Epilepsy treatment: medication, diet, regimen + first aid

Pharmacological therapy

The goal of antiepileptic therapy is to achieve a satisfactory quality of life for the patient, i.e. complete elimination of seizures with minimal side effects of medication.

If the desired effect is not observed, an alternative monotherapy, i.e. replacement of the drug with another type of active substance, follows. The dosage starts at the lowest effective dose and is slowly increased while monitoring the effect of the treatment.

If monotherapy fails, we proceed to combination therapy, where we add another drug to one drug. Combinations of drugs with different mechanisms of action are preferred.

The mechanism of action of antiepileptic drugs is based on inhibition of cortical activity by interfering with cellular ion concentrations.

The drugs of first choice are:

• Lamotrigine - a broad-spectrum antiepileptic drug for the treatment of focal and generalized epileptic seizures
• Levetiracetam - a broad-spectrum drug that does not exacerbate any type of seizure and has minimal side effects
• Valproate - a well-tolerated drug, also effective in preventing migraines
• Carbamazepine - the drug of choice for focal seizures in the treatment of neuralgia and neuropathy, but has the disadvantage of potential neurotoxicity, bone thinning and slowing of thinking
• Ethosuximide - a narrow-spectrum antiepileptic, used especially in childhood absences

Other antiepileptics used in monotherapy are gabapentin, eslicarbazepine, lacosamide, topiramate, zonisamide and others.

As an additional, so-called add-on therapy, the following are used when monotherapy fails:

• Benzodiazepines clonazepam or diazepam - mainly for acute seizure management or for transient worsening of seizures
• Phenobarbital and primidone - used in young adolescents when monotherapy has failed, with the disadvantage of impaired cognition and mood
• Phenytoin - risk of cosmetic side effects such as increased male pattern hair growth in females, thinning of bones, etc.
• Pregabalin - has a positive effect on sleep and has an analgesic effect in restless legs syndrome, neuralgia and neuropathies
• Retigabine - effective in the treatment of focal seizures, but side effects include altered pigmentation of skin, nails and mucous membranes

Ketogenic diet

This is a diet high in fat and restricting sugars. The Atkins form of the diet is most commonly used.

The main source of energy for the brain in this case is ketone bodies instead of sugars.

It is the high concentration of ketone bodies in the brain, metabolic acidosis and other biochemical processes that underlie the anticonvulsant effect of this diet.

Regimen measures

Since there are various provoking factors that trigger or aggravate epileptic seizures, effective therapy includes limiting these factors by regimen measures.

Regular lifestyle, adequate and undisturbed sleep are essential. If the patient's seizures are not related to sleep, sleep during the day is allowed. In other cases, it is not permissible.

Furthermore, complete abstinence from alcohol is recommended, which is also essential for the proper effect of antiepileptic therapy.

If there are known provoking factors such as photosensitivity, hypersensitivity to noise, etc., it is recommended to avoid such stimuli (e.g. disco lights, strobe lights, noisy concerts, etc.).

In the case of active epilepsy with seizures, an assessment with a ban on driving, night work and working at heights is appropriate.

Grand mal seizure treatment + first aid

How to treat whole-body convulsions? And how to give first aid?

When a tonic-clonic seizure with loss of consciousness occurs, it is advisable to remove from the vicinity of the affected person all objects that could injure him/her during the duration of the seizure.

By propping the head, we prevent it from hitting the hard floor.

Loosen the clothing around the neck to prevent deepening hypoxia and suffocation.

Never try to hold the limbs and trunk to prevent convulsions.
Fractures and dislocations could occur.

We do not put any objects in the mouth, try to force the mouth open, pull out a stuck tongue, etc.

Wait until the seizure is over.

If unconsciousness lasts for a longer period of time, we position the patient in a stable position with the mouth open (unless they are already convulsing).

The seizure may recur... Therefore, even after the convulsions have subsided, a resting position in the supine position and without activity is appropriate.

Status epilepticus and its therapy

Status epilepticus is a seizure that persists uninterrupted for more than 30 minutes. It can also be a cluster of seizures between which the patient does not regain consciousness.

In generalised convulsions lasting more than half an hour, irreversible damage to nerve cells occurs, leading to their death.

In the therapy of status epilepticus, benzodiazepines administered intravenously in an infusion have a prominent place. If intravenous administration is not possible for some reason, rectal administration of diazepam or intranasal administration of midazolam is used.

If necessary, early monitoring of vital signs with resuscitation (CPR, defibrillator) is initiated.

Surgical treatment of epilepsy

Surgical treatment of epilepsy is considered as a radical and invasive treatment for epilepsy that is resistant to all conservative methods of treatment. Before surgery, the patient undergoes a thorough diagnosis, preferably in a specialized epileptology center.

Among the examinations, video EEG, MRI of the brain, or positron emission tomography of the brain (PET CT) using a special radiopharmaceutical are essential.

Once the epileptic lesion in the brain, which is the source of the pathological hyperactivity of the cerebral cortex, has been detected, the patient is prepared for surgery. This involves surgical removal of the lesion. This may be a local lesionectomy or a wider cortical resection. In very severe epilepsies, a large part of the tissue must be removed (hemispherectomy).

If it is not possible to remove the lesion, a procedure called subpial transection is performed. This involves making thin incisions across the surface of the cortex, cutting through the thin horizontal nerve fibres while leaving the main vertical nerve pathways intact.

The post-operative effect of the treatment is evaluated according to the so-called Engleman classification:

1. Grade - no restrictive seizures - Approximately 50-80% of patients who have been operated on are in this group. Success also depends on the location of the brain lobe where the procedure was performed. Patients with temporal lobe epilepsy respond best.
2. Grade - almost seizure-free
3. Grade - significantly improved quality of life, but seizures returned after two years
4. grade - no significant improvement in quality of life