What treatments are available for people with epilepsy?

Epilepsy is any condition that causes seizures. Seizures are an electrical storm of the brain. When the storm is in one small area, it activates that area and causes that part of the brain to send signals. For example, when the storm involves the part of the brain that controls muscles, it causes the muscles to contract.

The electrical storm most often causes rhythmic electrical discharges of the brain cells. There is muscle contraction with each lightning strike, which causes the jerking seen in generalized tonic-clonic seizures, or what were previously called “grand mal” seizures. Focal seizures start in one area of the brain as a “focus” that then spreads throughout the brain, while the entire brain is involved from the onset in generalized seizures.

The traditional approach to treatment is with medications that suppress seizures. Seizure medications are taken daily with the goal of “no seizures, no side effects,” according to the Epilepsy Foundation. About half of patients with epilepsy are able to suppress seizures with the first medication they use, but about a third of patients continue to have seizures despite trying several different medications and despite the FDA approval of 14 medications in the past 20 years. The clinical trials program at the University of Virginia Comprehensive Epilepsy Program has participated in the development of all of these drugs and is enrolling patients in clinical trials of three new drugs.

Focal seizures can be treated with surgery to remove or destroy the focus if the area of the brain does not control an important function. Surgery on the temporal lobe is the most commonly performed procedure and renders about 65% of people essentially seizure free, with only a 1% risk of a serious complication. Minimally invasive laser ablation can be performed by placing a laser-tipped thin wire into the seizure focus. The laser heats the affected area and destroys it without the need for traditional open surgery. The UVa Comprehensive Epilepsy Program is also performing a research study of focused ultrasound as a potential option for some forms of epilepsy that begin deep in the brain. Focused ultrasound is a noninvasive way to heat and destroy the seizure focus.

Vagus nerve stimulation (VNS), deep brain stimulation (DBS) and responsive neurostimulation (RNS) are devices implanted to help control seizures when destruction of the seizure focus is not possible — for example, when seizures begin in an important brain area. They reduce the frequency of seizures on average by about 40%. For VNS, a generator is implanted in the chest wall and a wire is led to the vagus nerve in the neck. The device delivers a continuously cycling electrical stimulation to the nerve, which is transmitted back the brain. For DBS, a wire is implanted in the thalamus in the middle of the brain, which is the relay station for signals throughout the brain. DBS provides continuous stimulations similar to VNS. RNS is different in that the wires are implanted into or on top of the seizure focus and are connected to a microprocessor implanted in the skull. The device monitors brain waves and delivers a very small electrical shock to the seizure focus when it detects a seizure.

The quality of life for people with epilepsy has improved with the development of drugs with fewer side effects along with surgery and devices to treat drug-resistant epilepsy, but new treatments are still needed for people who continue to have seizures despite our best efforts.

For more information, visit uvahealth.com/services/epilepsy.

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Dr. Nathan B. Fountain is director of the F.E. Dreifuss Comprehensive Epilepsy Program at the University of Virginia.

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