Category: Disorders and Conditions

There are a number of other neurological conditions in which anti-epileptic drugs are used. These may occur in patients with co-existing epilepsy. It may be useful in these patients to use an anti-epileptic drug which has efficacy for both conditions to avoid polypharmacy and drug interactions. Migraine affects approximately 15% and epilepsy 2% of the population at any one time. As both are so common it is likely that some patients will have both epilepsy and migraine simply by chance; however, the literature suggests a clear association between the two. One theory behind their association is that both conditions are channelopathies. In some cases, the underlying aetiology may be a clear …

Older adults have increased steadily in number and proportion of the total world population. In the United States, the population aged 65 and older numbered 35 million in 2000 and is expected to more than double by 2050. The older population was 12% of the total population in 2000 and will increase to 20% by 2050. The increase …

Although seizures are a frequent occurrence in older adults, epilepsy is often perceived as an uncommon diagnosis of later life. There are several possibilities that explain this observation. The most obvious reason is that seizures are not recognized because of the non-specific nature by which they present in older adults. Older patients tend to have more frontal and parietal lobe foci as opposed to the more commonly recognized temporal lobe foci of younger adults. Because of the frontal and parietal lobe foci, older adults will commonly report auras of dizziness. Unfortunately, dizziness is a common and non-specific symptom and is reported with a …

There are few trials to support the choice of one medication for all older patients with epilepsy. However, some comparative head-to-head trials of anti-epileptic drugs in older adults have been conducted. Craig and colleagues compared valproic acid with phenytoin. A total of 166 patients over the age of 65 with adult-onset seizures were randomized to either valproic acid or phenytoin. The median age of patients was 78 years. The investigators found that 78% of valproic acid patients and 76% of phenytoin patients were seizure free at 6 months. Moreover, there were no cognitive differences that were noted between the two anti-epileptic drugs. This study was important in that this was one …

In the clinical context, since anti-epileptic drugs are the mainstay of treatment, treatment-resistant epilepsy usually refers to resistance to anti-epileptic drug therapy. Long-term outcome studies suggest that up to one-third of patients continue to have seizures despite appropriate drug treatment. This chapter reviews the treatment options that may be considered for adult patients who are considered to have drug-resistant epilepsy, and gives a brief overview on what other approaches might become available in future. Primarily, adult data will be reviewed, although paediatric evidence will also be highlighted where appropriate. Before the various treatment strategies are discussed, it is necessary to …

Before the specific treatment strategies for drug-resistant epilepsy are discussed, it is important to first consider who should receive such treatment; that is, when is drug resistance recognized? Such consideration has practical implications, particularly given that some of the treatments for drug-resistant epilepsy may be associated with permanent complications, as in the case of surgery. Elements of definition A unifying definition of drug resistance in epilepsy remains hotly debated. The term is often used interchangeably with ‘medical intractability’, pharmacoresistance or refractory epilepsy. It should be emphasized that, by default, intractability is a relative concept rather than an absolute …

For adults with refractory epilepsy, current evidence supports the use of several treatment options, including epilepsy surgery, vagus nerve stimulation and ‘rational’ polytherapy. Epilepsy surgery It is recommended that patients whose epilepsy remains uncontrolled despite treatment with two appropriately chosen anti-epileptic drugs, either singly or in combination, in adequate doses should be evaluated for the suitability of epilepsy surgery. Aided by technical advances in neuroimaging and video-electroencephalography monitoring, improvements in technique, and a better understanding of the anatomical and pathophysiological basis of the epilepsies, resective surgery has become a highly effective …

Treatment strategies under investigation for drug-resistant epilepsy It should be apparent from the previous discussion that current strategies for the treatment of drug-resistant epilepsy have limited efficacy and are associated with risks of adverse effects/complications. To overcome treatment resistance, a number of innovative techniques are under investigation. Some of the approaches already in clinical development will be briefly reviewed. Strategies currently in the pre-clinical stage of development, such as stem cell transplantation and gene therapy, will not be discussed. Novel drug targets/chemical structures The new generation of anti-epileptic drugs have not proved …

A ‘staged’ approach is recommended for the treatment of epilepsy. This means that monotherapy should be initiated for the newly diagnosed patients, the majority of whom will become seizure free with a single anti-epileptic drug, often at modest or moderate dosage. A drug should be chosen with a spectrum of activity and side-effect and interaction profiles that has the potential to produce seizure freedom without intolerable toxicity or long-term sequelae for that individual. The choice should ideally be matched to the patient’s seizure type(s) and/or epilepsy syndrome, age, gender, weight, psychiatric history, other disease states, concomitant medication and lifestyle. If the first anti-epileptic drug produces an idiosyncratic reaction, side-effects at low …

Paediatric epilepsy is amazingly diverse. In some children, basic diagnosis, seizure classification and treatment are straightforward. Other patients have difficult-to-diagnose seizures, complicated seizure classification and a …