Epilepsy E-book Flashcards
(33 cards)
Focal Seizures 1st line treatment:
• Carbamazepine: either immediate or prolonged release formulations (Tegretol)
§ Immediate release: Initially 100–200 mg 1–2 times a day, increased in steps of 100–200 mg every 2 weeks; usual dose 0.8–1.2 g daily in divided doses; increased if necessary up to 1.6–2 g daily in divided doses
§ Prolonged release: Initially 100–400 mg daily in 2 divided doses, increased in steps of 100–200 mg every 2 weeks, dose should be increased slowly; usual dose 0.8–1.2 g daily in 2 divided doses, increased if necessary up to 1.6–2 g daily in 2 divided doses
• Lamotrigine (can be used as a monotherapy or as an adjunct to valproate)
§ Monotherapy: Initially 25 mg once daily for 14 days, then increased to 50 mg
once daily for further 14 days, then increased in steps of up to 100 mg every
7–14 days; maintenance 100–200 mg daily in 1–2 divided doses; increased if necessary up to 500 mg daily, dose titration should be repeated if restarting after interval of more than 5 days
§ Adjunct with valproate: Initially 25 mg once daily on alternate days for 14
days, then 25 mg once daily for further 14 days, then increased in steps of up to 50 mg every 7–14 days; maintenance 100–200 mg daily in 1–2 divided doses, dose titration should be repeated if restarting after interval of more than 5 days
Focal Seizures 2nd line treatment:
• Levetiracetam monotherapy: Initially 250 mg once daily for 1–2 weeks, then increased to 250 mg twice daily, then increased in steps of 250 mg twice daily (max. per dose 1.5 g twice daily), adjusted according to response, dose to be increased every 2 weeks
• Oxcarbazepine monotherapy: Initially 300 mg twice daily, then increased in steps of up to 600 mg daily, adjusted according to response, dose to be adjusted at weekly intervals; usual dose 0.6–2.4 g daily in divided doses
• Sodium Valproate: Initially 600 mg daily in 1–2 divided doses, then increased in steps of 150–300 mg every 3 days; maintenance 1–2 g daily, alternatively maintenance 20–30 mg/kg daily;
maximum 2.5 g per day
The following drugs may be considered for adjunctive treatment
carbamazepine, clobazam, gabapentin, lamotrigine, levetiracetam, oxcarbazepine, sodium valproate, or topiramate
Tonic Seizures
Clinical features:
• In a tonic seizure, a person’s muscle tone is greatly increased causing the body, arms, or legs to become suddenly stiff or tense. There are 2 types of tonic seizures, focal and generalised, depending on the location of the seizures start point in the brain
• When it starts in one area of the brain:
o Stiffening of a part of the body may begin in one area and stay local. These are called
focal tonic seizures
• When it starts on both sides of the brain:
o The whole body or both sides of the body may become stiff or tense from the beginning. These are called generalized tonic seizures
Symptoms of tonic seizures
- A person may be aware or have only a small change in awareness during a seizure.
- If the respiratory muscles are included a stridor or loud cry may be heard.
- Usually occur during sleep.
- Short, usually less than 20 seconds.
- A person may fall if they are standing when a tonic seizure starts
Tonic Seizures 1st line treatment:
Sodium Valproate (except for woman of childbearing age)
• Initially 600 mg daily in 1–2 divided doses, then increased in steps of 150–300 mg every 3 days; maintenance 1–2 g daily, alternatively maintenance 20–30 mg/kg daily; maximum 2.5 g per day
Tonic Seizures 2nd line treatment:
Lamotrigine as adjunctive (if sodium valproate not suitable)
• Initially 25 mg once daily for 14 days, then increased to 50 mg once daily for further 14 days, then increased in steps of up to 100 mg every 7–14 days; maintenance 100–200 mg daily in 1–2 divided doses; increased if necessary up to 500 mg daily, dose titration should be repeated if restarting after interval of more than 5 days
Do not use… in tonic seizures
carbamazepine, gabapentin, oxcarbazepine, pregabalin, tiagabine or vigabatrin
Tonic-Clonic Seizures (Grand Mal) Clinical features:
• Tonic-clonic seizures are the type of epileptic seizure most people recognise.
• Previously called grand-mal seizures
• Typically, generalised onset
o Affects both sides of the brain from the start
o Focal tonic-clonic seizure
• Can start in one side of brain and spread to affect both
o Called focal to bilateral tonic-clonic seizure
o Can have symptoms of a focal seizure immediately before you lose consciousness
o Symptom examples:
§ Feeling frightened
§ Having a rising sensation in your stomach
§ Smelling something that’s not there
• Typically, last between 1 and 3 minutes
o If longer than 5 minutes can turn into status epilepticus
There are 2 phases in a tonic-clonic seizure: the ‘tonic’ phase, followed by the ‘clonic’ phase.
Symptoms during the tonic phase:
- Loss of consciousness
- Stiff muscles, people standing may fall to the floor
- Air pushing past voice box, sounds like crying out
- Biting down on tongue or inside mouth
There are 2 phases in a tonic-clonic seizure: the ‘tonic’ phase, followed by the ‘clonic’ phase.
Symptoms during the clonic phase:
- Quick and rhythmic jerking limbs
- Loss of bladder and/or bowel control
- Breathing affected, mouth may turn blue
Tonic-Clonic Seizures (Grand Mal) 1st line treatment
Sodium Valproate (except for woman of childbearing age) • Initially 600 mg daily in 1-2 divided doses, then increase in steps of 150-300 mg every 3 days; maintenance 1-2 g daily, alternatively maintenance 20-30 mg/kg daily; maximum 2.5 g per day
Tonic-Clonic Seizures (Grand Mal) 2nd line treatment:
Lamotrigine
• Initially 25 mg once daily for 14 days, then increased to 50 mg once daily for further 14 days, then increased in steps of up to 100 mg every 7-14 days; maintenance 100-200 mg daily in 1-2 divided doses; increased if necessary up to 500 mg daily, dose titration should be repeated if restarting after interval of more than 5 days
Emergency action for tonic-clonic seizures
Less than 5 minutes:
• Protect them by:
o Cushioning their head with something soft or your hands.
o Remove potentially harmful items around them or move them away.
• Avoid restraining them or putting anything in their mouth.
• Once the seizure stops, check airway, put into recovery position and monitor until they have
recovered.
• Ensure they get admitted into the hospital if it is their first seizure.
More than 5 minutes:
• In addition to above,
o First line - buccal midazolam (dose for patients 10 years and over is 10 mg).
o Second line - rectal diazepam (or if preferred can be 1st line) if midazolam unavailable (dose for adults is 0.5 mg/kg).
Absence - Typical and Atypical
Absence seizures can be broken down into two different types; typical or atypical. Both are often short
(less than 15 seconds) and symptoms come and go very quickly. However, both seizures present slightly different. Absence typical epilepsy is characterised by abrupt, short (5-10 seconds ) cessations of physical movement and generally occur in childhood in children between 4-14 years old (Epilepsy
Foundation, 2019). They occur due to brief abnormal electrical activity in the brain. As it is a generalised onset seizure, it begins in both side of the brain at the same time. They usually affect only a person’s awareness of what is going on at the time with immediate recovery following the seizure, although in some people’s recovery time may vary.
The frequency of absence typical seizures can vary. A child may have multiple number of absence seizures (up to 100) in a given day. Due to its nature, it may be overlooked and often mistaken for daydreaming or not paying attention.
Typical absence seizures exhibit a classic ictal EEG pattern of bilateral symmetric 3Hz spike and wave, which allows it to be identified
quite easily.
Atypical absence seizures may be longer, have a slower onset and offset, and involve different symptoms. They typical last less than 20 seconds but can be longer.
Symptoms – Absence Typical
- Person will stop all activity and may seem like they are staring off into space or just have a blank look
- Eyes may turn upwards and eyelids flutter
- Usually last 10 seconds
- If they are walking they may continue to walk, but not know what they are doing
Symptoms – Absence Atypical
- Seizure will normally start off with gazing into space, typically with blank look.
- Change in muscle tone and movement.
- Continuous blinking that resembles the fluttering of the eyelids.
- Lip smacking or chewing movements.
- Pill-rolling, piano finger like hand motions. Some may rub their fingers together.
- Arms and legs may go limp which could cause people to fall.
Pharmacological Management of Typical and Atypical Absence Seizures 1st line treatment:
Ethosuximide or Sodium Valproate. If risk of generalised tonic clonic seizure is high,
sodium valproate should be offered first, unless it is unsuitable
• Ethosuximide: For Adult:
o Initially 500 mg daily in 2 divided doses, then increased in steps of 250 mg every 5–7 days; usual dose 1–1.5 g daily in 2 divided doses, increased if necessary up to 2 g daily.
• Sodium Valproate (except for woman of childbearing age)
§ Initially 600 mg daily in 1-2 divided doses, then increased in steps of 150-300 mg
every 3 days; maintained 1-2 g daily, alternatively maintenance 20-30 mg/kg daily;
maximum 2.5 g per day.
Pharmacological Management of Typical and Atypical Absence Seizures 2nd line treatment:
Lamotrigine
Pharmacological Management of Typical and Atypical Absence Seizures 3rd line treatment:
if the above 1st and 2nd line are ineffective, (two first line anti-epileptic drugs (AEDs)):
combination of two or three AEDs as “add on”/adjunctive therapy. This can include ethosuximide, lamotrigine or sodium valproate. If adjunctive therapy fails to work or is not tolerated by the patient, they should be referred to a tertiary epilepsy specialist.
Which medications should not be offered for management of Typical and Atypical Absence Seizures
Carbamazepine, Gabapentin, Oxcarbazepine, phenytoin, pregabalin, tiagabine or vigabatrin should not be offered.
Myoclonic Seizures Clinical features and symptoms
• Brief, sudden and involuntary shock like muscle contracts involving the whole body, and just a few muscles or more than two contiguous regions
Symptoms
• Quick, uncontrolled muscle jerks.
• Jerky or rhythmic movements.
• Unusual clumsiness.
In epilepsy, myoclonic seizures result in abnormal movements of the body; bilaterally. These occur in a variety of syndromes which are characterised by different symptoms.
• Juvenile myoclonic epilepsy: These seizures are usually characterized by the involvement of
the neck, shoulders and upper arms. In many patients, these seizures take place shortly after waking up. They often begin around puberty or in early adulthood. There is no association between this form of epilepsy and intelligence. They can be well controlled through medication in most cases however, the medication must be continued throughout the duration of their lives.
• Lennox-Gastaut syndrome: This is a rare syndrome that usually includes other types of seizures and often begins in early childhood. The myoclonic seizures usually involve the neck, shoulders, upper arms, and often the face. They may be quite strong and are difficult to control.
• Progressive myoclonic epilepsy: This is a rare amalgamation of myoclonic seizures and tonicclonic seizures and treatment is usually unsuccessful as the patient deteriorates over time.
Myoclonic Seizures 1st line treatment:
Sodium Valproate (except for woman of childbearing age) • Adult: Initially 600 mg daily in 1–2 divided doses, then increased in steps of 150–300 mg every 3 days; maintenance 1–2 g daily, alternatively maintenance 20–30 mg/kg daily; maximum 2.5 g per day
