Dr. Sayeed Ahmad D. I. Hom. (London)
I - INTRODUCTION
Epilepsy, also called seizure disorder, chronic brain disorder that briefly interrupts the normal electrical activity of the brain to cause seizures, characterized by a variety of symptoms including uncontrolled movements of the body, disorientation or confusion, sudden fear, or loss of consciousness. Epilepsy may result from a head injury, stroke, brain tumor, lead poisoning, genetic conditions, or severe infections like meningitis or encephalitis. In over 70 percent of cases no cause for epilepsy is identified. Some 40 to 50 million people suffer from epilepsy worldwide and the majority of cases are in developing countries. According to the World Health Organization (WHO), an estimated 2 million new cases are diagnosed each year globally.
II - TYPES OF SEIZURES
Epileptic seizures vary in intensity and symptoms depending on what part of the brain is involved. In partial seizures, the most common form of seizure in adults, only one area of the brain is involved. Partial seizures are classified as simple partial, complex partial (also known as psychomotor), and absence (also known as myoclonic or petit mal) seizures.
People who have simple partial seizures may experience unusual sensations such as uncontrollable jerky motions of a body part, sight or hearing impairment, sudden sweating or flushing, nausea, and feelings of fear.
Complex partial seizures, also called temporal lobe epilepsy, last for only one or two minutes. The individual may appear to be in a trance and moves randomly with no control over body movements. The individual's activity does not cease during the seizure, but behavior is random and totally unrelated to the individual's surroundings. This form of seizure may be preceded by an aura (a warning sensation characterized by feelings of fear, abdominal discomfort, dizziness, or strange odors and sensations).
Absence seizures, rare in adults, are characterized by a sudden, momentary loss or impairment of consciousness. Overt symptoms are often as slight as an upward staring of the eyes, a staggering gait, or a twitching of the facial muscles. No aura occurs and the person often resumes activity without realizing that the seizure has occurred.
In a second type of epilepsy, known as generalized seizure, tonic clonic, grand mal, or convulsion, the whole brain is involved. This type of seizure is often signaled by an involuntary scream, caused by contraction of the muscles that control breathing. As loss of consciousness sets in, the entire body is gripped by a jerking muscular contraction. The face reddens, breathing stops, and the back arches. Subsequently, alternate contractions and relaxations of the muscles throw the body into sometimes violent agitation such that the person may be subject to serious injury. After the convulsion subsides, the person is exhausted and may sleep heavily. Confusion, nausea, and sore muscles are often experienced upon awakening, and the individual may have no memory of the seizure. Attacks occur at varying intervals, in some people as seldom as once a year and in others as frequently as several times a day. About 8 percent of those subject to generalized seizures may have status epilepticus, in which seizures occur successively with no intervening periods of consciousness. These attacks may be fatal unless treated promptly with the drug diazepam.
III - DIAGNOSIS
In persons suffering from epilepsy, the brain waves, electrical activity in the part of the brain called the cerebral cortex, have a characteristically abnormal rhythm produced by excessive electrical discharges in the nerve cells. Because these wave patterns differ markedly according to their specific source, a recording of the brain waves, known as an electroencephalogram (EEG) is important in the diagnosis and study of the disorder. Diagnosis also requires a thorough medical history describing seizure characteristics and frequency.
IV - TREATMENT
There is no cure for epilepsy but symptoms of the disorder may be treated with drugs, surgery, or a special diet. Drug therapy is the most common treatment-seizures can be prevented or their frequency lessened in 80 to 85 percent of cases by drugs known as anticonvulsants or antiepileptics. Surgery is used when drug treatments fail and the brain tissue causing the seizures is confined to one area and can safely be removed. A special high-fat diet known as a ketogenic diet produces a chemical condition in the body called ketosis that helps prevent seizures in young children. Like any medical condition, epilepsy is affected by general health. Regular exercise, plenty of rest, and efforts to reduce stress can all have a positive effect on a person with a seizure disorder.
First aid for generalized seizures involves protecting the individual by clearing the area of sharp or hard objects, providing soft cushioning for the head, such as a pillow or folded jacket and, if necessary, turning the individual on the side to keep his or her airway clear. The individual having a seizure should not be restrained and the mouth should not be forced open-it is not true that a person having a seizure can swallow the tongue. If the individual having the seizure is known to have epilepsy or is wearing epilepsy identification jewelry, an ambulance should only be called if the seizure lasts longer than five minutes, another seizure closely follows the first, or the person cannot be awakened after the jerking movements subside.
ANTI-EPILEPTIC ALLOPATHIC DRUGS
This is a powerful anti-epileptic drug with a wide range of activity. It is available as white tablets of two strengths (100 mg and 200 mg), and is usually given twice a day (say after breakfast, and then after the evening meal, around 12 hours later). An average sized adult usually requires between one and two tablets (200 mg size, twice a day).
If the dose is too high, the patient may appear to be "drunk", with drowsiness, lack of co-ordination in walking, etc. Reduction of the dose, based on blood levels, is all that is required.
Side effects (unwanted symptoms occurring in someone whose levels are correct) are common in the first few days or week or two, especially giddiness and light headedness, mild nausea, and dryness of the mouth. These usually disappear within a few days. They are less likely to occur if Tegretol is introduced in a gradual way. A measles-like rash sometimes occurs during Tegretol treatment, and in this event, Tegretol must be replaced by another anti-epileptic drug. Serious side effects are fortunately rare. They include jaundice due to liver involvement, and lowering of the white cell count of the blood, resulting in persistent ulceration of the throat and mouth.
The manufacturers recommend that blood tests (full blood count, tests of liver and kidney function) be carried out before starting Tegretol, and that the full blood count be repeated weekly for the first month of treatment, then monthly for the first year.
In practice, Tegretol side effects are usually mild, and disappear within the first week or two. It is arguably the most powerful and useful anti-epileptic drug currently available.
EPILIM Sodium valproate
This is another extremely useful drug with a wide range of anti-epileptic activity. It is thought to act by increasing the brain's levels of the inhibitory neurotransmitter, GABA.
Epilim is presented as lilac colored tablets of 200 mg and 500 mg strength. These should be swallowed whole. It is also available as crushable tablets of 100 mg strength, and as syrup of 200 mg/5ml strength, and sugar free liquid of similar strength.
It is usual to give Epilim twice a day, with meals, with roughly 12 hours between doses. Since blood levels of Epilim are unreliable as a guide, adjustment of the dosage is made according to the patient's body weight, and the adequacy of seizure control. The usual dose range is 20 to 30 mg/kg body weight/24 hours.
Mild side effects, especially nausea and diarrhea in the first few days, are common. A fine tremor of the hands is often noticed in patients taking Epilim over the long term. Weight gain and loss of hair (usually reversible) can also occur.
Very rarely, Epilim may produce acute liver disease, and there have been instances of acute liver failure, some fatal. Small children and infants with serious underlying medical conditions are most at risk. The question of the safety of Epilim has received careful study by Australian health authorities, and its continued use has been endorsed, for it is in practice a widely used, effective, and well tolerated medication.
It is suggested that Epilim be avoided in patients with a history of liver disease, and that blood tests to check liver function and the level of platelets in the blood (sometimes reduced by Epilim) be carried out before starting treatment, and repeated after one month's treatment, and thereafter at intervals of not more than 6 months. Minor abnormalities of liver function are common in patients taking most anti-epileptic drugs, but evidence of increasing abnormality would require substitution of Epilim.
Symptoms of this rare complication of liver failure include severe nausea persistent abnormal pain, jaundice (yellowish discoloration of the skin), severe nausea, weakness and tiredness, and swelling of the face. Any of these symptoms should be reported to the treating doctor.
DILANTIN Phenytoin sodium
This is the oldest of the effective major anti-epileptic drugs. It is still one of the most potent in preventing major seizures of tonic-clonic and other types, but its troublesome side effects have meant that the other, newer drugs such as Tegretol and Epilim are usually selected instead. Dilantin has a powerful action in controlling seizures, and is very useful as an additional drug where seizures cannot be controlled by one drug alone, or when it is not intended to continue treatment over a very long period (for example, when anti-epileptic drugs are given routinely for a year or two after brain surgery).
Dilantin is presented in capsule form (100mg, orange and white capsules, 30mg, all white capsules), in liquid form (30 mg/5ml strength for children, 100 mg/5ml. "Dilantin Forte Suspension" for adults), and as chewable tablets for children (50 mg, "Infatabs")
The drug is slowly released, so that theoretically it would be possible to take the medication as a dingle daily dose; however, people's memories being what they are, it is recommended that the medication be taken twice a day (e. g. after breakfast, and after the evening meal as a routine). The usual dose for an adult of average size is 3 to 4 capsules of 100 mg strength per 24 hours.
Dilantin overdose produces symptoms similar to drunkenness, with drowsiness, unsteadiness on the feet, etc. Blood levels of Dilantin will indicate the true picture.
Short term side effects of Dilantin are not usually a problem, but side effects developing gradually over a period of years do present serious objections to its long term use, especially as other effective anti-epileptic drugs which do not have these problems are now available. These long-term side effects of Dilantin are the growth of hair on the face, arms and legs, especially in female patients of dark complexion, unhealthy overgrowth of the gums, with a tendency for them to bleed, and mental sluggishness and loss of memory.
If Dilantin is to be taken over a long period, special attention should be paid to brushing the teeth and generally maintaining good oral hygiene. An uncommon complication of Dilantin therapy is the development of an allergic measles like rash, which requires substitution of the drug with another.
This drug is effective in controlling one form of epilepsy only, namely absence seizures (formerly known as "petit mal"). As this form of epilepsy begins in childhood, Zarontin is made available as a red syrup (250 mg/5 ml) and as capsules (250 mg). The dose required will vary according to blood levels and body weight, the average dose for a child aged 6 years being one capsule, 2 or 3 times a day.
Side effects are not common, but include nausea and digestive upset, drowsiness and sleep disturbance.
These drugs have sedative and anti-anxiety properties as well as being anti-epileptic. They are in fact only fairly week drugs against epilepsy, while their tendency to produce sedation and dependency greatly limit their usefulness. In practice, these drugs should never be used as a first choice, but rather reserved for those situations where epilepsy remains uncontrolled despite treatment with adequate doses of other anti-epileptic drugs.
The benzodiazepine drugs include:
The main side effects of these drugs are sedation and drowsiness in the daytime. There is a risk of producing drug dependency. Also, patients may experience various unpleasant side effects, such as restlessness, sleep disturbances, etc. when these drugs are withdrawn after a long period of administration.
These drugs were widely used in the 1950's and 1960's, but are now considered to be obsolete. They are not very effective in suppressing seizures, but they frequently cause slowing of the intellect and depression. Withdrawing these medications can be extremely traumatic, with anxiety, restlessness, tremors, insomnia, and an increased risk of convulsions being prominent as the drug leaves the system.
An effort should be made to change every patient still taking these drugs over to one of the newer anti-epileptic medications, difficult as this might be.
Barbiturate anti-epileptic drugs still available include:
OSPOLOT (Sulthiame, Bayer Pharmaceuticals)
This drug may have a special value in controlling epilepsy in intellectually disabled, aggressive children. It is not a very effective anti-epileptic, and is not widely used.
The Newest Anti-epileptic Drugs
These drugs are the outcome of research aimed at suppressing seizures by either increasing inhibition (through enhancing the activity of the natural inhibitory neurotransmitter GABA, or simulating its action); or, alternatively, reducing the effectiveness of natural excitatory neurotransmitters, such as glutamate.
The treatment of epilepsy should be directed to the underlying dyscrasia, as this is at fault in most, if not all, cases. Calcarea carbonica, with its rickety, tuberculous, scrofulous and flabby symptoms, its characteristic deficiency of lime assimilation, as shown in children by the open fontanelles and backward dentition, will frequently be the remedy with which to commence the treatment. The characteristic relaxation on falling asleep and the sweating of the head and neck are fine indications for its use. It has an excellent clinical record. A epileptic suffering continually from the dread of an attack will withdraw himself as much as possible from the outside world, brood over his affliction and become melancholic, and there is no other remedy so well adapted to this condition as Calcarea. Its anxiety, palpitation, apprehensive mood despondency, fretfulness and irritability, its weakness of memory, its loss of consciousness, its vertigo and convulsions are prominent and characteristic indications for its use in epilepsy. If epilepsy be caused by fright, suppression of some long standing eruption, onanism or venereal excess it will probably be one of the remedies to use in the course of the treatment, and here it would follow Sulphur well. The aura may begin in the solar plexus and pass upwards like a wave, or go from the epigastric region down to the uterus and limbs. Like Sulphur it has a sensation as if a mouse were running up the arm previous to the attacks.
Causticum, too, is closely allied to Calcarea, and is indicated in epilepsy connected with menstrual irregularities and also in epilepsy occurring at the age of puberty.
Epilepsy arising from fright, or self-abuse, or sexual excesses, will often find its remedy in Bufo rana. The aura preceding the attacks starts from the genital organs; even during coitus the patient may be seized with violent convulsions. In another form for which Bufo is suitable the aura starts from the solar plexus. Previous to the attacks, the patient is very irritable, often talks incoherently and is easily angered. It is especially in the sexual form, that brought on by masturbation, that Bufo is signally useful. It has also proved useful in severe cases in children where the head in the convulsion is drawn backwards. Indigo has epileptiform convulsions from the irritation of worms, but the patient must be low-spirited and sad-- "blue as indigo." It is the "bluest remedy in the materia medica." Dr. Colby, of Boston, considers it superior to the bromides. Flushes of heat seem to rise from the solar plexus to the head and there is an undulating sensation in the brain similar to Cimicifuga. Bufo, like Nux vomica, is vehement and irritable. These two remedies and Silicea and Calcarea have the aura starting from the solar plexus. Stannum is also a remedy for epilepsy arising from reflex irritation, as from worms and also from sexual complications.
Cuprum is a very deep-acting remedy, its well-known power of producing convulsions and spasms and its excellent clinical record make it a valuable remedy in epilepsy. We know positively that poisonous doses of Cuprum cause epileptic symptoms, and it is among the most curative remedies for epilepsy in child life. The convulsions start form the brain, though the aura, which is one of long duration, seems to center in the epigastrium. Owing to this long duration of the aura consciousness is not immediately lost, and the patient will often notice the contractions in the fingers and toes before they become unconscious. The face and lips are very blue, the eyeballs are rotated, there is frothing at the mouth and violent contractions of the flexors. The attacks is usually ushered in by a shrill cry and the cases are most violent and continued. It is also a remedy for nocturnal epilepsy when the fits occur at regular intervals, such as the menstrual periods. Epileptiform spasms during dentition or from retrocessed exanthema may indicate Cuprum. Dr. Halbert remarks that Cuprum will stop the frequency of the attacks more satisfactorily than any other remedy, it is his sheet anchor in old and obstinate cases.
Butler also claims his best results from this remedy. Argentum nitricum is also a remedy for epilepsy, the strong indicating features being the dilated pupils four or five days before the attack, and the restlessness and trembling of the hands after the attack. Menstrual and fright epilepsies often call for this remedy the characteristic being the aura, which lasts a number of hours before the attack. Moral causes may lead to an attack. Patient is low spirited, easily discouraged and frightened.
Perhaps no remedy in the materia medica more closely pictures epilepsy than �nanthe. Its use in the disease has been mainly from clinical data, but there is ample proof from studying toxic cases that it is hom�opathic to many cases of epilepsy. The reliable and practical symptoms calling for its use may be summed up as follows: Sudden and complete loss of consciousness; swollen livid face; frothing at the mouth; dilated or irregular pupils; convulsions with locked jaws and cold exremities. Dr. S. H. Talcott, of the Middletown State Hospital, summed up his experience with the remedy as follows:
1. The fits decrease in number 40 to 50 per cent.
2. The convulsion are less severe than formerly.
3. There is less maniacal excitement before the fits.
4. Less sleeplessness, stupor and apathy after the fits and
the debilitating effects of the attacks are more quickly recovered from.
5. The patients treated with �nanthe are less irritable, less suspicious and less fault finding.
6. The patients are more easily cared for.
The writer can add his testimony to the effect of �nanthe in controlling attacks of epilepsy. It seems to act better in the 3X or 6X potency than in the tincture. Cases of cure of the disease are becoming more numerous. Artemisia vulgaris is another remedy which has been successfully used for epilepsy from fright or some mental emotion, where the attacks occur in rapid succession, and also in petit mal, where the patient is unconscious only for a few seconds and then resumes his occupation as if nothing had happened. Artemisia absinthium indicated in seizures preceded by vertigo, a warm sensation rising from the stomach, and by a slight impairment
of speech, and Solanum Carolinense are also remedies which in some cases have wrought cures, the latter according to
Dr. Halbert, of Chicago, also praises it. Melancholia seems to be an indication and also attacks appearing at menstrual periods. Verbena hastata is also recommended, but no special indications are to be found.
This remedy should have no place in the hom�opathic treatment of epilepsy; it is given here because it is the principal drug employed by the allopathic school, and because nearly all cases coming to us for treatment from old school hands are liable to be complicated by a previous treatment with the bromides, notable the Bromide of Potash. It is not a curative remedy, but a palliative one; it strikes at the attack and not the disease. It will often modify the attacks, and used as a prophylactic may avert the seizure, but its prolonged use works inevitable harm. It weakens the mental faculties and hastens imbecility. Camphora is useful to prevent the attacks, shorten the duration and lessen the intensity. It is indicated by all the characteristic of epilepsy and hence is a safer prophylactic than the Bromide of potash. Camphora, Nux vomica and Zincum are mentioned as antidotes for the abuse of the Bromide of Potash. Bromide acne is often present in cases coming to us from old school hands.
Silicea is one of our most valuable remedies in epilepsy. It suits especially scrofulous and rickety subjects. The aura starts from the solar plexus, as in Bufo and Nux vomica. Certain phases of the moon are said to affect the attacks, which are brought on by an overstrain of the mind or emotions. Nocturnal epilepsy, feeling of coldness before an attacks is also characteristic of the drug, and the fit is followed by warm perspiration. Cuprum is also a remedy for nocturnal epilepsy and must be thought of when attacks invariably occur in the night. When Silicea is required there is an exalted susceptibility of the upper spinal cord and the medulla and an exhausted condition of the nerves. The attacks occur about the time of the new moon. It comes in after Calcarea in inveterate chronic cases, and coldness of the left side of the body preceding the attack is very characteristic.
The characterizing feature of epilepsy is loss of consciousness, therefore, Nux vomica is not often a remedy in the idiopathic form. It suits cases arising from an excess of the reflex action caused, for instance, by indigestion. The aura in a case calling for Nux starts in the solar plexus, and among the most characteristic symptoms is a sensation of ants crawling over the face. The middle and higher potencies will be found more useful in the spinal form of epilepsy, and this is the form most suitable to Nux. Plumbum has caused epilepsy, and we may use it for these symptoms: the attack is preceded by a heaviness of the legs and is followed by paralysis; epileptic seizures from sclerosis, or from tumors of the brain, consciousness returning slowly after an attack is another indication and it is more suitable to the chronic forms of the disease. Constipation and abdominal pains further indicate. Secale is recommended for sudden and rapidly recurring convulsions, with rapid sinking of strength and paralysis of the spinal nerves.
The indications for cicuta are sudden rigidity followed by jerks and violent distortions, and these followed by utter prostration. The prostration is characteristic, being equaled only by that of Chininum arsenicosum. There is
a tonic spasm renewed by touch simulating Strychnia; but in Cicuta there is loss of consciousness, thus resembling more the epileptiform. There is great oppression of breathing, lockjaw, face dark red, frothing at the mouth and opisthotonos. The reflex excitability under Cicuta is much less than under Strychnia. Another characteristic of Cicuta is fixed staring eyes; others are trembling before and after the spasm and strange feeling in the head preceding the attack. Bayes, however, regards muscular convulsions as a specially prominent symptom for Cuprum.
Like Calcarea, Sulphur is a constitutional or basic remedy, and it will act well where there is a scrofulous taint. It is useful for the same class of cases as is Calcarea; namely, those brought on by sexual excesses or the suppression of some eruption. The convulsions are attended with great exhaustion and it is suitable to the chronic form of epilepsy in children who are typical Sulphur patients. There is perhaps a tendency to fall to the left side. Sulphur is also a useful intercurrent remedy in the course of the treatment of an epilepsy. Psorinum may also be needed as an intercurrent.
In epileptic convulsions Hyoscyamus is a most valuable remedy. There is much twitching and jerking and hunger previous to the attack, there is frothing at the mouth and biting of the tongue. A violent fright will produce an attack that will call for Hyoscyamus. The convulsions seem to have more of a hysterical nature, and there are illusions of sight and hearing. Stramonium has epilepsy from fright, sudden loss of consciousness and jerking of the head to the right, with rotary motion of the left arm. Stramonium is the opposite of Belladonna, for whereas the Belladonna patient shuns light, fears noises and is sensitive in the highest degree, the Stramonium patient fears darkness and hates to be alone; he acts like a coward and trembles and shakes. Agaricus 30 cured a case of epilepsy of 22 years' standing for Dr. Winterburn. He was led to its prescription by the unusual symptom of "great flow of ideas and loquacity after the attack."
Belladonna is especially a remedy for acute epilepsies, when the cerebral symptoms ar prominent, where the face is flushed and the whole trouble seems to picture cerebral irritation, and more especially if the patient be young. There is an aura as if a mouse were running over an extremity, or of heat rising from the stomach. There are illusions of sight and hearing, and the convulsions are apt to commence in an upper extremity and extend to the mouth, face and eyes. The great irritability of the nervous system, the easily disturbed sleep, the startings, the tremors and twitching and the general Belladonna symptoms will render the choice easy. Atropine, the alkaloid of Belladonna, has also been used successfully in the treatment of epilepsy. Hydrocyanic acid. Another remedy is Hydrocyanic acid, to which Hughes ascribes specific powers in the disease. In recent cases it perhaps our best remedy. the cases calling for it will be characterized by loss of consciousness, clenched hands, set jaws, frothing at the mouth, inability to swallow, and the attack is followed by great drowsiness and prostration. Children are disinclined to play and take but little interest in anything. It is one of our mainstays in epilepsy and its clinical record ranks it high.
Causticum is useful in Petit mal, also when the patient falls while walking in the open air, but soon recovers. It is said to be useful when the attacks occur at new moon. It menstrual epilepsy and that occurring at puberty Causticum is the remedy. Kafka recommends Hepar in nocturnal epilepsy. Causticum is perhaps better suited to recent and light cases. Another preparation of potash, Kali muriaticum, is a most useful remedy in epilepsy; it has an affinity for the nerve centers and it is a slow acting remedy.
MS Encarta Encyclopedia 2002.
Copyright with Dr. Sayeed Ahmad 2004
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