Causes & Diagnosis

The diagnosis of epilepsy usually requires that the seizures occur spontaneously. Nevertheless, certain epilepsy syndromes require particular precipitants or triggers for seizures to occur. These are termed reflex epilepsy. For example, patients with primary reading epilepsy have seizures triggered by reading. Photosensitive epilepsy can be limited to seizures triggered by flashing lights. Other precipitants can trigger an epileptic seizure in patients who otherwise would be susceptible to spontaneous seizures. For example, children with childhood absence epilepsy may be susceptible to hyperventilation.

In fact, flashing lights and hyperventilation are activating procedures used in clinical EEG to help trigger seizures to aid diagnosis. Finally, other precipitants can facilitate, rather than obligatory trigger seizures in susceptible individuals. Emotional stress, sleep deprivation, sleep itself, heat stress, alcohol and febrile illness are examples of precipitants cited by patients with epilepsy. Notably, the influence of various precipitants varies with the epilepsy syndrome. Likewise, the menstrual cycle in women with epilepsy can influence patterns of seizure recurrence. Catamenial epilepsy is the term denoting seizures linked to the menstrual cycle.

There are around 180,000 new cases of epilepsy each year. About 30% occur in children. Children and elderly adults are the ones most often affected.
There is a clear cause for epilepsy in only a minority of the cases. Typically, the known causes of seizure involve some injury to the brain. Some of the main causes of epilepsy include:

  • Low oxygen during birth
  • Head injuries that occur during birth or from accidents during youth or adulthood
  • Brain tumors
  • Genetic conditions that result in brain injury, such as tuberous sclerosis
  • Infections such as meningitis or encephalitis
  • Stroke or any other type of damage to the brain
  • Abnormal levels of substances such as sodium or blood sugar

In up to 70% of all case of epilepsy in adults and children, no cause can ever be discovered.

Diagnosing epilepsy is a multi-step process, usually involving the following evaluations:

  • Confirmation through patient history, neurological exam and supporting blood and other clinical tests that the patient has epileptic seizures and not some other type of episode such as fainting, breath-holding (in children), transient ischemic attacks, hypoglycemia or non-epileptic seizures
  • Identification of the type of seizure involved
  • Determination of whether the seizure disorder falls within a recognized syndrome
  • A clinical evaluation in search of the cause of the epilepsy
  • Based on all previous findings, selection of the most appropriate therapy

Provide Information to Help the Doctor

If you have had a seizure and you seek medical help, your doctor will want to know:

  • Was the seizure caused by a short-term problem (like fever or infection) that can be corrected?
  • Was it caused by a continuing problem in the way your brain’s electrical system works?
  • Is there anything about the structure of your brain that could cause seizures?
  • Was the seizure an isolated event, or does it mean that you have epilepsy?

Diagnostic Methods and Tools

The doctor’s main tool in diagnosing epilepsy is a careful medical history with as much information as possible about what the seizures looked like and what happened just before they began.

The doctor will also perform a thorough physical examination, especially of the nervous system, as well as analysis of blood and other bodily fluids.

A second battery of diagnostic tools includes an electroencephalograph (EEG). This is a machine that records brain waves picked up by tiny wires taped to the head. Electrical signals from brain cells are recorded as wavy lines by the machine. Brainwaves during or between seizures may show special patterns which help the doctor decide whether or not someone has epilepsy.

Imaging methods such as CT (computerized tomography) or MRI (magnetic resonance imaging) scans may be used to search for any growths, scars or other physical conditions in the brain that may be causing the seizures. In a few research centers, positron emission tomography (PET) imaging is used to identify areas of the brain which are producing seizures.Which tests and how many of them are ordered may vary, depending on how much each test reveals.

The Treatment Decision

The decision to treat is highly individualized, weighing the risks of treatment against the risks of seizures.

In determining whether to treat, physicians consider the risk-benefit ratio, which varies according to the age of the patient and his or her activity level. Waiting to see whether another generalized tonic-conic seizure occurs is less risky for a child living in a sheltered home environment than it is for a salesman who lives most of his life driving a car, or an elderly person with brittle bones. On the other hand, antiepileptic drugs have side effects which, while generally mild, can in some cases include liver damage and potentially fatal rashes and blood disorders. Thus the decision to treat becomes a highly individualized one in which the risks of the treatment are weighed against the risks of the seizures.

Factors Influencing Decision to Treat:

  • Abnormal EEG
  • Previous Seizure
  • Person Drives
  • Other Neurological Impairment
  • Elderly

There is debate about whether or not children with febrile (fever caused) seizures should be placed on antiepileptic drugs. Current opinion favors withholding therapy for most of these children, since side effects of the medication may cause more problems than recurrent febrile convulsions. There may be instances, however, when treatment is prescribed.

If you have epilepsy and are thinking about getting pregnant, you probably have some important questions. Is it safe for me to get pregnant? Will having epilepsy make it harder for me to conceive? If I do get pregnant, how will I manage my seizures while I’m expecting? Could my anti-seizure drugs harm my baby?

Fortunately, most women with epilepsy give birth to normal, healthy babies, if you take precautions; your chance of having a healthy child is greater than 90%.

“There are increased risks, but these risks can be minimized by working carefully with your doctor. Don’t let these risks keep you from having a family if that’s what you really want,” says epilepsy expert Mark Yerby, MD, MPH, associate clinical professor of neurology, public health, and preventive medicine, Oregon Health Sciences University in Portland.

Before you try to conceive, you should talk to your neurologist and your obstetrician. Most doctors recommend that women with epilepsy be cared for by a high-risk obstetrician during their pregnancy. Both will want to monitor you closely throughout.

Getting Pregnant With Epilepsy

It’s possible that having epilepsy may make it more difficult for you to get pregnant. Women with epilepsy have fewer children than women in general. Their fertility rate is between 25% and 33% lower than average. Why is this? Here are some possible reasons:

  • Women with epilepsy have higher rates of some conditions that can cause infertility. One of these is polycystic ovarian syndrome (PCOS)
  • Women with epilepsy are more likely to have irregular menstrual cycles, which can make it more difficult to get pregnant
  • Women with epilepsy are also more likely to have menstrual cycles that do not produce an egg. These are called anovulatory cycles
  • Some ant seizure drugs may affect the hormone levels in your ovaries, which can affect reproductive functioning
  • Women with epilepsy are more likely to have abnormalities in hormones involved in pregnancy

If your seizures are not under control, that may affect your fertility, as well. Experts say that if a woman is having seizures around the time her body is preparing to ovulate, they may disrupt the signals that make that process occur.

Once you become pregnant, it will be even more important to control your seizures. Having seizures during pregnancy can affect the health of your baby. You might fall, or the baby may be deprived of oxygen during the seizure, which can injure the baby and increase your risk of miscarriage or stillbirth.

Unfortunately, some of the most common drugs for controlling seizures have been found to increase the risk of birth defects. In the general population there is a 2%-3% chance that a child will have a birth defect. In women with epilepsy, this risk goes up to 4%-8%.

To help decrease the chance of birth defects, especially neural tube defects that can affect the brain and spinal cord, women with epilepsy should take at least 0.4 milligrams per day of folic acid supplements, before they try to conceive.

Epilepsy Drugs Safe for Pregnancy

Which epilepsy drug should you take? Unfortunately, there is no clear answer. There are no anti-seizure drugs that are completely without risk of causing birth defects. But some anti-seizure medications appear to be more dangerous for a developing baby than others, and your doctor may be able to avoid prescribing them. Here’s what doctors know so far:

But that’s not the whole story. Research has recently shown that women taking Lamictal have a higher risk of breakthrough seizures during pregnancy. That’s because metabolism of Lamictal — as well as other antiepileptic drugs — increases during pregnancy. This can cause a drop in the level of ant seizure medication in your system. If that level gets too low, you could have a seizure. But if your doctor prescribes a higher dose of Lamictal to make sure that you don’t have breakthrough seizures, there could be a higher risk of damage to your baby.

What makes things a bit more confusing is that information about the safety of antiseizure drugs during pregnancy is changing all the time. “This makes managing epilepsy during pregnancy very complicated,” says Jacqueline French, MD, professor of neurology at New York University’s Langone Medical Center and co-director of Epilepsy Research and Epilepsy Clinical Trials at the NYU Comprehensive Epilepsy Center. “It’s important that women with epilepsy who want to become pregnant make sure they are seeing a doctor who keeps up to date on all the newest research. What we know about epilepsy and pregnancy literally changes from month to month.” You can also check with the Epilepsy Foundation if you have questions.

Prepare in Advance for Pregnancy With Epilepsy

Depending on what your doctor says about your epilepsy, you may want to change medications before you get pregnant, or it might be fine to stay with the one you are taking now. If you are taking more than one antiseizure drug, your doctor may recommend that you taper down to just one. That’s because combinations of drugs to treat epilepsy have a higher risk of causing birth defects than just one drug alone.

If you are making any changes in your antiseizure medications at all, you should do that at least a year before getting pregnant. Switching medications has risks, too. You may not respond well to the new drug and have breakthrough seizures, which could be harmful to a pregnancy. When changing medications, doctors will usually add the new drug before stopping the old one. If you become pregnant during this time, the baby could be exposed to both drugs instead of just one.

Whether you change seizure drugs or not, be sure to add folic acid to your daily schedule. Starting before you get pregnant, take prenatal vitamins with 0.4 milligrams of folic acid every day, and keep taking them throughout the pregnancy. Folic acid has been shown to reduce the risk of some birth defects by 60% to 70%. Because there are some extra risks associated with pregnancy when you have epilepsy, it’s important to do everything you can to minimize those risks.

Epilepsy and Labor

Many women with epilepsy worry that they will have a seizure during labor. This is an understandable fear. As your pregnancy progresses, your metabolism changes. By the time you are nine months pregnant, the blood volume in your body is 50% greater than it was before you got pregnant. This means that the antiseizure medications in your body will be more diluted. That’s why your doctor will be monitoring the levels of medication in your blood throughout your pregnancy, and might increase the dosage if it’s getting too low.

So when labor starts, you may already be a little more vulnerable to a seizure. Then, you may miss a dose, because things don’t always go exactly according to plan when a woman goes into labor. You will also be in pain and breathing hard, which can increase the chance of a seizure. This doesn’t mean that seizures are common during labor and delivery, but they are a possibility.

What happens if you do have a seizure during labor? Your doctor may give you IV medication to stop the seizure. If that doesn’t work, you may have to have a caesarean section. Although most women with epilepsy have normal vaginal deliveries, they do have a higher rate of C-sections than other women. Sometimes, anticonvulsant drugs can also reduce the ability of the muscles of your uterus to contract. If this happens, your labor might not progress as well and a C-section may be your best option.

All of these concerns can seem overwhelming, but there’s no need to become overly anxious. “Although women have to be aware of the risks, the vast majority of women with epilepsy get through pregnancy just fine,” says French. Your chances of having a healthy child are excellent, especially if you talk with your doctor early and often, follow the advice you are given, and take good care of yourself.

The challenges of parenting are compounded if your child has epilepsy. Not only do you have the normal concerns about raising a child, but now you have to address emotional concerns both you and your child may have about living with epilepsy.

Emotional Toll of Epilepsy

It’s natural for a child who has a chronic illness or who is different from other children to feel resentful. Children with an illness such as epilepsy may develop emotional problems, such as poor self-esteem or depression. These problems may come from within (anger, embarrassment, frustration), or from outside (children with epilepsy may be teased by other children).

As a parent, you can help your child deal with these feelings in the following ways:

  • Make sure your child understands as much about his or her disease as possible
  • Try to get your child to be positive about his or her disease and focus on things he or she can do
  • Help your child accept being a “different normal” and accept that there will be some risk in activities

As for your other children and the rest of your family:

  • Be sure your other children understand about their sibling’s illness. If they are feeling neglected, try to spend more time with them
  • If you think it’s necessary, seek family counseling to help everyone understand how to deal with the illness
  • Let your extended family know about your child’s illness and answer any questions they may have

Children and Epilepsy Drugs

If your child is taking epilepsy drugs, you can work with your child’s doctor to make sure that your child is taking them correctly. You will need to:

  • Learn the schedule for the medications (how many times a day to take them, whether they should be taken with food, etc.)
  • Know if any of the medications require blood tests
  • Find out what to do if your child forgets to take a dose of medication
  • Be aware of the potential side effects of the medications and what to do about them
  • Ask the doctor what to do if your child is ill or has a fever. (Fever sometimes brings on seizures.)
  • Make sure your child’s school knows that he or she takes epilepsy medication, and that arrangements are made for him or her to take it at school (if necessary)
  • Always carry a detailed list of your child’s medications

What Else Can I Do to Protect My Child?

If your child has epilepsy, monitor him or her near water, whether at home or outside.

Here are some tips for inside the home:

  • Keep an eye on your child while he or she is in the bathtub
  • Make sure the bathroom door opens outward rather than inward, so that it can still be opened in case your child falls. Take the locks off the bathroom door
  • Check the bathtub drain to make sure it’s working properly
  • Keep the water in the tub at low levels
  • Keep the water temperature low to prevent scalding
  • Install a shower or tub seat with a safety strap in the tub for older children
  • Keep all electrical appliances away from the sink or bathtub

Outside the home:

  • Don’t let a child with epilepsy swim alone
  • Make sure all adults, including the lifeguards and swimming instructors, know that your child has epilepsy
  • If your child has a seizure while swimming, get him or her out of the water as soon as possible. If anything seems wrong, contact the doctor right away
  • Install a shower or tub seat with a safety strap in the tub for older children
  • Keep all electrical appliances away from the sink or bathtub