Diagnosis and management of epilepsy

Most patients with epilepsy can be helped to live a normal, fit-free life, says Dr Alison Glenesk.

Epilepsy is one of the most common neurological conditions, particularly in young people, with over 70 per cent of those who develop epilepsy doing so before the age of 20. Unlike most other neurological diseases it is treatable, with most patients going on to lead a normal, fit-free life. It is very important, therefore, that the initial diagnosis and treatment are correct.

Diagnosing epilepsy
As usual, the key to diagnosis is in the history. You should ask the patient or a witness whether the patient was acting oddly before the episode; about any wetting or tongue biting; the length of the episode; about any loss of consciousness; generalised or specific movements; or palpitations. Also check for history of excess alcohol; drug history, especially non-prescription drugs; fever (in a young child) and family history of epilepsy.

In young people referral to a neurologist is essential. Many centres now run 'first fit' clinics, allowing speedy and standardised assessment.

In older patients a cause is more likely to be found. Alcohol or drug withdrawal, cerebral metastases from occult tumours and cardiac arrhythmias should be considered. An ECG and, if indicated, continuous ECG monitoring, is essential. Pseudo-seizures are also common, often with a background of psychological or social distress.

EEG is the gold-standard investigation for diagnosis and classification, however, only about a third of people with epilepsy will have a positive result on first testing, rising to about 70 per cent with repeat recording.

EEG with synchronised video during a fit is almost certain to be diagnostic. Sleep EEG can also be helpful.

Brain imaging in the form of MRI scanning will show abnormalities in about a third of those presenting with epilepsy, such as AV malformations - most are not treatable, however.

CT scanning is less sensitive but useful if MRI scanning is contraindicated.

The decision to start treatment is dependent upon the risk of further seizures. Generally, patients with tonic-clonic seizures, those with EEG abnormalities, those with congenital neurological deficits and those particularly keen to avoid further seizures are offered treatment early.

Drugs are generally used as monotherapy, starting with a low dose and increasing until fits are controlled or there are unacceptable side-effects. If one particular drug is unsuitable, it is tapered off while a new drug is being added.

Drugs suitable for partial seizures include carbamazepine, sodium valproate, lamotrigine and oxcarbazepine.

Drugs suitable for generalised seizures or seizures difficult to classify are sodium valproate and lamotrigine.

When monotherapy fails, it may be necessary to use two or even three appropriate agents.

After a fit-free period, patients may be keen to stop therapy. Complex tables exist indicating the likely risk of recurrence. If control is good, however, and if the patient has resumed driving, the risk may not be acceptable.

Surgery can sometimes help in drug-resistant patients, usually in the form of resection of parts of the brain. This tends to be reserved for severe and intractable disease.

Status epilepticus
This is defined as epilepsy continuing for more than 30 minutes. Treatment in the community involves general measures such as administration of oxygen, obtaining IV access and administration of diazepam or lorazepam.

Fortunately, rectal diazepam usually works well, particularly in children, because obtaining IV access can be problematic.

Young women and epilepsy
Problems can arise with enzyme-inducing drugs when prescribing the oral contraceptive pill.

In pregnancy, anti-epileptic drugs increase the baseline risk of fetal abnormality by two or three times, but uncontrolled seizures are possibly more dangerous. Generally, the simplest regimen at the lowest dosage possible is the best plan, and it may occasionally be possible to withdraw drugs completely.

Pre-conceptual counselling is advised, but is unfortunately not always possible.

DVLA regulations state that a person may not drive for one year after a fit. This can obviously have major implications for employment and family life. Regulations for nocturnal epilepsy are more complex (see www.dvla.gov.uk).

Dr Glenesk is a GP trainer in Aberdeen

Key points

  • Epilepsy is one of the most common neurological conditions.
  • The key to diagnosis is in asking the right questions and it is important to refer to a neurologist.
  • Treatment consists of anti-epileptic drugs and/or surgery in severe cases. If monotherapy fails, two or three drugs may be necessary.

Have you registered with us yet?

Register now to enjoy more articles and free email bulletins


Already registered?

Sign in

Follow Us:

Just published

Hospitals adding to GP crisis with constant flow of work dumped on practices, say LMCs

Hospitals adding to GP crisis with constant flow of work dumped on practices, say LMCs

Hospitals are compounding the GP workload crisis by dumping 'endless tasks' on primary...

Abnormal vaginal discharge - red flag symptoms

Abnormal vaginal discharge - red flag symptoms

Advice on red flag symptoms in patients with vaginal discharge, including what examinations...

GMC demands 'greater autonomy' to tackle bias against BAME doctors

GMC demands 'greater autonomy' to tackle bias against BAME doctors

The GMC has called for ‘greater autonomy’ to choose the complaints it investigates,...

UK COVID-19 vaccination programme tracker

UK COVID-19 vaccination programme tracker

GPs across the UK are playing a leading role in the largest-ever NHS vaccination...

Government must invest to end 'historic' GP crisis in wake of COVID-19, says BMA

Government must invest to end 'historic' GP crisis in wake of COVID-19, says BMA

General practice is facing 'historic workforce and workload crises' that have been...

Most GP care should be face-to-face post-COVID, says RCGP

Most GP care should be face-to-face post-COVID, says RCGP

General practice faces a 'rebalancing' between face-to-face and remote consultations...