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Symptoms

A grand mal seizure, otherwise known as a generalized motor convulsion, is what most people think of when they hear the word "seizure." People with epilepsy often notice a warning signal right before a grand mal seizure such as a familiar feeling in the stomach or an involuntary jerking in the hand or foot. They may stiffen and fall down. Next, the person's body will begin jerking. The seizure usually lasts 60 to 120 seconds. After the attack, the person may appear confused and may fall asleep. Although 95 percent of the time these types of seizures are over within 2 minutes and cause no permanent harm, the shaking can be frightening to those not familiar with seizures.

Petit mal seizures, also called "absence seizures," usually start around grade school age. They commonly cause a brief lapse of consciousness with only slight facial twitching or fluttering of the eyelids. Sometimes the person may seem to be daydreaming. These types of seizures typically come without warning and are not followed by confusion or sleepiness.

Partial seizures are classified as "simple" or "complex" and involve involuntary movements without a complete loss of consciousness.

• The "simple" partial seizure, also called a "focal motor seizure," can involve twitching of the face, hand or leg on one side of the body. The patient's consciousness and memory are usually unaffected during simple partial seizures.
• During a "complex" partial seizure, also called a "psychomotor seizure," patients may look dazed, confused, or puzzled. They may smack their lips, make sucking, drooling, or swallowing movements, or pick at their clothing. They may also appear to behave normally, however if asked questions, they will be unable to respond appropriately. These attacks last for several minutes. After they are over, the person is often confused and unable to remember anything about the seizure.

Diagnosis

Medical history

Your medical history, including your history of previous seizures, helps us to make a diagnosis. For example:

• Make sure to tell us about your seizures and any incontinence, extreme sleepiness, and/or amnesia that followed. 
• If you have a family member or friend who witnessed one or more of your seizures, it's a good idea to bring them with you to your appointment. They will be able to describe features of the seizure that you may not be able to recall.

We will evaluate the information you give us to rule out other conditions that may be causing your symptoms. For example, many cases of loss of consciousness are due to simple fainting, known as syncope. It is not always easy to tell the difference between syncope and a seizure. As a general rule, a simple faint usually lasts less than a minute whereas a seizure lasts longer. Also, patients usually recover quite quickly after fainting (often within seconds), but seizures often cause periods of confusion or even sleepiness that can last 20 minutes or longer.

A single seizure does not mean that you have epilepsy, which is defined as a tendency to have recurrent seizures. In fact it is about 10 times more common to have a single isolated seizure in your life, than it is to have recurrent seizures, or epilepsy. As well as evaluating your medical history, we may also recommend further tests, including:

• EEG or Electroencephalogram is a recording of electrical activity generated by the brain.  This test can be helpful but cannot always confirm epilepsy.  We may perform the test after a period of sleep deprivation to encourage you to fall asleep during the test. Some seizure patterns are much more visible during sleep.
• CT scan or MRI are imaging studies that can show an abnormality of the brain.
• Blood tests can help us identify an electrolyte or other metabolic abnormality that could trigger your seizures.

Treatments

Medication

At present, there is no cure for epilepsy. However, in most cases, antiepileptic medication can prevent all, or nearly all, of your seizures. Determining exactly the right medication and dose can take time because each person reacts differently. We prefer to treat this condition with a single drug prescribed in increasing doses until the seizures are controlled. Occasionally, seizures cannot be completely controlled with medication and we need to consider other forms of treatment. The choice of drug depends on the kind of seizures you have. We will also consider the following factors before deciding on a medication regime for you:

• Age
• Gender
• Other health issues
• Side effects
• Other medications that you are taking
• What you wish to gain from the treatment

If you are female between the ages of 18 to 44, we take family planning into consideration, for example:

• We may recommend that you take folic acid if you are planning on starting a family.
• If you are on birth control medications, we will consult with your Ob/Gyn physician before you start medications for seizures. Medications for epilepsy may decrease the effectiveness of birth control medications.
• Some antiepileptic medications increase the risk of birth defects.

For some patients, controlling seizures may require such a high dose that side effects become problematic. If that is the case, we will  change the drug or try to find the right combination of drugs to control your seizures and minimize side effects.

Discontinuing medication

If you have been taking antiepileptic medication for more than 2 years and have been seizure free, we can consider discontinuing your medication. This decision will depend on a number of factors including your type of epilepsy, initial response to medication, EEG results and age. There is a risk that if you discontinue the medication, seizures will recur. However recent studies indicate that more than 50 percent of patients who have been seizure free for more than 2 years can stop medication without experiencing further seizures.  Do not stop taking your medication before discussing it with us. Sudden withdrawal can cause new seizures or episodes of severe, prolonged or continuous seizures.

Surgery

Epilepsy surgery

Medications do not effectively control seizures for all epileptic patients. For some patients, surgery to remove the part of the brain causing the seizures may be a more effective way to minimize these episodes. Surgery is most appropriate for patients with temporal lobe epilepsy or other kinds of epilepsy, where the seizures originate in one specific area of the brain. If you are a candidate for epilepsy surgery, we may monitor you in a specialized hospital unit, called an epilepsy monitoring unit, in order to observe and better understand the nature of your seizures and which part of the brain is affected.

Vagus nerve stimulation

Vagus nerve stimulation (VNS) is a different kind of surgical procedure that is used to help control seizures.  VNS directs short bursts of electrical energy into the brain via the vagus nerve, a large nerve in the neck. The energy comes from a small battery, which is surgically implanted under the skin, usually on the chest.

Lifestyle Management

First Aid during a seizure

Tell friends and family about your seizures and ask them to review the following First Aid advice in case they are with you, or anyone else, during a seizure.

• Stay calm.
• Move objects out of the way that could hurt them, for example, sharp and heavy items.
• Don't attempt to restrain the person or prevent their arms and legs from moving.
• Monitor how long the seizure lasts.
• Loosen clothing, especially anything around the neck, such as a tie or scarf, that may prevent breathing.
• Protect the head by placing a jacket, pillow or other soft, flat item underneath it.
• Turn the person gently onto their side to ensure the airway is open.
• There is no need to protect the person’s tongue.  Do not try to force the mouth open in any way.
• Make sure someone stays with the person until the seizure ends.
• Allow the person to regain consciousness at their own pace.  Be there to reassure and comfort them.
• Offer to help the person get home, or call a friend or relative to assist them, especially if s/he seems confused or tired.

Check before you drive

• We are required to report lapses of consciousness to the Department of Motor Vehicles in California.
• The DMV will decide if you may continue to drive.
• The DMV requires a form from your physician that documents your compliance with medication and how long you have been seizure free.

Get enough sleep

• In some cases, lack of sleep may trigger seizures.
• We recommend that everyone, especially epilepsy patients, get eight hours sleep a night.
• If you have epilepsy, it's particularly important to avoid staying up late on a regular basis.

Keep a seizure log

• Keep a detailed record of your seizures to help us to understand your condition better and make appropriate treatment decisions.
• Include the date and time of day of each seizure, description of the seizure (you will need help from a witness, if available) and how long it lasted.
• Note down any other observations that may be relevant. For example, what were you doing when the seizure occurred? Were you under stress? Had you changed your medication recently? Were you tired?

Getting Your Care at Kaiser Permanente

Epilepsy can be a chronic long-term condition.  Either I, or another neurologist in our department, will manage your ongoing epilepsy care.  I will work closely with your personal physician, who will continue to oversee your care for non-epilepsy health issues.  Our electronic medical record system allows us to review your medical records together at any time and work in partnership to treat your symptoms. 

If you were first seen in the Emergency Department after a seizure, the Emergency Department physicians may refer you directly to our department.  If you are having epilepsy symptoms, and you have not yet been diagnosed with epilepsy, your first contact will typically be with your personal physician. S/he will evaluate your health and symptoms and determine whether specialty care may be needed.

Your personal physician can connect you with me or one of my colleagues in Neurology in a variety of ways. Depending on your symptoms, s/he may schedule a specialty appointment before you leave the clinic, or s/he may send a referral and my staff will contact you to make the appointment. In some cases, your personal physician may call me or one of my colleagues while you are in the office so we can all discuss your care together. If we decide you need an appointment with me after our discussion by phone, we can usually schedule it the same day.

When You See Me

During your first appointment, I will ask you about your medical history and symptoms. I will also review any lab tests ordered by your personal physician, and order any further tests that may be necessary. If we determine that you need an EEG, we will make a separate appointment for you to have an EEG. We perform EEGs in the Neurology Department.

If you were taken to the Emergency Department after a seizure, you may have had a brain scan while you were there. Otherwise, I may order a CT scan or an MRI to look for any abnormality in the brain that may be causing your seizures.

I may order lab tests to look for electrolyte or other metabolic abnormalities that could trigger seizures. I will order these tests during your visit and you can have them done at any Kaiser Permanente laboratory. When the results are ready, you can view them from my home page. I will review the results and contact you by phone, letter, or e-mail to explain them.

If you are a candidate for epilepsy surgery or vagus nerve stimulation, I will refer you to our Neurosurgery Center at Redwood City Medical Center for an evaluation. You will be contacted by the Neurosciences Department at Redwood City Medical Center. You may need to stay in the hospital for more detailed brain evaluation before surgery takes place.

Contacting Me

After you have seen me, if you have follow-up questions, please call my office and leave a message. You can also e-mail me from my home page whenever it is convenient for you. Our Appointment and Advice line is available for general medical advice 24 hours per day, 7 days per week.  

From my home page, you can also take advantage of a variety of convenient online services offered by Kaiser Permanente. In addition to the ability to e-mail me, you can view and refill your prescriptions, view test results and summaries of prior visits, check the status of your preventive screenings, and find health information and interactive health tools.