Herbal Health » Epilepsy

DIAGNOSING EPILEPSY: REFERRAL TO A SPECIALIST

admin — Sat, 19 Feb 2011 14:07:15 +0000

Once it has been decided that what happened to you was, in all probability, a seizure, your doctor will want to discover whether it was due to some underlying cause that should be treated, and whether the fits are likely to recur.
It is possible that if this is your first fit the doctor may adopt a ‘wait and see’ policy. But they may – and certainly if you have had one or more previous attacks, they will – refer you to a neurologist.
Doctors, like gardeners, have their own fields of expertise. Medicine moves so fast nowadays that it is virtually impossible for a GP to be up to date with every new development in every field of medicine. Unless your GP has a special interest in epilepsy it is quite possible that their ideas about treating the condition may not be right up at the frontier of current thinking. Your GP may, for example, want to start treating you without referring you for further investigations. It is not unheard of for a GP to say to a patient, ‘You’ve got epilepsy. Go away and keep taking these tablets.’
This used to be normal practice because it used to be thought that the cause of epilepsy was unimportant. Indeed, in most cases it was believed that there was no cause to be found, and that most instances of epilepsy were ‘idiopathic’, that is, that there was no known cause for them. Investigations were pointless because so far as treatment was concerned the end result was much the same: ‘Keep on taking the tablets.’
Things are rather different now. New methods of imaging the brain have been developed which can produce a highly detailed picture of our most complex organ. The use of these new methods has shown one thing very clearly, and that is that epilepsy usually occurs for some reason. The old concept of idiopathic epilepsy, epilepsy without a cause, no longer holds true.
A neurologist will carry out tests to detect abnormalities either in the structure of your brain or in the way it is working. You will also be given blood tests, which can indicate whether there is any medical reason which might account for your seizure. These routine tests are all quite straightforward and painless and carry no risk. Usually the tests will give detailed information about the cause of the epilepsy.
Discovering the cause of your epilepsy is important for two reasons. To begin with, it may affect the choice of treatment. Until you are certain what is causing the epilepsy it is not possible to choose the appropriate treatment. And secondly, it helps most people who have epilepsy to know why it developed. It helps their families too. Whenever a child is ill, for example, parents tend to blame themselves, however illogical this may be. They want to know how it happened, and to be able to explain it to themselves.
Whether or not you are referred to a neurologist may also depend on whether or not you ask for a referral. Some people feel easier if they have as much information as possible about what is wrong with them; others are happy simply to accept what they are told and to leave all decisions up to their doctor. Neither approach is either right or wrong; it is very much a matter of your own particular personality. However, if you ask to be referred to a neurologist who has a special interest in epilepsy and your doctor seems reluctant to do so, it is reasonable to ask why. If they continually refuse to refer you, it might be worth changing your doctor to one who has a broader understanding of epilepsy.
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THE MEDICAL TREATMENT OF EPILEPSY

admin — Thu, 03 Jun 2010 09:49:54 +0000

The drugs used in the treatment of the various types of epilepsy we have discussed vary according to the seizure type. Some drugs are better for certain seizures than others. It is, however, important to remember that few anticonvulsants are very specific for particular seizures and that there is a choice of drugs for any particular seizure type. The choice may be related to your doctor’s experience, the side effects that he or she might anticipate and the way in which you as an individual tolerate a particular medication. The choice of a single drug is therefore not absolute.
Grand mal seizures: medications used in the treatment of grand mal seizures include carbamazepine, sodium valproate, phenytoin, primidone, phenobarbitone and clonazepam. The order in which the drugs are listed represents some personal bias by the author. Most people would feel that carbamazepine would be effective with the least side effects, but may disagree with the ‘preference’ listing of the rest of the drugs. It is important for patients to realise that the solution to which drug is best for them may not be a black and white issue. Different doctors may have slightly different approaches to a particular problem.
Absences (petit mal): the drug of choice for this condition is ethosuximide. An excellent alternative is sodium valproate, but its possible liver side effects make it a drug of second choice. In children whose absences are particularly resistant to treatment, clonazepam may be helpful.
Temporal lobe epilepsy (complex partial seizures): carba-mazepine is the drug of choice with phenytoin or sodium valproate being acceptable alternatives. Clobazam may be a useful adjunct (additional therapy) in some people with temporal lobe seizures.
Focal seizures: carbamazepine is the drug of choice, followed by phenytoin, sodium valproate or one of the barbiturates.
Reflex epilepsy: drug therapy is not often needed in this condition. Those whose fits are induced by sitting very close to the television should view it from three metres away in a well lit room. In addition, they should not approach the set in order to adjust it or change the channel. If the photosensitivity is induced by sunlight, then polarised sun glasses should be worn. If medication is required, sodium valproate is the drug of choice.
Infantile spasms: the treatment of this condition is difficult and the basis of it little understood. The drugs most commonly used are corticosteroid preparations such as corticotrophin (ACTH) and prednisone. An alternative is a group of drugs, the benzodiazepines, of which the most familiar to the general public would be diazepam (Valium). From this particular group of drugs, nitrazepam and clonazepam may be useful in the management of infantile spasms.
Myoclonic and tonic seizures: these are perhaps the most difficult forms of seizures to treat. The drugs of choice are probably sodium valproate, nitrazepam, clonazepam, and ACTH. If these have failed in children, the use of a ketogenic diet, which will be discussed later, may be considered.
Status epilepticus: as previously mentioned, status epilepticus is a medical emergency. The possibilities for non-professional management of this situation at home are limited. However, in children who recurrently have severe or prolonged seizures, it may be appropriate for a parent to administer rectal diazepam (Valium) to their child. This can be done by drawing up some diazepam into a narrow syringe and inserting it into the child’s rectum (back passage) and injecting the solution. Not all parents wish to do this, but it can be very useful and avoid a lot of trips to hospital.
A further matter worthy of discussion is that of therapeutic drug monitoring (blood level monitoring). Patients with epilepsy will be familiar with the practice of having blood samples taken from time to time to measure the blood levels of their anticonvulsant drugs. When a drug is administered to a person, it accumulates in the body over a few days and eventually reaches a certain level in the blood stream. As far as anticonvulsants are concerned, after taking medication regularly for about a week, the blood concentration will be at what is called ‘steady state’. If the patient continues to take the medication regularly thereafter, while there may be slight ups and downs in the concentration (level) over a 24-hour period, it will eventually remain stable (at a steady state).
Therapeutic drug monitoring determines whether the patient’s blood level is within what is called the ‘therapeutic range’. This is the range of blood concentrations within which the majority of people with epilepsy will have good seizure control with minimal drug side effects. This does not mean that every patient has to be within the therapeutic range. Some patients may be controlled very well with their blood levels below the therapeutic range, while others, if they do not have side effects, may need to be above the therapeutic range. The therapeutic range is just an average level. However, the therapeutic range and blood level monitoring are very useful for the doctor for some anticonvulsants, especially for phenytoin. Blood level measurements may be useful for carbamazepine, phenobarbitone, primidone and perhaps ethosuximide. They are of little, if any, value for sodium valproate, nitrazepam, clonazepam or clobazam.
When should blood levels be measured? Unfortunately, it has become almost routine to measure the blood levels of anticonvulsants in all epileptic patients, every time they visit their doctor. This is quite unnecessary and has almost replaced the conversation with the doctor which is so essential to those who have epilepsy. Obviously, if a patient has good seizure control and no side effects, there is little need to measure any blood levels. The indications for blood level monitoring include:
Poor seizure control. This may be because the person is not taking his or her medication (non-compliance), is not receiving a sufficient amount of an appropriate medication, or is receiving an inappropriate medication. It may also be because the fits are uncontrollable or that the diagnosis of epilepsy is in fact wrong.
Polytherapy. This describes patients who are receiving more than one drug, usually because their seizures are difficult to control. There may be interactions between the drugs and in that case measuring the blood levels may be of value.
Side effects. If a patient is on only one drug (monotherapy) and has side effects, there may be no need to measure the blood level as it will be obvious what the cause is. It may be sufficient to stop the drug for a day or two to let the blood level decline. On the other hand if a patient is receiving several drugs (polytherapy), it may not be possible to know which drug is causing the problem without measuring the blood levels.
In the very young, the elderly or the handicapped: These groups may handle anticonvulsants differently in the body and may not be able to describe side effects which they are experiencing.
Phenytoin. Phenytoin is broken down in the body by the liver in a rather complicated way which is different to other anticonvulsants. The difficulty with phenytoin is that, contrary to expectation, as the dosage is increased the concentration in the blood stream does not increase proportionally. This means that as the dosage is increased, the blood concentration may suddenly rise quite precipitously and the patient may become intoxicated. For this reason, patients who are receiving phenytoin should have regular blood tests, at least when they are being started on treatment, until they are stabilised on the medication.
There are a number of other indications for blood level monitoring which are still open to debate, but these are uncommonly needed and will not be discussed in detail. As children grow they will need to have their anticonvulsant dosage increased, so occasional blood level tests may be of value.
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Epilepsy

THE CAUSES OF EPILEPSY: PRECIPITANTS OF SEIZURES-ALCOHOL

admin — Tue, 28 Apr 2009 12:32:01 +0000

One of the most common reasons for staying up later than usual is to go to a party, where alcohol may be drunk. The social use of alcohol depends largely on its ability to remove inhibiting factors in our personalities and conversation, thereby making us perhaps more interesting and amusing. A similar removal of inhibition of an epileptic focus may allow a seizure to occur. Often, however,’ the seizure occurs during the ‘hangover’, at a time when the blood alcohol is falling, or near zero. It is probable that other changes in body chemistry, particularly in the distribution of water within and outside cells, plays a part in causing such seizures. Over-hydration of experimental animals with epilepsy may precipitate seizures, so there are grounds for believing that large quantities of beer, containing both alcohol and much water, may be more likely to precipitate an attack than moderate use of wine or spirits.

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