Transcript Frequently asked questions - Northeast Regional Epilepsy Group

Frequently asked questions
in Epilepsy
Enrique Feoli MD
North East Regional Epilepsy
Group
October 2016
New patient visit for seizures
 26 year old woman with a history of two febrile seizures
 In the past several 6 months, two episodes concerning for generalized tonic-clonic
seizures.
 Aura of odd hot, flushing sensation rising from the pit of her stomach
 For the past few years, recalls episodes of similar auras followed by brief episodes of
loss of awareness where she loses a period of time without having convulsions
 No other medical history
 Social alcohol
 No tobacco or drugs
 Married, no children but planning in the next few years
 Works as an elementary school teacher
 Medications: birth control and multivitamins
 Exam: normal
Follow up visit
 Inpatient continuous video-EEG: captured typical
auras, episodes of losing time, and one generalized
tonic-clonic seizure consistent with focal epilepsy of
right anterior temporal region
 MRI of the brain: right mesial temporal sclerosis
 Treatment: Lamictal, tolerating well thus far without
further seizures
She has several questions
 Do I have epilepsy?
 If so, why do I have epilepsy at my age?
 Can I continue my normal daily activities, my job?
 Are there activities or other medications I need to avoid?
 Do I need to take special precautions as a woman?
 Can I have healthy children?
 Do I need to take medications forever?
 Where can I find out more information?
What is epilepsy?
 Two or more unprovoked seizures that occurred
>24 hours apart
 One unprovoked seizure and a probability of
further seizures similar to the recurrence risk of
having had 2 unprovoked seizures
 Diagnosis of epilepsy syndrome
Fisher et al, 2013 ILAE
Why do I have epilepsy?
 As of 2013, about 2.9 million people had epilepsy in the
US
Hauser, et al. 1993, Epilepsia
CDC
Common causes of epilepsy
 Genetic
 Channelopathies
 Malformations of cortical development
 Metabolic or mitochondrial
 Cerebrovascular
 Trauma
 Infection
 Autoimmune
 Neoplasms
Continuum, June 2013
How does this affect my life?
WORK
American Disabilities Act (ADA)
 Prohibits employment discrimination against
qualified individuals with disabilities
 The “qualified individual” should be able to
perform the job functions with or without
reasonable accommodations
 Accommodations
need to be individualized due
to variability in seizures and in job functions
Epilepsy Foundation: www.epilepsy.com
Job considerations
 Does the job involve flying, driving, or climbing up
buildings/telephone poles, performing surgery,
firearms?
 Does the job require frequent change in the daily
schedule and shift work?
 Is there someone who works with you who can help if
you have a seizure?
Law enforcement officers
 No federal laws exist to restrict people with epilepsy
from working as a LEO
 However, certain medical requirements may need to
be met in certain organizations
 May not be ideal if
 Person with epilepsy poses a “direct threat” to the safety of
himself or others even with reasonable accommodations
 If providing accommodations would pose an undue burden on
the employer
Epilepsy Foundation: www.epilepsy.com
Military
 Does not have to abide by ADA rules
 May need deployment to areas with limited medical
care or limited medication availability
 Will evaluate individual cases, especially if seizure
free for >5 years OFF medications
 Medical Review Board will evaluate if epilepsy
develops after enlistment
Epilepsy Foundation: www.epilepsy.com
Federal Aviation Administration (FAA)
 Anyone with a diagnosis of epilepsy or “disturbance
of consciousness without a satisfactory medical
explanation of cause” are prohibited from obtaining a
pilot’s license
 Office of Federal Air Surgeon can make exceptions in
certain situations if appealed

ie, if seizure free off medications for >10 years
Epilepsy Foundation: www.epilepsy.com
Commercial driving license (CDL)
 Federal Motor Carrier Safety Administration (FMCSA)

Prohibited if taking anti-seizure medications

May be allowed if seizure free for >10 years off medications
if history of epilepsy

May be allowed if seizure free for >5 years off medications
if history of a single unprovoked seizure

http://www.fmcsa.dot.gov/regulations/title49/section/391
.43
How does this affect my life?
DRIVING
DMV reporting states
 CA, DE, NJ, NV, OR, PA
Driving in NJ
 Mandatory physician reporting state, within 24 hrs



Recurrent convulsive seizures
Recurrent period of unconsciousness or impairment,
Loss of motor coordination due to conditions such as, but not limited to
epilepsy in any of its forms which persist or recur despite medical treatment
 Seizure free period: 6 months
Epilepsy Foundation: www.epilepsy.com
Driving in NY
 Not a physician reporting state
 Seizure free period: 12 months
 Exceptions:
 1) it was due solely to a physician-directed change in
medication and the physician submits a statement to that effect
 2) the person submits a physician's statement confirming his
knowledge of all such incidents and recommending licensing
despite the medical history, because in his opinion the
condition will not interfere with the safe operation of a vehicle
and the Department’s medical consultant has no objection to
such issuance
Epilepsy Foundation: www.epilepsy.com
Seizure free interval requirement
 Studies have not demonstrated consistent data in regards
to risk of accidents related to seizures
 Many states have no defined seizure free interval
requirement
 Most states that do have a requirement set it to 3-12
months of seizure freedom, median ~6 months

In a study comparing 50 drivers with epilepsy who had seizurerelated crashes and 50 drivers with epilepsy who did not, compared
to a shorter seizure free period…


If seizure free for >12 months: risk of MVA reduced by 93%
If seizure free for >6 months: risk of MVA reduced by 85%
Krauss et al. 1999 Neurology
How does this affect my life?
DAILY ACTIVITIES
Impact of alcohol on seizures
 Risk of seizures increases in the setting of alcohol
withdrawal
 Binge drinking can also increase the risk of seizures
 Anti-seizure medications may decrease the tolerance of
alcohol
 Alcohol may induce clearance of anti-seizure medications,
making them less effective
 Chronic alcoholism and alcohol related seizures may
increase the risk of future unprovoked seizures and epilepsy
Leach, et al. 2012 Epilepsia
Common triggers of seizures
 Missing medications
 Sleep deprivation
 Stress
 Excessive alcohol intake or alcohol withdrawal
 Illicit drugs
 Medications

antihistamines, antibiotics, certain pain medications, stimulant
medications

many others, should discuss with your doctors first
Safety precautions
 Avoid climbing up on ladders
 Use the back burners when cooking
 Use showers instead of baths
 Lower the maximum temperature of the water to 110
degrees F in case a seizure occurs while bathing
 Do not use power tools if seizures are not well
controlled
Safety in sports/recreational activities
 Swim and exercise with supervision
 Always wear appropriate protective
equipment when exercising
 Downhill skiing is contraindicated with
uncontrolled seizures
 Scuba diving:

If seizure free for >4 years on stable AED therapy
Almeida, et al. Epilepsia 2007
Women with epilepsy
CATAMENIAL EPILEPSY
PREGNANCY
Catamenial epilepsy
 Seizures increase during certain phases of the




menstrual cycle
Consistent two-fold increase in seizure frequency
during these phases
More common with focal epilepsies
Increase can occur when the levels of estrogen are
relatively higher than progesterone or when the levels
are rapidly changing
May treat with additional medications during the
specific phase or with progestin-only contraceptive
agent
Continuum, June 2013
Prenatal considerations
 Many anti-seizure medications can
interact with hormonal contraceptives


Hepatic inducers will decrease the efficacy of
hormonal birth control
For the strong inducers, the risk of birth
control failure outweighs the potential benefit
of its use with the birth control
 May consider alternative forms of
contraception


Progestin implant
IUDs
Continuum, June 2013
Folic acid
Continuum, June 2013
Pregnancy considerations
 Minor anomalies 6-20%
of babies

2.5 times the general
populate rate
 Major malformations
3.1-9% of babies exposed
to AEDs

General population and
women with epilepsy not
on AEDs: 1.6-3.2%
 Polytherapy increases
risk of malformations
Continuum, June 2013
Malformations associated with medications
 Valproic acid: facial clefts, neural tube defects,




hypospadias
Phenytoin: cleft palate
Carbamazepine: posterior cleft palate
Phenobarbital: cardiac malformations
Topiramate: oral clefts, hypospadias
 * seizures during pregnancy can lead to fetal hypoxia,
miscarriages, stillbirths
Continuum, June 2013
Prognosis
How long will I have epilepsy?
 Epilepsy is considered “resolved” if it was an age-
dependent syndrome, and the patient has now
passed the applicable age
 Epilepsy is considered “resolved” if the patient has
remained seizure free for 10 years with no antiseizure medications for the last 5 years
Fisher et al, 2013 ILAE
When to withdraw medications
 In children <16 years of age
 Discontinuing anti-seizure medications before 2 years of
seizure freedom -> increased the risk of seizure recurrence
by 34%
 Risk increases with focal seizures, abnormal EEG, history
of status epilepticus, low IQ, prior high frequency of
seizures
 No well conducted studies in adults to guide
medication withdrawal
Strozzi, et al. 2015 Cochrane Database
SUDEP
 Sudden Unexpected death in epilepsy
SUDEP
 By definition,
 (1) death is sudden and unexpected,
 (2) a clear cause of death must be absent, and
 (3) victims must have had epilepsy.
What Causes it
 Although the cause of death is unknown,
 irregularity in the heart rhythm.
 impaired breathing (apnea),
 increased fluid in the lungs (impairing the exchange
of oxygen and carbon dioxide), and being face down
on the bed.
 In many cases, death probably occurs after a seizure
has ended.
Frequency
 1:3000/year
 1;300/year in patients with severe epilepsy.
 More frequent in men, age 20-40
Risk Factors
 frequent convulsive seizures
 early age of onset of epilepsy
 long duration of epilepsy
 higher number of antiepileptic medications, and at
high doses
 frequent medication changes
Tips for prevention
 Patients should make sure to take the medications
prescribed for them.
 Patients should visit with their doctor regularly,
especially if convulsive seizures are not completely
controlled.
Prevention
 Adult patients with a high likelihood of tonic-clonic
seizures in sleep should be supervised whenever
possible. (SUDEP is extremely rare in children with
epilepsy and in other patients who are well
monitored. In fact, supervision has emerged as a
protective factor for SUDEP, independent of seizure
control.)
Prevention
 Basic first aid should be provided during a seizure,
including rolling the person onto one side, checking
respiration and avoiding putting any object in the
patient’s mouth.
 Family members and/or caregivers of patients with
uncontrolled convulsive seizures should learn
cardiopulmonary resuscitation.
Video Games
 Are video Games safe?
 Can Video Games cause epilepsy
Video Games
 1981 The Lancet “space invader epilepsy”
 1981 Jeavons (UK) Seizure by a hand held video game.
 1983 Dahlquist (USA) first US video game sz report
 1991 Nintendo starts putting warning on games.
 1992 UK a child died following a seizure induced by video
game.
 1994 Ferrie, 35 cases, coined the term video game epilepsy
 1997 Pokemon Incident.
Pokemon Incident
An unplanned Experiment in Nature
 Pokemon incident in Japan
 Most Dramatic
 December 16, 1997.
 A rocket launch sequence of flashing red and blue lights
changing at 12.5 sec for 4 sec. was shown on Tokyo TV.
 685 children went to the hospital
 560 of this children had seizures
 Rest had migraines, nausea, motion sickness.
Pokemon Incident
75 % of the children did not have epilepsy
Given that 7 million children were watching the
program, this suggests that 1 in 10,000 had a seizure
in response to photic stimulation.
Terms
 Photic Induced Seizures: a seizure provoked by visual
stimulation.
 Photoparoxysmal response, an abnormal EEG response to
light or pattern, consisting of spikes, spike waves or slow
waves, should not be confined to the occipital region, should
not be confused with photic driving.
 Photosensitivity: abnormal response of the EEG to light or
pattern consisting of a PPR.
 Photomyoclonic response: forehead and muscle twitching in
response to the light flash, disappearing with eye opening
Video Games
Misnomers
Video Game Epilepsy
Photic Induced Epilepsy
Video Games
Can Individuals with epilepsy, but with no known
photoparoxysmal sensitivity safely play a video game?
 Millet and colleagues 1999
 212 patients, with Epilepsy no EEG photic or pattern
sensitivity
 Randomly assigned to a video game or leisure activity.
 Then crossover
 End point clinical seizure
Video Games
25 seizures 13 during video game, 12 during other
activities.
ANSWER IS
Patients with Epilepsy with no know
photoparoxysmal sensitivity MAY SAFELY play video
games.
TV RECOMMENDATIONS
 View TV from > 8 feet
 View in a well-lit room, with a small lamp on top of
the TV set.
 Do Not approach the TV to switch channels.
 Cover one eye if it is necessary to go near the TV
 Wear polarized glasses on sunny days to reduce
flickering reflection from water.
 Play for one hour then take a break.
Patient resources
 Epilepsy Foundation: www.epilepsy.com
 American Epilepsy Foundation:
www.aesnet.org/for_patients
 Centers for Disease Control:
www.cdc.gov/epilepsy/index.html
 Online seizure log: www.seizuretracker.com
 Epilepsy group:
http://www.epilepsygroup.com/living-with-epilepsy