Seizures and Epilepsy

Evidence

https://pubmed.ncbi.nlm.nih.gov/25679244/ 

A Sahib El-Radhi 

Seizures are common events in children and up to 10% of all children experience at least one seizure during their childhood. They can be triggered by many conditions such as fever, medications or injury.  

Febrile seizures are the most common type of seizures, affecting 3-4% of children. While epilepsy is typically recurrent and unprovoked, a single, isolated seizure is not epilepsy. Taking a detailed history of the seizure description helps establish the diagnosis. A video recording of the event can also support the diagnosis and rule out non-epileptic seizures that resemble seizures, such as pseudo-seizure. Seeing a child having a seizure, particularly if it is the first one, is usually frightening and distressing for the parents. First seizure should always be evaluated by health professionals because of a possible serious underlying cause. 

The care of a child who does have epilepsy is best achieved by a community or hospital epilepsy specialist. 

Education  

What is a Seizure? 

A seizure is a sudden and temporary change in the electrical and chemical activity in the brain. Seizures differ from person to person, and some people experience more than one type of seizure. Depending on the type of seizure, it can affect a person’s: 

• Level of awareness and consciousness 
• Movement 
• Behaviour 
• Sensation and feelings 
• Emotions 

Seizures vary and can be very brief or last up to two or three minutes. Most seizures are generally over in less than two minutes. Some seizures are severe and some are very subtle. 

Not all people who have seizures are diagnosed with epilepsy. 

What is epilepsy? 

Epilepsy is diagnosed when someone has a tendency to have recurrent seizures. 

Epilepsy is a neurological disorder and seizures are caused by a temporary disruption of the electrical activity in the brain. 

While 1 in 200 children have epilepsy. Approximately 1% of Australians will be diagnosed with epilepsy at some point in their lives. At the moment over 250,000 Australians currently live with epilepsy. 

Epilepsy occurs regardless of age, gender, cultural or socio-economic background. Epilepsy is more common in children, adolescents and people over 60 years. 

There are many different types of epilepsies and people’s experiences differ greatly. Depending on the type of epilepsy, some children will stop having seizures. In other cases, epilepsy is a life-long condition. 

For almost 60% of people diagnosed with epilepsy, the cause of their seizures is not immediately known and further investigations will be needed to determine the potential underlying cause. 

Approximately 70% of people with epilepsy can have good seizure control if they take their medication correctly as prescribed by the doctor. 

Seizure Types 

Seizure classification is a way of naming the many different types of epileptic seizures and putting them into groups. 

Doctors look at the following three things when classifying a seizure: 

• Where in the brain the seizure starts.  
• If the person is aware or not during the seizure. 
• Whether the seizure involves movement.

Seizures can be divided into three major groups: 

1. Focal Onset 

2. Generalised Onset 

3. Unknown Onset

Most people will only have one or two seizure types. Sometimes a person with more complex or severe epilepsy may experience a number of different seizure types. 

1. Focal Onset Seizures

Focal onset (formerly known as partial seizures) means the seizure starts in just one small region of the brain. It may spread to other areas of the brain. 

These seizures can often be subtle or unusual and may go unnoticed or be mistaken for anything from being intoxicated to daydreaming. About 60% of people with epilepsy have focal onset seizures – which are also simply known as focal seizures. 

Focal onset seizures can be further divided into two groups relating to a person’s awareness during a seizure: 

Focal aware: the person is fully aware of what’s happening around them but may not be able to talk or respond (formerly known as simple partial seizures). They are usually brief and are often called a warning or ‘aura’ (that a more significant seizure may develop) but are part of the seizure. 

Focal impaired awareness: awareness is affected (formerly known as a complex partial seizure) and the person may appear confused, vague or disorientated. 

A focal seizure may progress to a bilateral tonic-clonic seizure meaning that it starts in one area of the brain and then spreads to both sides causing muscle stiffening and jerking. 

2. Generalised Onset Seizures

Generalised onset means the seizure affects both hemispheres (sides) of the brain from the onset. Because of this, a person may lose consciousness at the start of the seizure. Generalised onset seizures almost always affect awareness in some way, so the terms ‘aware’ or ‘impaired awareness’ aren’t used. However, they can be classified further by movement: 

Generalised motor seizure: may involve stiffening (tonic) and jerking (clonic), known as tonic-clonic (previously known as grand mal) or other movements. 

Generalised non-motor seizure: These seizures involve brief changes in awareness, and staring, and some may have automatic or repeated movements like lip-smacking. 

Types of Generalised Onset Seizures 

Absence seizures – a sudden lapse in awareness and responsiveness that look like brief staring spells or daydreaming. 

Tonic-clonic seizures – the body stiffens (the tonic phase) and then the limbs begin to jerk rhythmically (the clonic phase). 

Myoclonic seizures – sudden single jerks of a muscle or a group of muscles that may last no more than a few seconds. 

Tonic seizures – Can occur when a person is asleep or awake and involve a brief stiffening of the body, arms or legs. The person will suddenly fall if standing or sitting. 

Atonic seizures – brief seizures that cause a sudden loss of muscle tone and the person often falls to the ground or will have a sudden head nod if sitting. These seizures usually last less than 15 seconds and are often called ‘drop attacks.  

Clonic seizures – although uncommon they cause jerking in various parts of the body. 

3. Unknown Onset Seizures

Unknown onset means the seizure cannot be diagnosed as either focal or generalised onset. Sometimes this classification is temporary and as more information becomes available over time or through further testing, the type of seizure may be changed to a generalised or focal onset seizure. 

Rarely, doctors might be sure that someone has had an epileptic seizure, but can’t decide what type of seizure it is. This could be because they don’t have enough information about the seizure, or the symptoms of the seizure are unusual. 

How is your child Diagnosed? 

If your child has had a seizure and has been to the doctor or accident and emergency, it is most likely they will have a referral for an EEG and a neurologist appointment.  

Procedures to help diagnose epilepsy: 

• EEG – This is a non-invasive test used to look at the electrical activity of the brain. 
• Neuroimaging – These are brain scans and include MRI, SPECT, PET and CT scans. 
• Neuropsychological tests – Look at how your brain is working and how the epilepsy affects your day to day functioning. 

EEG (Electroencephalogram) 

Routine EEG 

An electroencephalogram (EEG) is a test done to look at the electrical activity of the brain – that is, how the brain is functioning. Brain cells communicate by producing tiny electrical impulses and seizures are a result of abnormal electrical activity, so it is logical to have an EEG. 

If a person is thought to be having seizures, they will be referred to a clinic to have an EEG. It is a simple, painless test and involves no needles or injections. 

An example EEG 

During the test, small discs called electrodes are placed on the scalp with glue or paste. The EEG machine then records the electrical activity of the brain. 

An EEG usually takes less than an hour. It is important to help your child be relaxed because movement can affect results. 

Most of the test is done with the eyes closed, and sometimes your child will be asked to open them briefly. It is routine to be asked to breathe deeply (hyperventilate) for 2-3 minutes and later have a flickering strobe light, flickering at various speeds. These forms of stimulus can provoke EEG changes in some forms of epilepsy. 

It is not uncommon for people with epilepsy to have a normal EEG in between seizures. 

An EEG recorded during sleep may also give additional information. This may sometimes be needed if your first EEG returns normal. 

An EEG is harmless. No electrical current from the machine passes into the person’s brain during the procedure.  

Treatment 

Anti-seizure medications (ASMs) are the most common treatment for epilepsy. Around 70% of people with epilepsy can have good seizure control if they take their medication correctly. Your neurologist will choose the appropriate ASM for your child’s type of epilepsy. 

A typical approach goes a bit like this: 

Treatment usually starts using one ASM at a low dose, which is increased slowly, until your child’s seizures are controlled or there are medication side effects.  

If the seizures are not controlled with ASM or side effects are intolerable, a different one is added and the first is slowly reduced and withdrawn. If the seizures are not controlled with a single medication, then another ASM might be added to be used in combination. 

Empowerment  

Seizures are usually unpredictable, and it is upsetting to watch, and have no control over them. We say “stay calm” but you see your child having a seizure and it is difficult to not feel anxious, upset, and frightened. 

There are many questions. You are probably asking “Why? Why does my child have epilepsy?” “Why has this happened to us?” What have we done to deserve this?” 

You are not alone with these questions, and most parents experience uncertain feelings at some stage. You are merely having a normal response to being given a diagnosis that creates uncertainty. 

Sometimes, diagnosis can be a relief. You finally know what is happening with your child and can face the future with some understanding of what to do and expect. 

Useful Links 

Special thanks to The Epilepsy Foundation for content sharing and providing support for families.  

Epilepsy Foundation, Australia 

National Epilepsy Support Service:  1300 761 487 

https://www.epilepsyfoundation.org.au 

Epilepsy Action Australia 

https://www.epilepsy.org.au/ 

Epilepsy Smart Australia 

https://epilepsysmart.org.au/ 

Raising Children Network, Australia 

https://raisingchildren.net.au/guides/a-z-health-reference/epilepsy-seizures