Exploring Non-Pharmacological Interventions for Epilepsy

November 28, 2022 - Epilepsy is a neurological disorder characterized by abnormal brain activity, which can cause seizures, unusual behavior, sensations, and loss of awareness. Two or more unprovoked seizures within 24 hours are necessary for an epilepsy diagnosis. According to the CDC, approximately 3.4 million people in the United States have epilepsy, about 1.2% of the nation's population. Of those 3.4 million people, about 470,000 of them are children. The WHO states that nearly 50 million people worldwide have epilepsy, with 80% of patients living in low- and middle-income countries. There are multiple different approaches to treating epilepsy, including medications and non-pharmacological treatments.

Seizure Classifications and Symptoms

For patients over 18, active epilepsy is an epileptic or seizure disorder for which a patient is currently taking medication or when a patient has had one or more unprovoked seizures in the past year.

Symptoms

Temporary confusion, staring spells, stiff muscles, uncontrollable movements, loss of consciousness, and anxiety are all signs or symptoms of seizures.

Seizures can contribute to many life-threatening complications, including falling, drowning, car accidents, pregnancy complications, mental health issues, status epilepticus, and sudden unexpected death from epilepsy. The Mayo Clinic states that status epilepticus “occurs if you're in a state of continuous seizure activity lasting more than five minutes or if you have frequent recurrent seizures without regaining full consciousness in between them. People with status epilepticus have an increased risk of permanent brain damage and death.”

Focal Seizures

There are two classifications of seizures: focal and generalized. Focal seizures result from abnormal activity in one area of the brain and can be without loss of consciousness or cause impaired awareness. Focal seizures without loss of consciousness may alter emotions and perceptions and cause involuntary body movements, dizziness, or tingling.

Focal seizures with impaired awareness — previously called simple partial seizures — may cause a patient to stare off into space, be unresponsive, and perform repetitive motions.

Generalized Seizures

Unlike focalized seizures, generalized seizures occur in all brain areas. Subclassifications of generalized seizures include absence, tonic, atonic, clonic, myoclonic, and tonic–clonic seizures. Absence seizures are most common in children and are associated with subtle body movements lasting up to ten seconds. These seizures are typically clustered and can happen up to 100 times daily.

Tonic seizures cause stiff muscles — typically in the back, arms, and legs — and may impact consciousness. Additionally, atonic seizures can cause complete loss of muscle control and may lead to collapse. Clonic seizures cause repeated jerking movements, typically affecting the neck, face, and arms.

Myoclonic seizures cause brief but sudden jerks or twitches in the upper body, arms, and legs. Tonic–clonic seizures, which many know as grand mal seizures, are the most visual. According to the Mayo Clinic, “they can cause an abrupt loss of consciousness and body stiffening, twitching, and shaking. They sometimes cause loss of bladder control or biting your tongue.”

Causes of Epilepsy

Numerous factors may contribute to epilepsy, and genetic predisposition to seizures may be a contributing cause of epilepsy. A family history of epilepsy may be associated with a higher risk of developing epilepsy. The Mayo Clinic states, “researchers have linked some types of epilepsy to specific genes, but for most people, genes are only part of the cause of epilepsy. Certain genes may make a person more sensitive to environmental conditions that trigger seizures.”

Head trauma, brain abnormalities, infections, prenatal injury, and developmental disorders may also cause epilepsy. Head trauma may include car accidents and other traumatic injuries. Brain abnormalities, including tumors or vascular malformations, can cause epilepsy, with stroke being the most common cause of epilepsy in those over 35.

Prenatal injury may include brain damage due to maternal infection, malnutrition, or oxygen deficiencies. Other risk factors may include age, stroke, vascular disease, dementia, and childhood seizures.

Diagnostic Methods for Epilepsy

To diagnose epilepsy, providers typically conduct a neurological exam which may include evaluations of behaviors, motor abilities, cognition, and other neurological functions. Additional testing may consist of a blood test to find signs of infections or genetic conditions contributing to seizures.

An electroencephalogram (EEG) may also be considered for diagnosing the disease. During an EEG, a cap is put on a patient, and electrodes record brain activity. EEG studies may be done at home, in a doctor’s office, or in a hospital. Doctors attempt to capture brain activity during a seizure to determine the type of seizure a patient has. A high-density EEG may have closer leads for collecting additional brain activity data.

Doctors may also opt for medical imaging such as CT scans, MRIs — functional or resting state, and PET scans. A battery of neuropsychological tests may also assess speech, memory, and thinking.

Epilepsy Treatment

Treating epilepsy can be particularly challenging as not all patients are responsive to medication.

Medications

According to the Mayo Clinic, “most people with epilepsy can become seizure-free by taking one anti-seizure medication, which is also called anti-epileptic medication. Others may be able to decrease the frequency and intensity of their seizures by taking a combination of medications.”

There are challenges associated with finding the proper seizure medication, with over 20 available kinds. Drugs may also have side effects, including fatigue, dizziness, weight fluctuations, reduced bone density, rash, coordination issues, speech and cognition problems, depression, and organ inflammation.

Despite antiseizure medications’ ability to treat up to 70% of epileptic patients, there is a persistent treatment gap. Low and middle-income countries have limited availability of drugs.

According to the WHO, “discontinuing anti-seizure medicine can be considered after two years without seizures and should take into account relevant clinical, social, and personal factors.”

Surgical Interventions

Providers may consider alternative nonpharmacological interventions if a patient’s seizures cannot be controlled with medication. One potential intervention may be surgery. Providers may seriously consider surgery for patients whose seizures are contained in a small, well-defined area of the brain that does not interfere with speech, language, motor function, vision, or hearing.

The Mayo Clinic states, “for some types of epilepsy, minimally invasive approaches such as MRI-guided stereotactic laser ablation may provide effective treatment when an open procedure may be too risky. In these procedures, doctors direct a thermal laser probe at the specific area in the brain causing seizures to destroy that tissue in an effort to better control the seizures.”

Nutrition

For some patients, specifically children, nutrition and dietary changes may help reduce the number of seizures an epileptic patient has. Many sources cite a ketogenic diet as an effective tool for minimizing the number of seizures. However, this diet is also associated with side effects such as dehydration, constipation, growth issues, and kidney stones.

Vagus Nerve Stimulation

In addition to medication or surgery, providers may consider vagus nerve stimulation (VNS), where a device is implanted under the skin and delivers bursts of electrical energy to the vagus nerve and brain. Researchers are still determining why this works for some patients but have found that up to 40% of seizures can be reduced.

“Most people still need to take anti-epileptic medication, although some people may be able to lower their medication dose. They may experience side effects from vagus nerve stimulation, such as throat pain, hoarse voice, shortness of breath, or coughing,” stated the Mayo Clinic.

The Epilepsy Foundation states that the FDA approves VNS for anyone over four years old as an additive therapy for patients with focal or partial seizures that have not responded to medication. According to a publication in Frontiers in Neurology, approximately 100,000 people worldwide, mainly in Europe and the US, are treated with VNS. VNS is most effective in patients with seizures originating in the limbic system, thalamus, and thalamocortical projections.

As an alternative to invasive VNS, clinicians may consider transcutaneous VNS (tVNS), which “acts on the auricular branch of the vagus nerve (ABVN), targeting thick-myelinated afferent fibers in the cymba conchae, and hence activating the ipsilateral nucleus of the solitary tract (NTS) and locus coeruleus.”

Deep Brain Stimulation

Deep brain stimulation (DBS) may also be considered for patients with epilepsy. DBS requires surgically implanting electrodes into the brain to deliver electrical stimulation and modulate brain activity. The multistep procedure is somewhat invasive and has many potential drawbacks. However, DBS benefits include the ability to customize stimulation, constant stimulation, and reversibility.

Other Non-Pharmacological Stimulation

Other treatments being explored include subthreshold stimulation, transcranial magnetic stimulation, transcranial direct current stimulation, and trigeminal nerve stimulation.

Trigeminal nerve stimulation (TNS) is another nonpharmacological intervention for epilepsy that delivers noninvasive high-frequency stimulation. Transcranial direct current stimulation (tDCS) is when weak constant electrical currents are delivered through two skull electrodes. Transcranial magnetic stimulation (TMS) is low-frequency, repetitive magnetic stimulation to reduce cortical excitability.

As neurologists gain additional insight into the causes of epilepsy and what makes a particular treatment effective in each patient, they may consider incorporating or opting for nonpharmacological therapies.