Epilepsy

Jerome Engel Jr MD PhD (Dr. Engel of the David Geffen School of Medicine at the University of California, Los Angeles, has no relevant financial relationships to disclose.)
Originally released October 18, 1993; last updated March 27, 2017; expires March 27, 2020

This article includes discussion of epilepsy and seizure disorder, which may include conditions not considered to be epilepsy, as well as specific epileptic seizure types and epilepsy syndromes.

Overview

Epilepsy is a common serious disorder of the brain characterized by recurrent epileptic seizures. Differential diagnosis depends on distinguishing between nonepileptic events that resemble epileptic seizures, epileptic seizures that are provoked and do not indicate a diagnosis of epilepsy, and epilepsy, which implies the presence of an epileptogenic disturbance in the brain even when seizures are not occurring. Treatment is based on diagnosis of specific epileptic seizure types and, when present, specific epilepsy syndromes. Pharmacotherapy is the treatment of choice, and 60% to 70% of patients have seizures that can be controlled with medication. Alternative therapies include, but are not limited to, surgical treatment, which is highly effective for specific types of pharmacoresistant epilepsy; neuromodulation, including vagus nerve stimulation, responsive neurostimulation, and deep brain stimulation; and the ketogenic diet. The health burden of epilepsy results not only from the epileptic seizures, but also from the social, psychological, and neurologic consequences of these seizures, which can include disabling morbidity and increased mortality. In this updated article, the author stresses the importance of referral to a full-service, multidisciplinary epilepsy center when trials of 2 antiseizure drugs fail.

Key points

 

• Epilepsy is the most common serious primary disorder of the brain: 10% of people will have at least 1 seizure in a lifetime. One third of these will develop epilepsy, and between 0.5% and 1% of the world's population has active epilepsy.

 

• Epilepsy is not a benign condition: it accounts for 1% of the global burden of disease due to disability and premature death, equivalent to lung cancer in men and breast cancer in women.

 

• The global burden of disease attributed to epilepsy is comparable to depression, dementia, and substance abuse.

 

• The primary treatment for epilepsy is antiseizure drugs, which can control disabling seizures in approximately two thirds of people with epilepsy.

 

• People with epileptic seizures that are not controlled by medication are at greater risk for irreversible disability and increased mortality and should be referred to a full-service epilepsy center.

Historical note and terminology

The earliest medical writings of antiquity mention epileptic seizures, and some accurately ascribed them to disorders of the brain. However, the dramatic intermittent nature of this affliction caused it to be shrouded in mysticism for many centuries. In medieval Europe, it was known as the falling sickness or the sacred disease and was often ascribed to possession by evil spirits (Temkin 1945). Later, it was generally considered to be a psychiatric condition, until a biological basis was seriously considered in the mid-19th century. The introduction of effective treatment at about the same time, including antiseizure drugs such as bromides and barbiturates, as well as surgical intervention, did much to alleviate the suffering of many persons with epilepsy, but stigma and misconceptions surrounding the diagnosis of epilepsy have persisted in all cultures and still contribute greatly to the disabilities associated with this disorder. There are several comprehensive textbooks on epilepsy (Engel and Pedley 2008; Panayiotopoulos et al 2010; Bureau et al 2012; Engel 2013; Shorvon et al 2015; Wyllie 2015). In 2012, the Institute of Medicine Committee on the Public Health Dimensions of the Epilepsies published a comprehensive report with recommendations concerning epilepsy care, prevention, and surveillance (England et al 2012).

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