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On the Frontline of Epilepsy Treatment

Medically Reviewed by Christopher Melinosky, MD on January 22, 2021

Treatments for epilepsy have come a long way in the last several years with new epilepsy medications proving more and more effective. Researchers have learned more about the causes of epilepsy and continue developing new methods of treatment, like nerve stimulation.

This all adds up to a good prognosis for the nearly 3,4 million people with epilepsy in the U.S. With proper treatment, most people with epilepsy can live healthy lives without seizures.

To find out the current state of epilepsy treatment, WebMD talked to neurologist Gregory L. Barkley, MD, past chairman of the Epilepsy Foundation's Professional Advisory Board. Barkley also practices at the Henry Ford Health System in Detroit.

What Can Someone With Epilepsy Expect From Treatment Today?

The expectation for people with epilepsy is that they should be free of seizures, but not on a dose of medication that gives them unacceptable side effects. That's what we're aiming for: no seizures, no side effects. If you're still having seizures or side effects with treatment, then you have to seek expert care.

What's the Most Common Treatment for Epilepsy?

Medication remains the most common treatment for people with epilepsy. Most epilepsy syndromes and the vast majority of genetic syndromes that cause seizures are adequately treated with existing medication. The good news is that if they get identified properly and are prescribed the right kind of medication, most people with epilepsy will do well.

But the bad news is that many doctors don't recognize specific epilepsy syndromes and don't use the right medication to treat them. If you're on the right drug, you're likely to have good control of your seizures. But if you're on the wrong drug, you may keep having seizures -- and you might not even know that there are better approaches out there. That's why getting expert care can be important.

Drugs Used to Treat Epilepsy

There are numerous drugs now used to treat epilepsy. They include:

Narrow-spectrum AEDs (for specific types of seizures): carbamazepine (Carbatrol, Epitol, Equetro,Tegretol), clobazam (Onfi), diazepam (Diastat, Valium), divalproex (Depakote). eslicarbazepine acetate (Aptiom), ethosuximide (Zarontin),  felbamate (Felbatol), gabapentin (GraliseNeurontin), lamotrigine (Lamictal), levetiracetam (Keppra), lacosamide (Vimpat), methsuximide (Celontin), oxcarbazepine (Oxteller XR or Trileptal), perampanel (Fycompa), phenobarbital, phenytoin (Dilantin, Phenytek), pregabalin (Lyrica), rufinamide (Banzel), tiagabin hydrochloride (Gabitril), vigabatrin (Sabril)

Broad-spectrum AEDs (for seizures in one of more part of the brain):clonazepam (Klonopin), clorazepate (Tranxene-T), ezogabine (Potiga), felbamate (Felbatol), lamotrigine (Lamictal), levetiracetam (Keppra, Spritam), lorazepam (Ativan), primidone (Mysoline), topiramat (Topamax, Qudexy XR, Trokendi XR), valproic acid (Depacon, Depakene, Depakote, Stavzor),or zonisamide (Zonegran).

The nice things about these newer drugs is they tend to have fewer side effects. They're easier to use and more predictable. That's helpful, since we know that drug interactions are the bane of many patients.

The drug Epidiolex, which is made from cannabidiol (CBD) a form of medical marijuana, has been found to be effective in treating very severe or hard-to-treat seizures.

When Should Someone With Epilepsy Consider Surgery?

Well, when medicines don't work, you think about epilepsy surgery. People used to think of surgery as a last resort, but that isn't the case anymore. Surgery can lead to long-term remission. It can be a true cure for epilepsy.

One study came out in 2001 that showed that about 60% of people who had a temporal lobectomy (in which the temporal lobe located on the side of the brain is removed) had no seizures, or at most, a few auras afterward. In the other group, which got the best medication we have but didn't get surgery, only about 8% got the same results.

Surgery may also be good for people in early stages of the disease. 

What Role Do Implantable Devices Play in Epilepsy Treatment?

When epilepsy isn't being controlled by medication and surgery isn't an option, we turn to devices. There are two on the market now:

Both are consideered low-risk procedures.

How Does the Vagus Nerve Stimulator Work?

VNS therapy works by sending an electrical pulse to the vagus nerve in the neck. It's not clear how VNS therapy stops seizures, but it's believed that the device blocks certain brain impulses that direct the body to start a seizure.
The VNS device is powered by a small battery implanted in the chest. In some cases, it can make someone almost seizure-free.

How Does NeuroPace Work?

The NeuroPace is a reactive neurostimulator that detects seizures and shocks the brain to stop them.

The device is set to send out pulses of a certain duration at certain intervals and it goes around the clock. It uses the technology from cardiac defibrillator devices to respond to electrical activity in your brain. Electrodes are placed where seizures are suspected of coming from, either on the surface of the brain or deep within it. This is hooked up to a miniature recording device that samples brain activity, like a tiny EEG machine. When it senses that the pattern is abnormal, it fires an electrical pulse to disrupt the pattern.

The Ketogenic Diet for Epilepsy

It can be a valuable tool in certain children with catastrophic epilepsy. About a quarter of the people who go on it get good control of the seizures. The problem is that the safety of the diet for long-term use is in question.

The brain is tricked into thinking that you're starving to death so that you wind up with decreased calorie intake. It makes the brain burn ketones instead of glucose (sugar from food) and your seizures are controlled. But it can slow down the growth of children. In addition, you can't eat a high-fat diet for a long time because of the dangerous long-term consequences of eating a high-fat diet in adults.

The ketogenic diet can be a reasonable alternative to intractable epilepsy. It is not recommended for adults. It's such an unpalatable diet that probably only young kids can stay on it, since they have no choice in what they eat because their parents make their meals.

Are There Benefits for Focused Radiation Epilepsy Treatments, Like the Gamma Knife?

While radiation can destroy the focus of a seizure, it can also damage the brain cells around it. Even though these radiation beams are focused, no matter how carefully you aim them, the radiation will still scatter. These beams are not like a laser. They're not as precise as surgery.

While it should be considered in some cases, such as in people who have lesions that need to be removed but who aren't suitable for surgery, it is not a good substitute for standard surgery.

What New Epilepsy Treatment Approaches Are on the Horizon?

A lot of people are working on the genetics of epilepsy now. We already know the genes that cause a few rare forms of epilepsy. But for most forms, we don't know which genes are involved. Once we learn how to locate these genes and understand what they do, imagine how we can improve therapy. We could develop blood tests to see what kind of epilepsy a person has. Most of the time, when a person walks in the office who has recently developed epilepsy, we don't understand why it happened. Studying the genetics of the disease could give us that information and allow us to be much more precise in our treatment.

What Else Should People With Epilepsy Know About Treatment?

The bottom line is that if you're still having seizures or side effects after treatment, then go see your doctor and try a new approach. If that doesn't work, see a specialist.

WebMD Medical Reference

Sources

SOURCES:
Gregory L. Barkley, MD, Henry Ford Hospital, Detroit; chairman, Epilepsy Foundation's Professional Advisory Board; associate professor of neurology, Case Western Reserve University.
The Epilepsy Foundation.

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