Treatment Options

There is no cure for epilepsy, yet. Medications do not cure epilepsy in the same sense that penicillin can cure an infection. For many people with epilepsy, however, the medication will prevent seizures as long as they are taken regularly; but, successful drug therapy requires the active cooperation of the patient.

Antiepileptic drugs successfully prevent seizures in the majority of people who take them regularly and as prescribed. It has been estimated that at least fifty percent of all patients with epilepsy gain complete control of their seizures for substantial periods of time. Another twenty percent enjoy a significant reduction in the number of seizures. If patients, in collaboration with their physicians, decide to attempt withdrawal from medications, they should be aware that the seizures may recur and should closely observe seizure precautions. Some individuals, however, have an excellent chance of remaining seizure free without medication in the future.

When the doctor has made a diagnosis of seizures or epilepsy, the next step is to select the best form of treatment. If the seizure was caused by an underlying correctable brain condition, surgery may stop seizures. If epilepsy — that is, a continuing tendency to have seizures — is diagnosed, the doctor will usually prescribe regular use of seizure-preventing drugs. If drugs are not successful, other methods may be tried, including surgery, a special diet or vagus nerve stimulation (VNS). The goal of all epilepsy treatment is to prevent further seizures, avoid side effects, and make it possible for people to lead active lives.

MEDICATION
Most epilepsy medicines are taken by mouth. The doctor’s choice of which drug to prescribe depends on what kind of seizure a person is having. People react to medicines in different ways. Some experience side effects, others may not. Some people’s seizures will respond well to a particular drug while someone else will have seizures that continue. It may take some time to find exactly the right dose of the right drug for each person with epilepsy.

For information on individual medications: http://epilepsyfoundation.org/Medications-Database.cfm

VAGUS NERVE STIMULATION
Vagus nerve stimulation (VNS) is a type of treatment in which short bursts of electrical energy are directed into the brain via the vagus nerve, a large nerve in the neck. The energy comes from a battery, about the size of a silver dollar, which is surgically implanted under the skin, usually on the chest. Leads are threaded under the skin and attached to the vagus nerve in the same procedure. The physician programs the device to deliver small electrical stimulation bursts every few minutes. This is a relatively new type of treatment. It may be tried when other treatment is not effective.

One of the most unusual aspects of VNS is the part that a special magnet plays in the treatment. It gives people with VNS implants some control over the device and how it works.
The special, thin block magnet is attached to a strap. It can be worn on the wrist like a watch, or clipped to a belt like a pager.

Although the VNS system delivers stimulation automatically in regular pulses all the time, the magnet can be used to deliver extra electronic stimulation in between cycles. The patient does this by passing the magnet over the area of the chest where the VNS device is implanted.

Magnets Can Help with Seizures
People use the magnet in this way when they sense a seizure is about to happen. For some, the extra stimulation stops the seizure, shortens it, makes it less severe, or reduces the time it takes to recover afterwards. Other people say using the magnet has little or no effect on their seizures.

Tips on Handling Magnets

  • Don’t place or store the magnet near credit cards, televisions, computers, computer disks, microwave ovens or other magnets. Keep it at least 10 inches from these items.
  • Do not drop the magnet. It can break if it falls on a hard surface.
  • Carry the magnet with you. If your seizures stop or are shorter when extra stimulation is turned on, show family members or caregivers how to use the magnet when you have a seizure.
  • Ask your doctor about how much and for how long you can safely use the magnet to activate the device.
  • Not everyone with a VNS implant has a warning before a seizure begins. However, family members and caregivers can also be shown how to pass the magnet over the implant when that person has a seizure.
  • Magnets can also be used to give people a short break from the programmed stimulation.

Magnets Can Stop Stimulation
By holding a magnet in place over the device, someone with a VNS implant can stop stimulation or turn off the pulse generator for a short time.

Reasons for wanting to stop the stimulation may include:

  • Plans to sing or speak in public (to prevent changes in voice tone during stimulation)
  • Eating (if people have a pre-existing condition that makes swallowing difficult)
  • Experiencing pain or other unusual discomfort during the stimulation phase.

In addition, a VNS patient can use the magnet daily to check whether the pulse generator battery is working properly.

SURGERY
When antiepileptic drugs fail to control or reduce seizures, surgery on the brain may be considered. Although some of the techniques are recent, surgical removal of seizure-producing areas of the brain has been an accepted form of treatment for more than 50 years.

Brain surgery can be a successful way of treating epilepsy. Surgery is most likely to be considered when someone with epilepsy:

  • Has documented epileptic seizures and not pseudoseizures.
  • Has already tried the standard medicines without success (or has bad reactions to them).
  • Has seizures that always start in just one part of the brain.
  • Has seizures in a part of the brain that can be removed without damaging important things like speech, memory or eyesight.

Surgery for epilepsy is a delicate, complicated operation. It must be performed by a skilled, experienced surgical team. It is usually done at special medical centers that treat patients with epilepsy. In addition to operations that remove a small part of the brain where seizures begin, other procedures may be done to interrupt the spread of electrical energy in the brain.

People who are going to have epilepsy surgery may have several special tests first. In some cases, electrodes have to be implanted in a separate operation to locate seizure sites deep in the brain. Sometimes these tests take days or even weeks to complete.

In some cases, the patient may be awake during part of the operation. This is not usually the case with small children. This is possible because the brain does not feel pain. Having the patient awake helps the doctors make sure that important parts of the brain are not damaged.

Afterwards, some seizure medications may have to be continued, usually for a year or two. Then, if no further seizures occur, the medicine may be slowly withdrawn. At this point, chances of living free of seizures and free of medication are good. However, many people will have to continue with medication and some do not benefit from surgery.

KETOGENIC DIET
Normally, our bodies run on energy from glucose, which we get from food. We can’t store large amounts of glucose, however. We only have about a 24-hour supply. When a child has no food for 24 hours — which is the way the diet begins, usually in a hospital — he or she uses up all the stored glucose. With no more glucose to provide energy, the child’s body begins to burn stored fat.

The ketogenic diet keeps this process going. It forces the child’s body to burn fat round the clock by keeping calories low and making fat products the primary food that the child is getting. In fact, the diet gets most (80 percent) of its calories from fat. The rest comes from carbohydrates and protein. Each meal has about four times as much fat as protein or carbohydrate. The amounts of food and liquid at each meal have to be carefully worked out and weighed for each person.

Doctors don’t know precisely why a diet that mimics starvation by burning fat for energy should prevent seizures, although this is being studied. Nor do they know why the same diet works for some children and not for others. Trying to put a child on the diet without medical guidance puts a child at risk of serious consequences. Every step of the ketogenic diet process must be managed by an experienced treatment team, usually based at a specialized medical center.

Chances of Success
Often, a period of fine-tuning is needed before it’s clear whether or not a child is going to respond to the ketogenic diet. Doctors often ask parents to try the diet for at least one month, and even as long as two or three, if it’s not working at first. A child on the diet usually continues taking anti-seizure medicine, but may be able to take less of it later on. If a child does very well, the doctor may slowly taper the medication with the goal of discontinuing it altogether. About a third of children who try the ketogenic diet become seizure free, or almost seizure free. Another third improve but still have some seizures. The rest either do not respond at all or find it too hard to continue with the diet, either because of side effects or because they can’t tolerate the food.

A side benefit of the diet is that many parents say their children are more alert and make more progress when on the diet, even if seizures continue. If the diet seems to be helping, doctors will usually prescribe it for about two years. Then, they may suggest that parents slowly begin including regular food in the child’s diet to see if the seizures can still be controlled, even with a normal diet.

Side Effects
Like all the other treatments for epilepsy, the ketogenic diet has some side effects, which may or may not affect a particular child. Some side effects may go away if caught and managed early on. Knowing what to look for can make a big difference. Reported side effects include dehydration, constipation, and, sometimes, complications from kidney stones or gall stones.

Adult women on the diet may have menstrual irregularities. Pancreatitis (inflammation of the pancreas), decreased bone density and certain eye problems have also been reported. Again, this is why the medical team closely follows children or adults who are on the diet.

The diet lacks several important vitamins which have to be added through supplements. Sometimes high levels of fat build up in the blood, especially if a child has an inborn defect in his ability to process fat. This possibility can lead to serious effects, which is another reason for careful monitoring.

Making the Decision
Most experts say the diet is worth trying when two or more medications have failed to control seizures, or when medications cause side effects that are having a harmful effect on a child’s life. It also helps to have a child who is willing to try foods that he might otherwise not be enthusiastic about, and is tolerant and not fussy about eating.

The diet seems to work for more than one kind of seizure, and for children who have a lot of seizures or few seizures. But most doctors say it shouldn’t be used instead of medications if the drugs are working and the child is not having bad side effects. Parents generally decide to try the diet because they hope it will give their child a better chance for a normal life.
However, the diet can be a barrier to some normal life experiences for children, especially those that revolve around food and holidays. And, like other treatments for epilepsy, it also can have side effects that affect some children more than others. So, as with any kind of treatment, there’s a lot to think about before deciding to try the diet.

Going over all the possibilities with your doctor is the best way to make the decision. It may also be helpful to talk with other parents whose children have been on the diet.

Resources for more information about the Ketogenic Diet:

Epilepsy Foundation National Office has a national online forum:
eCommunities: Parents Helping Parents online forum to meet others whose children are using the ketogenic diet.

Charlie Foundation:
www.charliefoundation.org