EPILEPSY

EPILEPSY
• Epilepsy is a general term that includes various
types of seizures. Epilepsy is characterized by
unprovoked, recurring seizures that disrupt the
nervous system.
 WHAT ARE SEIZURES?
• Seizures (or convulsions) are temporary alterations in brain
functions due to abnormal electrical activity of a group of
brain cells that present with apparent clinical symptoms and
findings
An epileptic seizure is a transient paroxysm of uncontrolled
discharge of neurons causing an event that is discernible by
person experiencing seizure and/or by an observer. The
tendency to have recurrent attacks is known as epilepsy.
Epileptic seizures or attacks are symptoms of many different
diseases and term epilepsy is loosely applied to number of
conditions that have in common a tendency to have a
recurrent epileptic attacks. A patient with epilepsy will show
recurrent epileptic seizures that occur unexpectedly and stop
spontaneously.
 SEIZURES

GENERALIS
PARTIAL
ED

MYOCLONI TONIC
SIMPLE COMPLEX ABSENCE
C CLONIC

TONIC ATONIC
GENERALISED SEIZURES

It result in impairment of consciousness

from onset . various types of generalised
seizures

TONIC CLONIC CONVULSIONS

its often called grand mal attacks , these are the

commonest of all epileptic seizures without warning,

the patient suddenly goes stiff, falls and convulses, with

labored breathing and salivation.

ABSENCE ATTACKS

it is often called petit mal. These are much

rarer form of generalized seizure. They
happen almost exclusively in childhood
and early adolescence.
The child goes blank and stares. fluttering
of eyelids and flopping of head may occur.

MYOCLONIC SEIZURES

These are abrupt, very brief involuntary shock like jerks, which may involve the

whole body, or arms or head. They usually happen in morning, shortly after walking.

They may sometimes cause person to fall, but recovery is immediate. It should be

noted that there are forms of non-epileptic myoclonic jerks that occur in a variety of

other nerve diseases and may also occur in healthy people, particularly when they are

just going off to sleep.

ATONIC SEIZURES

These comprise a sudden loss of

muscle tone causing person to
collapse to ground recovery
afterwards is quick. They are
rare accounting for less than
1%.

SIMPLE PARTIAL SEIZURES: In these

seizures discharge remains localized and
consciousness is fully preserved. These are
rare and usually progress to other forms of
partial seizure. It depends on area of
discharge and differs from patient to
patient. Localized jerking of limb or a face,
stiffness or twitching of one part of body
are examples of what may occur in this
type of seizure.
COMPLEX PARTIAL SEIZURES: Patient may
present with altered or automatic behavior: plucking
his or her clothes, fiddling with various objects and
acting on confused manner. Lip smacking or chewing
movements, grimacing, undressing ,performing
aimless activites, and wandering around in a drunken
fashion may occur on their own or in different
combinations during partial seizures. Mainly these
originate from frontal or temporal lobes.
 TREATMENT
• Convulsive seizures may look frightening but patient is not in pain, will usually have no recollection of
event afterwards and is usually not seriously injured. During seizures , patients should not be moved unless
they are in dangerous places like in road etc and should not be forced anything between teeth. This usually
results in damage and broken teeth may be inhaled causing secondary lung damage. If a seizure persists for
more than 10 minutes, if a series of seizures occur or if seizure is particularly severe ,then intra-venous or
rectal administration of 10-20mg diazepam for adults with lower doses being used in children is
advisable.
 SATUS EPILEPTICUS
• Initial management of status epilepticus is supportive and may include:

• Positioning the patient to avoid injury.

• Supporting respiration.
• Maintaining blood pressure.
• Correcting hypoglycemia.
• Drugs used include intravenous lorazepam or
diazepam.
• Alternative medicines include midazolam in cases where patient has not responded to first line
drugs and buccal midazolam can be used.
• In severe case phenytoin, clonazepam, phenobarbital sodium or paraldehyde may be
required.
 FEBRILE CONVULSIONS
• Convulsions associated with fever are termed febrile convulsions and may occur in the young.
• Brief febrile convulsions are managed conservatively with primary aim of reducing temperature of
child.
• Prolonged febrile convulsions lasting 10-15 minutes or longer or in a child with risk factors require
active management to avoid brain damage.
• The drug of choice is diazepam
TYPE FIRST LINE TREATMENT SECOND LINE TREATMENT

SIMPLE PARTIAL CARBAMZEPINE VIGABATRIN

ZONISAMIDE
COMPLEX PARTIAL PHENTOIN CLOBAZAM

SECONDARY GENERALISED VALPROATE PHENOBARBITAL

LAMOTRAGINE ACETAZOLAMIDE
GABAPENTIN
TOPIRAMATE
ZONISAMIDE
TONIC CLINIC VALPROATE VIGABATRIN

TONIC CARBAMZEPINE CLOBAZAM

CLONIC PHENYTOIIN PHENOBARBITAL

LAMOTRIGINE
ABSENCE ETHOSUXIMIDE CLONAZEPAM
VALPROATE LAMOTRIGINE
ATONIC CLONAZEPAM LAMOTARIGINE
CLOBAZAM PHENYTOIN
MYOCLONIC VALPROATE PHENOBARBITOL
CLONAZEPAM ACETAZOLAMIDE
 CARBAMAZEPINE:
It is first line therapy for patients with newly diagnosed
partial seizures and for patients with primary
generalized convulsive seizures.
Mechanism of action:
It acts by inhibition of voltage gated sodium
channels and also interaction with voltage gated
calcium and potassium channels also contribute to
its activity.

CLOBAZAM
It is a 1,5-benzodiazepine that is said to be less sedative than
clonazepam and diazepam. It is used as an adjunctive therapy for
patients with partial or generalized seizures who have proved
unresponsive to other antiepileptic medication
 CLONAZEPAM:
• It is a 1,4-benzodiazepine and a
drug of choice for myoclonic
seizures and as adjunctive
therapy for partial seizures.
• Effectiveness often wears off
with time as tolerance develops.

DIAZEPAM
• It is mainly used in the treatment of
status
epilepticus, intravenously or in the acute
management of febrile convulsions and
status epilepticus as a rectal solution.
• Absorption from suppositories or
following

intramuscular injection is slow

 FELBAMATE:
Mechanism of Action:
It acts by blocking N-methyl D-aspartate (NMDA)
synaptic responses and by modulating GABA-a
receptors. At higher dose it may modulate sodium
channels and inhibit high voltage activated calcium
channels.

GABAPENTIN:
It is a second line agent for patients with partial seizures
who have failed initial treatment.
Mechanism of Action:
It was designed to be a GABA agonist but does not react at
GABA receptor.
It inhibits high-voltage activated calcium channels.
It elevates human brain GABA levels possibly via
alterations in GABA synthesis or reversal of neuronal
GABA transporter, resulting in non vesicular release of
GABA.
LAMOTRIGINE:
It is useful as both adjunctive treatment in
patients with partial seizures and as
monotherapy.

Mechanism of action:
It inhibits voltage dependent sodium
channels and also inhibits voltage-
activated calcium channels.

PHENOBARBITAL
It is drug of choice for neonatal seizures. It may be
useful when given intravenously in refractory status
epilepticus
Mechanism of action : it elevate seizures threshold by
interacting with GABA receptors to facilitate chloride
channels and by blocking high voltage activated
calcium channels
TIGABINE:
It is used in partial seizures.

Mechanism of Action:
It is a potent and specific inhibitor of GABA uptake
into glial and other neuronal elements.
It enhances action of GABA by decreasing its
removal from synaptic space.

VIGABATRIN:
It is an inhibitor of GABA transaminase but because of
poor safety profile, it is a last resort drug for partial
seizures.
It doesn`t interact with other drugs apart from
decreasing phenytoin levels, probably by blocking its
absorption.
Adverse effects are behavioural disturbances ranging
from agitation and confusion, psychosis, visual field
defects, drowsiness, headache, psychosis.
ZONISAMIDE:
It is approved for adjunctive treatment of partial
seizures.
Mechanism of Action:
It is a sulfonamide.
It inhibits slow sodium channels and blocks T-type
calcium channels, inhibition of glutamate release.
 MONITORING TREATMENT
• Its essential to follow up patients is whom antiepileptic drug treatment has been started. This follow up is
particularly important in early stages of treatment when an effective maintenance dose may not have been
fully established, when importance of regular compliance may not have been recognized by patient or
when psychological adjustment to regular treatment may not be resolved.

• Monitoring antiepileptic therapy

Therapeutic drug monitoring (tdm) involves measurement of plasma drug levels and their pharmacokinetic
interpretation . it is an integral component in management of patients receiving phenytoin and
carbamzepine but is less useful in patients receiving acetazolamide , barbiturates, benzodiazepines,
ethosuximide, gabapentin, lamotrigine, so dium valproate.