MEDICATION [ back to Medication Main Page ]

EPILEPSY
The condition of epilepsy is a tendency towards recurrent seizures or electrical storms in the brain. Epilepsy can develop spontaneously from genetic factors in children. In adults it is typically seen following TBI, burst aneurysm with subarachnoid hemorrhage, hemorrhagic stroke, brain tumors and brain surgery for tumor excision. Anti-epileptic medication at best suppresses seizures. It does not cure the underlying disorder.

The first known anti-epileptic drugs were bromides used in the 1850s in an attempt to "cure" mental illness. Although highly toxic, these metal compounds did reduce seizure activity in some patients housed in mental asylums. In 1912 the sleeping medication phenobarbitol was released, and quickly became a mainstay for treatment of epilepsy. The drawback was oversedation of the patients with reduced cognition, memory and energy.

It is rarely used today, and only in the last resort. Phenytoin came out in 1938, and is still much used today. Valium, a tranquilizer introduced in the 1950s, was used to suppress seizures by promoting secretion of GABA (the most common inhibitory neurotransmitter in the cortex). Although less sedating than phenobarb, it is still too sedating for most patients. Some modern medications were used initially to treat shooting, burning nerve pain like Depakote (divalproex) and Neurontin (gabapentin). All of these medications are meant to suppress hyper-excitation, yet very rapid transmission of nerve impulses is need from some brain activities including thinking, memory retrieval, visual tracking of a moving object and walking on uneven surfaces, where rapid adjustments must be made. It is no wonder that common side effects of these medications include memory loss, blurry vision, dysequilibrium and incoordination. I once represented a hair stylist who kept burning herself with a curling iron and nicking customers' ears with the scissor, until we looked up the side effects of Neurontin and found "ataxia" (uncoordinated movement due to disruption of the cerebellum). Once she went off the medication, those problems stopped.

In order to be effective, anti-seizure drugs must reach, but not exceed, therapeutic levels in the patient's bloodstream. When blood levels are too low the drugs have no effect. When blood levels are too high, the drugs are toxic. Patients taking the drugs should have their blood levels monitored frequently. Often a patient doing well on these meds will show a marked drop in blood levels when he starts a new drug for a different condition that activates enzymes which eliminate the anti-seizure drugs from the bloodstream. An interesting counter-example is Prozac. An epilepsy patient who could not get his blood levels of Dilantin and Tegretol to therapeutic levels, suddenly did so after starting Prozac for depression. Apparently Prozac inhibits the enzymes that eliminate those drugs from the bloodstream. See, Journal of Clinical Psychopharmacology 1999;19:471-2.

Anti-seizure drugs carry a trade off between relative freedom from seizures vs. side effects which may be bad enough to induce stopping the drug. Many anti-seizure medications cause nausea and vomiting (especially when taken on an empty stomach). Gabatril can cause rashes on the skin with blue or purple spots. Topomax can cause extreme fatigue, double vision or temor. There is some indication that Depakene (valproic acid) can lower platelet count. Anti-seizure medications (e.g. Dilantin) can be highly toxic to developing fetuses and cause catastrophic neurologic damage; hence any woman who is pregnant or trying to become pregnant must consult a specialist if considering the use of such medications, either to control seizures or nerve pain. It is crucial for any TBI patient who is having seizures or concerned about getting them to consult a neurologist who specializes in management of epilepsy. The sub-specialists are known as Epileptologists, and have their own society for sharing of knowledge.

When medications fail, patients may find relief either from electric stimulation of the vagus nerve in the neck or surgical removal of epileptogenic "foci" in the brain. However, such radical measures should not be tried until the reason for medication failure is thoroughly explored. Sometimes the medication fails because the doctor has misdiagnosed the type of epilepsy or because the dose is too high or too low.