On the Frontline of Epilepsy Treatment

Treatments for epilepsy have come a long way in the last decade. There are twice as many epilepsy medications today than 10 years ago. 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 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 Gregory L. Barkley, MD, past chairman of the Epilepsy Foundation's Professional Advisory Board. Barkley also practices at the Henry Ford Hospital in Detroit, where he serves as chair of the neurology department.

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. There are about a dozen drugs now. 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.

How Have Newer Drugs Changed Epilepsy Treatment?

We've had a lot of new drugs in the last 10 years or so: Neurontin (which is now the generic gabapentin), Lamictal, Topamax, Zonegran, Keppra, Trileptal, and Gabitril, many of which are now generic.

I think that all of these drugs have been shown to be effective in controlled trials. One of 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.

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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. There's a trial under way comparing surgery with standard medical care in people who developed temporal lobe epilepsy in the last two years. It's called ERSET (the Early Randomized Surgical Epilepsy Trial). We'll have to wait for the results.

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's one on the market now: the vagus nerve stimulator (VNS). In about a quarter of the patients who get it, there's a substantial reduction in the number of seizures. It's certainly a low-risk procedure.

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. I've never personally seen someone who had no seizures with VNS, but others have reported that.

Then there are some other exciting stimulator research projects under way. There's one that adapts some of the brain stimulation therapy used for people with Parkinson's disease. We'll have to see what the results of the trial are.

The other stimulator trial that's going on is called NeuroPace, which I'm actually involved with. Most nerve stimulation is on a fixed program. You set the device to send out pulses of a certain duration at certain intervals and it goes around the clock. The NeuroPace is a different concept. 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.

Again, this is very early in the course of testing, so we don't know if it's going to work well enough to be licensed. But I think that there's a great deal of excitement about all of this stimulation work. [Note: NeuroPace was awaiting FDA approval as of June 2012.]

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Do You Think the Ketogenic Diet Is Helpful for Epilepsy?

It is 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. It's a starvation diet. 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. And you can't eat a high-fat diet for a long time. We already know the dangerous long-term consequences of eating a high-fat diet in adults.

So the ketogenic diet is a reasonable alternative to intractable epilepsy. But I'm reluctant to use it in adults. Besides, 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.

What Do You Think About Focused Radiation Epilepsy Treatments, Like the Gamma Knife?

I actually think that that this approach is overhyped. I don't doubt that radiation can destroy the focus of a seizure. But the problem is that 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. And we're talking about brain surgery, where a few millimeters can make all the difference in the world.

So I think 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. But I don't think that it's 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.

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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 Reviewed by Neil Lava, MD on January 21, 2017

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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