New Approaches for the Treatment of Epilepsy
Megan Selvitelli, MD
Usually, epilepsy patients' seizures can be successfully treated with anticonvulsant medications.
However, approximately one third of those newly diagnosed with epilepsy continue to experience seizures despite anticonvulsant therapy.
These patients can benefit from a specialized epilepsy center that provides a wide range of diagnostic and treatment services.
Listen in as Megan Selvitelli, M.D. talks about new approaches for the treatment of Epilepsy.
Dr. Megan Selvitelli (Guest): Good afternoon. I’m happy to be here. Epilepsy is a condition that’s caused by abnormal electrical activity within the brain, and generally speaking, a seizure occurs and lasts typically less than five minutes. The symptoms of the seizure are based on which region of the brain is stimulated during the seizure. People can have symptoms related to visual changes because it’s the region of the brain that’s causing interpretation of visual images or can cause a feeling of déjà vu because they can be activating the memory center. With regard to when epilepsy could occur, it can occur at any time during a person’s lifetime. There are specifically two peaks during which seizures occur, and those are in childhood and, again, sort of after 65 years of age. There’s different reasons for that. Typically, seizures are arising from the surface of the brain or the cortex, and there could be injuries that are specific to each time period. For example, in childhood, the seizures are more commonly due to injuries in utero or with birth or because of developmental problems that the children have for genetic reasons; whereas in adults, it’s more common for the seizures to occur because there is a stroke or brain tumor that’s irritating the surface of the brain.
Melanie: How is it diagnosed, Dr. Selvitelli?
Dr. Selvitelli: Well, there’s a number of different ways that we diagnose seizures and epilepsy. The first, of course, is the neurologic examination and history. We really try to get a good history from the patient or from the observers of the seizure because people frequently lose consciousness during their seizures. We’ll try and get as much detail about what happened during the seizure, and then we’ll do a neurologic exam to see if there’s any findings on the exam to say that there’s some differences in one side of the body to the other. Then we also do common tests or imaging of the brain, either a head CT or brain MRI—again, to look for any of these changes along the surface of the brain that might be a lesion that seizures arise from. And we will do EEG or electroencephalogram. That is what we call a functional test, so we can see what a brain wave activity is like, much like an EKG can tell us what the heart rhythm is like.
Melanie: Then if somebody is diagnosed, they’ve had some seizures, they’ve come to see you, you’ve diagnosed them with epilepsy, what are the standard current treatments?
Dr. Selvitelli: For the majority of patients, the first option that we talk about is anticonvulsant medication. There are currently about 20 medications that are on the market. They have fairly similar efficacy amongst the different medications. There are a few that are specific for a particular type of seizure epilepsy. There are a few that are more specific for treating focal seizures and a few that are more specific for treating generalized seizures. But really, the reason that we choose one anticonvulsant medication over another is based on how frequently people have to take it, what are the potential side effects. A number of the seizure medicines can treat other conditions. So an example is topiramate or valproic acid can both treat migraines as well as seizures. Then there’s a number of other treatment options beyond medication, although for the majority of patients with epilepsy, about 50 to 70 percent will have control of their seizures with either the first or the second anticonvulsant, which is why it’s generally considered first line. There are some things that patients can do as well that can help minimize their risk for seizures and also things like making sure they have regular sleep patterns and that they minimize stress and that they minimize alcohol intake. They also want to avoid certain medicines that can provoke seizures. There are a few other treatments that we generally reserve for people who aren’t controlled with the first or the second seizure medicine. Those are things like epilepsy surgery, where we potentially identify whether seizures arise from any particular region of the brain and take that region out. Or, we consider treatment with something called a vagal nerve stimulator. Or, the newest device that came out about a year ago called NeuroPace. The vagal nerve stimulator is an electrical device that’s implanted in the chest and gives stimulation for the vagus nerve and controls seizures that way. The NeuroPace is actually an electrical stimulator that’s implanted in the skull with electrodes that go to the two regions where seizures seem to arise from in the brain. What’s interesting about that is that it can not only detect seizures but also give the electrical stimulation to abort, so much like a cardiac defibrillator. These are the most common treatments.
Melanie: If the anticonvulsant medications don’t work—and you’ve mentioned some other types of treatments—tell us about your specialized epilepsy center at Maine Medical Center.
Dr. Selvitelli: Sure. Generally speaking, again, most patients are capable of having fairly good control of their seizures within the first or the second anticonvulsant medications. Up to 30 percent on patients who have epilepsy have what we consider medically refractory seizures. These are seizures that persist despite having a trial of adequate dosages of numerous medicines. In those patients, it’s really helpful to come to a comprehensive epilepsy center because not only we’re able to offer treatments such as epilepsy surgery or the vagal nerve stimulator that other facilities don’t have the capacity to offer, but we also try to look at the whole picture for these patients. So, not only how can we treat their epilepsy but how does their epilepsy affect them—things like driving, things like whether there’s comorbidities like anxiety and depression that are frequently present in these patients as well. How does it affect their living, their working, their everyday life?
Melanie: Tell us about living and working and everyday life and managing your life with epilepsy. Driving, you mentioned, caring for youngsters. Should you be worried about seizures? Do you trust your medications? What is the driving situation and those kinds of things?
Dr. Selvitelli: The driving situation has a very state-specific answer, and every state has its own jurisdiction in terms of when patients are capable of driving after they’ve had a seizure. If someone has been having a longstanding history of epilepsy and has a breakthrough seizure, generally speaking, they’re asked to refrain from driving for three months while their medications are adjusted. If someone’s newly diagnosed and chooses not to go on medicine or chooses not to have treatment, then they’re asked to refrain from driving for up to six months. This is all respective to Maine State Law. New Hampshire, Vermont, Massachusetts all have their own different time frame for that.
Melanie: If you have young children and you’ve been diagnosed with epilepsy, how do you work with people on managing those kinds of day-to-day lives without being afraid that something’s going to happen while they are, for example, caring for their youngster?
Dr. Selvitelli: This is a really difficult question. One of the things that we particularly are interested in and specialize in at the epilepsy center is patients who are pregnant and are having children, and there’s a particular concern not only for the questions you asked but also because the medicine do have a higher risk of having a child with birth defects. We have long conversations with most of the women who are potentially of child-bearing age to discuss the issue. With respect to caring for youngsters, when the children are first born, we often suggest that there are rolling bassinets that the baby can be put in so that if the mother has a seizure, that they don’t drop the baby; that there is people around throughout much of the day so that they can have extra care if they were to have a seizure, to be looked after themselves and also during the time period where they’re recovering from it. Generally speaking, what we really want to do for our patients is get the seizures under the best control possible, minimize any side effects from treatment, and really allow them to live the life that they want to live.
Melanie: In just the last minute, please tell us why listeners should come to Maine Medical Center and the epilepsy center.
Dr. Selvitelli: I think what we have to offer here is we have three wonderful physicians who have particular training in epilepsy who are looking not only at all the different treatment options that we have available, including the medications, the different surgical options. We also have a really sort of multidisciplinary approach for the patient. We do have our nursing staff and our medical assistants, who can answer questions regarding side effects and how they need to adjust their medications. We have a nurse practitioner who is able to meet with patients and talk about a lot of these different social difficulties that need to be addressed. We also just have great facilities. We have an epilepsy monitoring unit within the hospital to evaluate patients for possible surgery or assist with medication changes. Of course, for the last year, we’ve also had an epilepsy surgeon who is able to help us with the surgeries as well.
Melanie: Where can listeners get more information about epilepsy?
Dr. Selvitelli: Contact us through the Epilepsy Foundation of New England. There is a website called epilepsynewengland.org. They do some wonderful things throughout the year, including an epilepsy walk in the springtime. There’s an epilepsy fundraiser in November of each year. We also have generally an epilepsy talk once a year in the community so that patients and their family members can come and learn more.
Melanie: Thank you so much, Dr. Megan Selvitelli. For more information, you can go to mainemedicalcenter.org. That’s mainemedicalcenter.org, mmc.org. You’re listening to MMC Radio. This is Melanie Cole. Thanks so much for listening.