Epilepsy
Topic
34
Neurology
Video
Concept
195
Epilepsy
247
Dy6PDaW
images/videos/neurology.png
Quesmed Tutorial: Neurology
Video
Concept
195
Epilepsy
129
9WkzgUc
images/videos/neurology.png
Epilepsy syndromes
15700
Valproate is contraindicated in women of childbearing age due to its high risk of teratogenic effects, making levetiracetam a preferred first-line treatment for generalized tonic-clonic seizures because of its safer profile during pregnancy.
A 32-year-old female junior doctor is seen in a 'first fit' clinic after experiencing a generalised tonic-clonic seizure. They are awaiting further investigations, however the decision is made to start anti-epipleptic medication as the risk that a seizure at work would pose is very high. They have no known drug allergies and a past medical history of hypothyroidism.

What would be the most appropriate medication to start?
a