Epilepsy

Question 1

What is epilepsy?

Answer 1

Epilepsy is a common neurological condition characterised by recurrent seizures.

Question 2

How many people in the UK have epilepsy?

Answer 2

There are around 500,000 people in the UK with epilepsy.

Question 3

What percentage of people with epilepsy achieve satisfactory seizure control with medication?

Answer 3

Around two-thirds achieve satisfactory seizure control with antiepileptic medication.

Question 4

What are some conditions associated with epilepsy?

Answer 4

Conditions associated with epilepsy include cerebral palsy (around 30% have epilepsy), tuberous sclerosis, and mitochondrial diseases.

Question 5

What are some common causes of recurrent seizures?

Answer 5

Common causes include febrile convulsions, alcohol withdrawal seizures, and psychogenic non-epileptic seizures.

Question 6

What characterizes febrile convulsions?

Answer 6

Typically occur in children between 6 months and 5 years, affecting around 3% of children, and usually occur early in a viral infection as temperature rises rapidly.

Question 7

What is the peak incidence of alcohol withdrawal seizures?

Answer 7

The peak incidence of seizures is around 36 hours following cessation of drinking.

Question 8

What is the classification of seizures based on?

Answer 8

The classification is based on where seizures begin in the brain, level of awareness during a seizure, and other features of seizures.

Question 9

What are focal seizures?

Answer 9

Focal seizures start in a specific area on one side of the brain, with varying levels of awareness.

Question 10

What are generalised seizures?

Answer 10

Generalised seizures involve networks on both sides of the brain at onset, with immediate loss of consciousness.

Question 11

What is a focal to bilateral seizure?

Answer 11

A focal to bilateral seizure starts on one side of the brain before spreading to both lobes.

Question 12

What are infantile spasms?

Answer 12

Brief spasms beginning in the first few months of life, characterized by flexion and extension movements, often with poor prognosis.

Question 13

What is Lennox-Gastaut syndrome?

Answer 13

A syndrome that may extend from infantile spasms, characterized by atypical absences and falls, with a high rate of mental handicap.

Question 14

What are the symptoms following a generalized seizure?

Answer 14

Patients may bite their tongue and experience incontinence of urine.

Question 15

What investigations are done after a first seizure?

Answer 15

Patients generally have both an electroencephalogram (EEG) and neuroimaging (usually an MRI).

Question 16

When do neurologists typically start antiepileptics?

Answer 16

Most neurologists start antiepileptics following a second epileptic seizure.

Question 17

What is the recommendation regarding prescribing antiepileptics?

Answer 17

It is recommended to prescribe antiepileptics by brand rather than generically due to the risk of different bioavailability.

Question 18

What is the mechanism of action of sodium valproate?

Answer 18

Sodium valproate increases GABA activity and is used for generalized seizures.

Question 19

What are the adverse effects of carbamazepine?

Answer 19

Adverse effects include dizziness, ataxia, drowsiness, and visual disturbances.

Question 20

What is the acute management for seizures that do not terminate?

Answer 20

If seizures do not terminate after 5-10 minutes, benzodiazepines such as diazepam may be administered.

Question 21

What is status epilepticus?

Answer 21

Status epilepticus is a medical emergency where a patient continues to fit despite treatment.

Question 22

What are the three key features of the new basic seizure classification?

Answer 22

1. Where seizures begin in the brain
2. Level of awareness during a seizure
3. Other features of seizures

Question 23

What are focal seizures?

Answer 23

Focal seizures start in a specific area, on one side of the brain. The level of awareness can vary.

Question 24

What terms are used to describe the level of awareness in focal seizures?

Answer 24

Focal aware, focal impaired awareness, and awareness unknown.

Question 25

What types of focal seizures are there?

Answer 25

Focal seizures can be classified as motor, non-motor, or having other features such as aura.

Question 26

What are generalised seizures?

Answer 26

Generalised seizures engage networks on both sides of the brain at the onset, with immediate loss of consciousness.

Question 27

How are generalised seizures subdivided?

Answer 27

Generalised seizures can be subdivided into motor and non-motor.

Question 28

What are specific types of generalised seizures?

Answer 28

Tonic-clonic, tonic, clonic, typical absence, and atonic.

Question 29

What does 'unknown onset' refer to in seizure classification?

Answer 29

'Unknown onset' is reserved for when the origin of the seizure is unknown.

Question 30

What are focal to bilateral seizures?

Answer 30

Focal to bilateral seizures start on one side of the brain in a specific area before spreading to both lobes.

Question 31

What factors should women with epilepsy consider regarding contraception?

Answer 31

1. The effect of the contraceptive on the effectiveness of the anti-epileptic medication. 2. The effect of the anti-epileptic on the effectiveness of the contraceptive. 3. The potential teratogenic effects of the anti-epileptic if the woman becomes pregnant.

Question 32

What does the Faculty of Sexual & Reproductive Healthcare (FSRH) recommend for women with epilepsy?

Answer 32

Consistent use of condoms, in addition to other forms of contraception.

Question 33

What is the UKMEC classification for women taking phenytoin, carbamazepine, barbiturates, primidone, topiramate, or oxcarbazepine regarding the COCP and POP?

Answer 33

UKMEC 3: the COCP and POP.

Question 34

What is the UKMEC classification for women taking phenytoin, carbamazepine, barbiturates, primidone, topiramate, or oxcarbazepine regarding the implant?

Answer 34

UKMEC 2: implant.

Question 35

What is the UKMEC classification for women taking phenytoin, carbamazepine, barbiturates, primidone, topiramate, or oxcarbazepine regarding Depo-Provera, IUD, and IUS?

Answer 35

UKMEC 1: Depo-Provera, IUD, IUS.

Question 36

What is the UKMEC classification for women taking lamotrigine regarding the COCP?

Answer 36

UKMEC 3: the COCP.

Question 37

What is the UKMEC classification for women taking lamotrigine regarding POP, implant, Depo-Provera, IUD, and IUS?

Answer 37

UKMEC 1: POP, implant, Depo-Provera, IUD, IUS.

Question 38

What is the minimum amount of ethinylestradiol recommended in a COCP for women with epilepsy?

Answer 38

A minimum of 30 µg of ethinylestradiol.

Question 39

What is a typical feature of seizures in the temporal lobe?

Answer 39

May occur with or without impairment of consciousness or awareness. ## Footnote An aura occurs in most patients, typically a rising epigastric sensation, and can include psychic or experiential phenomena such as déjà vu, jamais vu, and less commonly, hallucinations (auditory/gustatory/olfactory).

Question 40

How long do seizures in the temporal lobe typically last?

Answer 40

Seizures typically last around one minute. ## Footnote Automatisms (e.g. lip smacking/grabbing/plucking) are common.

Question 41

What are the typical features of frontal lobe seizures?

Answer 41

Head/leg movements, posturing, post-ictal weakness, Jacksonian march.

Question 42

What is a typical feature of parietal lobe seizures?

Answer 42

Paraesthesia.

Question 43

What are the typical visual features of occipital lobe seizures?

Answer 43

Floaters/flashes.

Question 44

What are the risks of uncontrolled epilepsy during pregnancy?

Answer 44

The risks of uncontrolled epilepsy generally outweigh the risks of medication to the fetus.

Question 45

What should women considering pregnancy take to minimize the risk of neural tube defects?

Answer 45

Women should be advised to take folic acid 5mg per day well before pregnancy.

Question 46

What is the percentage of congenital defects in newborns born to non-epileptic mothers?

Answer 46

Around 1-2% of newborns born to non-epileptic mothers have congenital defects.

Question 47

What is the percentage of congenital defects in newborns if the mother takes antiepileptic medication?

Answer 47

This rises to 3-4% if the mother takes antiepileptic medication.

Question 48

What is the recommendation regarding antiepileptic drug levels during pregnancy?

Answer 48

There is no indication to monitor antiepileptic drug levels.

Question 49

What is sodium valproate associated with?

Answer 49

Sodium valproate is associated with neural tube defects.

Question 50

Which older antiepileptic is often considered the least teratogenic?

Answer 50

Carbamazepine is often considered the least teratogenic of the older antiepileptics.

Question 51

What congenital defect is phenytoin associated with?

Answer 51

Phenytoin is associated with cleft palate.

Question 52

What do studies suggest about lamotrigine and congenital malformations?

Answer 52

Studies suggest the rate of congenital malformations may be low; however, the dose of lamotrigine may need to be increased in pregnancy.

Question 53

Is breastfeeding safe for mothers taking antiepileptics?

Answer 53

Breastfeeding is generally considered safe for mothers taking antiepileptics, with possible exception of barbiturates.

Question 54

What should pregnant women taking phenytoin be given in the last month of pregnancy?

Answer 54

Pregnant women taking phenytoin should be given vitamin K to prevent clotting disorders in the newborn.

Question 55

What warning was issued regarding sodium valproate in the November 2013 Drug Safety Update?

Answer 55

There was a warning about a significant risk of neurodevelopmental delay in children following maternal use of sodium valproate.

Question 56

What is the conclusion regarding the use of sodium valproate during pregnancy?

Answer 56

Sodium valproate should not be used during pregnancy and in women of childbearing age unless clearly necessary.

Question 57

What should women of childbearing age do before starting treatment with sodium valproate?

Answer 57

Women of childbearing age should not start treatment without specialist neurological or psychiatric advice.

Question 58

When do most neurologists start antiepileptics for epilepsy treatment?

Answer 58

Following a second epileptic seizure.

Question 59

What do NICE guidelines suggest regarding starting antiepileptics?

Answer 59

Start after the first seizure if any of the following are present: 1. The patient has a neurological deficit. 2. Brain imaging shows a structural abnormality. 3. The EEG shows unequivocal epileptic activity. 4. The patient or their family or carers consider the risk of having a further seizure unacceptable.

Question 60

What is the risk associated with maternal use of sodium valproate?

Answer 60

It is associated with a significant risk of neurodevelopmental delay in children.

Question 61

What is the current guidance regarding sodium valproate use in pregnancy?

Answer 61

Sodium valproate should not be used during pregnancy and in women of childbearing age unless clearly necessary.

Question 62

What is the first-line treatment for males with generalised tonic-clonic seizures?

Answer 62

Sodium valproate.

Question 63

What is the first-line treatment for females with generalised tonic-clonic seizures?

Answer 63

Lamotrigine or levetiracetam.

Question 64

What is the first-line treatment for girls under 10 years with generalised tonic-clonic seizures?

Answer 64

Sodium valproate may be offered first-line if they are unlikely to need treatment when they are old enough to have children or if they are unable to have children.

Question 65

What is the first-line treatment for focal seizures?

Answer 65

Lamotrigine or levetiracetam.

Question 66

What are the second-line treatments for focal seizures?

Answer 66

Carbamazepine, oxcarbazepine, or zonisamide.

Question 67

What is the first-line treatment for absence seizures (Petit mal)?

Answer 67

Ethosuximide.

Question 68

What are the second-line treatments for absence seizures in males?

Answer 68

Sodium valproate.

Question 69

What are the second-line treatments for absence seizures in females?

Answer 69

Lamotrigine or levetiracetam.

Question 70

What should be noted about carbamazepine in relation to absence seizures?

Answer 70

Carbamazepine may exacerbate absence seizures.

Question 71

What is the first-line treatment for myoclonic seizures in males?

Answer 71

Sodium valproate.

Question 72

What is the first-line treatment for myoclonic seizures in females?

Answer 72

Levetiracetam.

Question 73

What is the first-line treatment for tonic or atonic seizures in males?

Answer 73

Sodium valproate.

Question 74

What is the first-line treatment for tonic or atonic seizures in females?

Answer 74

Lamotrigine.