Seizures are a temporary neurologic event that results from abnormal, hypersynchronous discharges from neurons in the central nervous system (CNS). Seizures can be variously characterized according to behavioral and electroencephalographic (EEG) changes. Recurrent seizures from one of many chronic processes are considered epilepsy; however, a single seizure or recurrent seizures from a correctable cause (e.g., febrile seizures) are not considered epilepsy.

The International League Against Epilepsy published a Classification of Epileptic Seizures in 1981 in which all seizures were classified according to clinical features and EEG changes. The three major categories of seizures are: partial, generalized, and unclassified.

Partial (or focal) seizures can be isolated to certain areas of the cerebral cortex and are further classified as simple-partial seizures (consciousness is preserved), complex-partial seizures (consciousness is lost), or partial seizures with secondary generalization.

Generalized seizures usually involve both cerebral hemispheres and are further classified as absence seizures (petit mal—brief loss of consciousness), generalized tonic-clonic seizures (grand mal—tonic contractions followed by unresponsiveness), atonic seizures (transient loss of muscle tone), and myoclonic seizures (transient muscle contractions).

Unclassified epileptic seizures include neonatal seizures, West syndrome (infantile spasms), Lennox-Gastaut syndrome, juvenile myoclonic epilepsy, and reflex epilepsy (e.g., seizures resulting from certain stimuli such as a flickering light).

• CNS infection (e.g., bacterial meningitis, encephalitis)
• Drug toxicity or withdrawal (e.g., alcohol or illicit drug use)
• Genetic mutations (e.g., myoclonic epilepsy with ragged red fibers [MERRF])
• Head trauma
• Electrolyte or metabolic derangements
• Drugs that lower the seizure threshold
• High fevers
• Brain abnormalities (e.g., tumors, stroke)
• Hypoglycemia and hypocalcemia

• History of febrile seizures
• Family history of seizures
• History of stroke
• Alzheimer's disease

The physical presentations of seizures are varied in duration, severity, and characteristics. Signs may include the following.

• Prodrome of generalized seizures (aura), including lethargy, depression, irritability, myoclonic jerks of limbs, abdominal pains, pale complexion, headache, constipation, or diarrhea
• Loss of consciousness
• Total or partial body muscle spasm (tonic contractions)
• Apnea (cessation of breathing)
• Cyanosis (bluish coloring) of skin and mucous membranes
• Dilated pupils that are unreactive to light
• Bowel or bladder incontinence
• Increased pulse and blood pressure
• Increased salivation and sweating
• Deep coma, postictal confusion, and deep sleep

Repeated seizures over a long period of time may result in:

• Absentmindedness
• Automatisms (e.g., lip smacking, chewing, fumbling)
• Declining school or work performance
• Loss of postural muscle tone

• Stokes-Adams attack
• Transient ischemic attack
• Syncope
• Hysterical (psychogenic) seizures
• Metabolic disturbances (e.g., delirium tremens)
• Migraine syndromes
• Sleep disorders (e.g., narcolepsy)
• Movement disorders (e.g., tics)

Initially, providers must attend to the seizure patient's respiratory and cardiovascular status and vital signs. After the patient is stable, a detailed history must be taken from family members, witnesses, and the patient (if possible) to determine definitively whether the patient actually experienced a seizure. Precipitating events (e.g., head trauma) and risk factors (e.g., family history of seizures) must be considered. The presence or absence of "auras," which are experienced by up to 60% of seizure patients, automatisms, myoclonus, postures (i.e., whether or not the patient fell), continence (loss of bowel function), and postictal confusion must be noted. These signs can help to differentiate the type of seizure experienced.

Laboratory values are often normal in seizure patients.

• Complete blood count to diagnose metabolic disorders and as a baseline before treatment
• Urine and blood toxicologic screens to determine any underlying drug use
• Serum electrolytes and liver function tests for baseline values before beginning treatment

In many cases, the brains of patients with generalized seizures appear normal; however, some seizure disorders have definable lesions: hamartomas, vascular abnormalities, areas of neuronal loss, fibrosis, scars, and tumors. In addition, traumatic (e.g., cortical contusions) or hypoxic (e.g., degeneration of Purkinje cells) effects can result from the seizures themselves.

• Magnetic resonance imaging (MRI) to diagnose cerebral lesions (e.g., tumors, vascular malformations)
• Computed tomography (CT) to diagnose CNS infection and cerebral lesions when MRI is not available
• Positron emission tomography (PET) to localize epileptogenic areas in cases refractory to medical treatment
• Single photon emission computed tomography (SPECT) to localize epileptogenic areas in cases refractory to medical treatment

• An EEG is the primary diagnostic tool used to categorize seizures. The epileptiform abnormalities (spikes and waves) on the EEG are recorded in 60% to 90% of patients.
• Lumbar puncture—to diagnose meningitis, encephalitis, and human immunodeficiency virus
• Closed-circuit television EEG (CCTV/EEG) for long-term monitoring in a hospital setting to localize epileptogenic foci for resective surgery
• Ambulatory EEG for long-term monitoring at home, school, or work to localize epileptogenic foci for resective surgery

Treating the seizure patient can be challenging. It includes diagnosing and treating any underlying condition (e.g., surgical removal of cerebral lesions, focal brain resection, temporal lobectomy, lesionectomy, hemispherectomy) that may be causing the seizure activity. Precipitating events (e.g., lack of sleep, alcohol ingestion) should be identified and then avoided. The goal of therapy is to stop the seizure without adverse side effects, to prevent recurrences, and to help patients readjust to their home life and work environment.

Ideally, patients should take only one medication. However, many patients need several medications for complete seizure control. Approximately 30% to 70% of seizure patients will have a second seizure within 1 year. Side effects from seizure medication are experienced by over 50% of patients. These include gastrointestinal complaints, gingival hypertrophy, weight gain or loss, hair loss or hirsutism, coarsening of facial features (especially children), drowsiness, impaired memory and concentration, depression, mood swings, insomnia, dizziness, tremor, headache, ataxia, dermatitis, hepatotoxicity, bone marrow suppression, aplastic anemia, thrombocytopenia, lymphadenopathy, and osteomalacia.

• Carbamazepine (Tegretol), 600 to 1,800 mg/day for tonic-clonic and focal-onset seizures
• Phenytoin (Dilantin), 300 to 500 mg/day for tonic-clonic and focal-onset seizures
• Valproic acid (Depakote), 750 to 2,000 mg/day for tonic-clonic, absence, myoclonic, and focal-onset seizures
• Phenobarbital (Luminal), 60 to 180 mg/day for tonic-clonic and focal-onset seizures
• Primidone (Mysoline), 750 to 1,250 mg/day for tonic-clonic and focal-onset seizures
• Lamotrigine (Lamictal), 150 to 500 mg/day for focal-onset seizures and Lennox-Gastaut syndrome
• Gabapentin (Neurontin), 900 to 2,400 mg/day for focal-onset seizures
• Ethosuximide (Zarontin), 750 to 1,500 mg/day for absence seizures
• Clonazepam (Klonopin), 1 to 12 mg/day for absence and myoclonal seizures
• Felbamate (Felbatol), 2400 to 3,600 mg/day for focal-onset seizures and Lennox-Gastaut syndrome

Some mild cases of seizures may be controlled by alternative therapies, specifically nutrition, the cornerstone of alternative treatment. Herbal treatment may be helpful if low blood sugar and/or stress are initiating factors. Precautions regarding sudden cessation of drugs must be adhered to as there are currently no adequate replacements to drug therapies and/or surgical interventions.

• A ketogenic diet (high fat, low protein, low carbohydrate) produces ketones in the bloodstream, which may help control the frequency of seizures, especially if low blood sugar, or skipping meals, is a trigger. Some studies have shown a connection with food allergies and seizures in children. Avoid alcohol, caffeine, and aspartame.
• Taurine: 500 mg tid, neuroinhibitory amino acid that inhibited experimentally induced seizures
• Folic acid: 400 mcg/day, depleted during seizures and in some persons with seizures, although higher doses than 400 mcg may actually precipitate some seizures. Should take with B12
• B12: 100 to 200 mcg/day
• B6: 20 to 50 mg/kg, especially in children may help control seizures; depleted in phenytoin therapy. However, B6 may inhibit phenytoin's effects.
• Magnesium: 500 to 750 mg/day (should be in a 1:1 ratio in persons taking calcium) for normal muscle and neuronal function
• Manganese: 5 to 15 mg/day, depleted in epileptics, especially in children
• Zinc: 30 mg/day, may be depleted by some medications, some concern that excess zinc may disrupt zinc/copper ratios and increase seizures, especially without sufficient taurine
• Dimethylglycine: 100 mg bid, anecdotal evidence for decreasing medication requirements

Herbs are generally a safe way to strengthen and tone the body's systems. As with any therapy, it is important to ascertain a diagnosis before pursuing treatment. Herbs may be used as dried extracts (capsules, powders, teas), glycerites (glycerine extracts), or tinctures (alcohol extracts). Unless otherwise indicated, teas should be made with 1 tsp. of herb per cup of hot water. Steep covered 5 to 10 minutes for leaf or flowers, and 10 to 20 minutes for roots. Drink 2 to 4 cups/day. Tinctures may be used singly or in combination as noted.

• Passionflower (Passiflora incarnata): to both prevent and treat seizures, may be effective without side effects, especially where stress is a precipitating factor. Dose is 30 drops tid to qid.
• Skullcap (Scutellaria lateriflora): antispasmodic and calmative herb, with historic use for epilepsy
• Valerian (Valeriana officinalis): spasmolytic, sedative, historically used for epilepsy, large doses may cause lethargy or gastrointestinal upset that resolve with discontinuation
• The above herbs may be used singly or in combination at 1 cup tea tid or 30 to 60 drops tincture tid. In addition, use milk thistle (Silybum marianum) to protect the liver from ill effects of some medications (70 to 210 mg tid).

An experienced homeopath should assess individual constitutional types and severity of disease to select the correct remedy and potency. For acute prescribing use 3 to 5 pellets of a 12X to 30C remedy every one to four hours until acute symptoms resolve. If symptoms persist consult with an experienced homeopath.

• Artemesia vulgaris for convulsions after exertion and/or visual stimulation
• Oenanthe for violent seizures, especially exacerbated menstrually or after a head injury
• Bufo for convulsions accompanied by delayed development
• Cicuta for violent seizures with arching of the back, especially with a long postictal drowsiness and/or after head injury
• Cuprum metallicum for seizures with mental dullness and/or difficulty breathing
• Causticum for seizures during menses or after a fright or receiving bad news
• Belladonna as general remedy, especially for convulsions followed by nausea

Chiropractic, osteopathic, or naturopathic manipulation may be quite helpful, especially in children with seizures or seizures appearing after a head trauma.

Acupuncture may be helpful with specific acupressure points that have been used to stop seizures.

Because of the toxicity of the antiepileptic therapy, patients must be monitored closely for myriad side effects, the most serious of which include hepatotoxicity, bone marrow suppression, aplastic anemia, thrombocytopenia, lymphadenopathy, hirsutism, osteomalacia, and ataxia. In addition, determining the correct dosage or drug combinations is an inexact science at present; thus, patients must be monitored closely for many months until seizures are under control and side effects are tolerable. Starting and stopping antiepileptic medications must be done slowly, often by overlapping drugs for several weeks. Monitoring should continue regularly to ensure patient compliance with the drug schedule.

Some patients can identify events that seem to trigger seizures such as alcohol, lack of sleep, stress, and, in certain individuals, visual or auditory stimuli (e.g., video games, music). Thus, these situations must be avoided. Also, strict compliance with the drug schedule is mandatory to ensure therapeutic blood levels. Dangerous activities such as swimming, operating equipment, working at heights, and driving are contraindicated initially, and perhaps forever, depending on the seriousness of the seizure disorder and the success of treatment.

• The diagnosis of a seizure disorder can drastically alter a person's outlook and restrict their productivity; in addition, patients may face occupational discrimination and loss of independence if they are unable to drive. Depression or other psychological disturbances may result.
• Serious injuries are often sustained with the first seizure and in seizure disorders that are refractory to treatment. Head injuries and broken bones are common sequelae.
• The long-term effects of antiepileptic drugs on the growth and development of children is unknown.
• Generalized status epilepticus is characterized by a series of grand mal seizures without regaining consciousness. This must be treated as a medical emergency as irreversible neurologic sequelae are common.
• Absence status is characterized by absence seizures that may last for hours. This may be labeled inattention or daydreaming by young schoolchildren who may fall behind developmentally if the seizure disorder is not diagnosed.

Approximately 60% of adults who have successful therapeutic treatments and are seizure-free for two to five years can stop taking their medication. The exact point at which a drug-free trial should occur is unknown, but often providers make a first attempt after two years. Seizures that are refractory to drug therapy (20%) may respond successfully to surgery if they fit the criterion for a good surgical candidate. The diagnosis of a seizure disorder can drastically alter a person's outlook and restrict their productivity.

While it is not uncommon for women with a seizure disorder to have a normal pregnancy and delivery, there may be changes in the frequency of the seizures, which can have a teratogenic effect. Also, women who experience grand mal seizures while pregnant are more likely to experience premature labor, spontaneous abortion, toxemia, and abruptio placentae and hypoxia. In addition, infants of women who are taking antiepileptic drugs have malformations two to three times as often as healthy women. These malformations include cleft lip and palate, cardiac abnormalities, anencephaly, and neural tube defects.

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