The goal is to strike a balance between the upside of fewer seizures — and better quality of life — and the downside of bothersome medication side effects. If medication proves ineffective at controlling seizures, other treatments may be required, such as epilepsy surgery, dietary changes, vagus nerve stimulation (VNS) therapy, or responsive neurostimulation. (3) But before you stop taking anti-seizure medication for any reason — including continued seizures, unacceptable side effects, or any other reason — talk to your doctor about stopping the drug or changing therapies. Don’t stop an anti-seizure drug on your own. Normally, anti-seizure drugs are tapered — taken in progressively smaller doses — before they are stopped entirely. Abruptly stopping a medication raises the risk of withdrawal seizures. Side effects from anti-seizure drugs (also called anti-epileptic drugs, or AEDs) are common, often leading to a reduced quality of life in people with epilepsy. Drowsiness, dizziness, double vision (diplopia), and impaired balance are common problems with all classes of anti-seizure medication. Other side effects are more specific to individual drugs, but common side effects can include difficulty concentrating, nausea, tremors, rash, weight gain or loss, and suicidal thoughts. Some people are eventually able to stop anti-seizure medication, but the ability to do so varies with age and type of seizure. One study showed that 75 percent of people who had been seizure-free for three years could discontinue medication without having more seizures. (1) For about 1 out of 3 people with epilepsy, seizures are not controlled by medication. These people are referred to as having drug-resistant or “refractory” seizures. Because using multiple anti-seizure drugs can lead to severe side effects, other treatments are often tried for refractory seizures.
Broad-Spectrum Anti-Seizure Drugs
These drugs are used to treat a broad range of seizure types, including both focal and generalized onset seizures:
rufinamide (Banzel)brivaracetam (Briviact)valproic acid (Depakene)felbamate (Felbatol)perampanel (Fycompa)levetiracetam (Keppra)lamotrigine (Lamictal)clobazam (Onfi)topiramate (Topamax)zonisamide (Zonegran)
Narrow-Spectrum Anti-Seizure Drugs for Focal Seizures
These drugs are used for focal seizures, even if they evolve to generalized seizures:
eslicarbazepine (Aptiom)phenytoin (Dilantin)tiagabine (Gabitril)phenobarbital (Luminal)pregabalin (Lyrica)gabapentin (Neurontin)vigabatrin (Sabril)carbamazepine (Tegretol)oxcarbazepine (Trileptal)lacosamide (Vimpat)
Narrow-Spectrum Anti-Seizure Drugs for Generalized Absence Seizures
The drug ethosuximide (Zarontin) is used for absence seizures only.
Cannabis-Based Anti-Seizure Medication
Cannabidiol (Epidiolex), a medication made from cannabidiol (CBD), a chemical present in the Cannabis sativa (marijuana) plant, was approved in 2018 by the Food and Drug Administration (FDA). CBD is not the chemical in marijuana that produces the “high”; that’s tetrahydrocannabinol (THC). As of July 2018, cannabidiol has been approved for refractory seizures in patients older than 2 years caused by the childhood epilepsy conditions Dravet syndrome and Lennox-Gastaut syndrome. It is the first cannabis-based medication to be approved by the FDA, and also the first medication approved for Dravet syndrome. (4) Any kind of surgery carries a level of risk, and brain surgeries can cause damage to surrounding tissue that can cause changes to a person’s cognitive (thinking) ability, or even to their personality. Brain surgeries for epilepsy are usually only considered if the person has tried and not seen improvement from at least two anti-seizure drugs, and if there is an identifiable cause of the seizures. There are a few main types of brain surgery for epilepsy: focal resection, corpus callosotomy, multiple subpial transection, and hemispherectomy. (5,6) Focal Resection Also known as lobectomy and lesionectomy, focal resection is the removal of the section of the brain where the seizures originate. This type of surgery is most likely to be successful at stopping seizures if doctors have identified a small and precise area of the brain where seizures originate, called the seizure focus. Corpus Callosotomy This type of surgery involves cutting the connections between the right and left halves (hemispheres) of the brain. Because generalized seizures are often focal (partial) seizures that then spread to both hemispheres of the brain, this surgery effectively keeps the seizure in the half of the brain where it started, so that only half the body is affected. Still, some people experience a worsening of focal seizures after this procedure. Multiple Subpial Transection In this type of surgery, multiple cuts are made into the brain tissue to disrupt the electrical transmissions that cause seizures. This kind of surgery is performed if the seizing part of the brain cannot be removed. Hemispherectomy and Hemispherotomy In an anatomical hemispherectomy, the affected brain hemisphere is surgically removed. In a functional hemispherectomy, less brain tissue is removed, and the remaining brain is disconnected from the other hemisphere (as in corpus callosotomy). In a hemispherotomy, even less brain tissue is removed, and the affected brain is disconnected from the healthy brain. If surgery is the appropriate course of treatment, experts recommend that it be performed sooner rather than later. Surgery can be an important and, some say, underutilized, treatment for people with drug-resistant focal epilepsy. Examples of diets tried for epilepsy include:
The ketogenic dietThe medium-chain triglyceride dietThe modified Atkins dietLow-glycemic-index diet
Reducing carbohydrate intake causes the body to burn more fat for energy, and when the body burns fat, acids called ketones are produced. Having a higher-than-normal amount of ketones in the bloodstream is known as ketosis. As long as there’s enough insulin available, the body can use ketones for energy. Low-carbohydrate diets are also associated with lower glucose and insulin levels in the blood. Researchers are unsure whether seizure improvement comes about because of changes caused by ketosis, by the presence of more fatty acids in the blood, or because there are fewer fluctuations in blood glucose levels. All of these diets are best learned under the care of a physician and nutritionist. Strict diets like the ketogenic diet may begin with a brief admission to the hospital for monitoring and teaching, followed by ongoing assessment of laboratory levels. (7) Vagus Nerve Stimulator Vagus nerve stimulators were approved by the FDA in 1997. The device is surgically implanted under the skin of the chest, and electrodes connect the device to the left vagus nerve in the neck. The device sends regular pulses of electricity to the brain to control abnormal electrical activity in the brain. Although vagus nerve stimulation may reduce seizures by 20 to 40 percent, people who use them will usually also need to keep taking medication. (3) Responsive Neurostimulation In responsive neurostimulation, a closed-loop system analyzes brain activity patterns and then delivers a shock if it detects that a seizure is coming. One of the first such systems, the NeuroPace, was approved by the FDA in late 2013. The battery-powered device is surgically implanted in the skull, and wires connected to the device are placed on the surface of the brain or inside the brain area where seizures originate. (8) Deep Brain Stimulation (DBS) The Medtronic DBS System for Epilepsy was approved by the FDA in April 2018. The pulse generator portion of the device is implanted in the chest, and two wires lead to a seizure focus in the brain. The device controls seizures by delivering ongoing electrical pulses to that area. The device is used in adults with focal seizures who have more than six seizures a month and who have not seen good results with at least three drugs. Certain medical procedures, including magnetic resonance imaging (MRI), cannot be performed with a DBS system in place, or permanent brain damage can occur. (9)
