Epilepsy

A seizure is a burst of disordered electrical activity in the brain. What it looks like depends on where it starts and how far it spreads: a few seconds of blankness, a strange smell or a rising feeling in the stomach, jerking of one limb, or a convulsion with loss of consciousness. Epilepsy is the diagnosis given when the brain has a lasting tendency to produce them, which in practice usually means two unprovoked seizures more than a day apart.

About half the time a cause is found: scarring in the temporal lobe, an old head injury, a stroke, an injury around birth, an infection such as meningitis or neurocysticercosis, an area where the brain's wiring formed abnormally, or a genetic tendency that runs in the family. In the other half the scans and the blood tests are normal and no cause is identified, and that group often responds particularly well to medication.

Most people with epilepsy stop having seizures on tablets. Roughly half are controlled by the first medicine they are given and a further group by the second, so around seven in ten settle on one drug taken daily and carry on driving, working and having children. Seizures that continue after two well-chosen medicines have each been taken at a full dose for long enough are called drug resistant, and it is that smaller group for whom an operation becomes a serious question.

The history carries more weight here than any scan. Your doctor asks exactly what happened before, during and after the event, and asks whoever was watching, since you cannot describe the part where you were unconscious. Bring a phone video if anyone took one. What they are separating out is a seizure from a faint, from a disturbance of heart rhythm, and from the non-epileptic events that look similar and are treated in an entirely different way. Triggers count too: sleep lost, alcohol, a missed dose, a long stretch in front of a flickering screen.

An EEG records the brain's electrical activity through electrodes on the scalp for about half an hour, usually with a spell of deep breathing and a flashing light to bring out abnormal patterns. It supports the diagnosis and it points to which type of epilepsy you have, and the type is what decides which medicine suits you. A normal EEG does not rule epilepsy out, so a sleep-deprived recording or a longer one over days is arranged when the first is unhelpful.

MRI of the brain looks for the causes worth finding: a scarred hippocampus, an area of malformed cortex, an old injury, a tumour. Blood tests and an ECG are done alongside to exclude the conditions that imitate seizures. Where seizures later prove resistant to medication, the MRI is read again against an epilepsy protocol, which is a more detailed reading than a routine scan of the head.

Control is what getting better looks like. A medicine is started low and built up over a few weeks to keep the drowsiness manageable, and judging it then takes time measured against your own pattern: if your seizures came monthly, three months without one says something, and if they came once a year it takes far longer. Your neurologist will usually let a drug reach a full dose before calling it a failure. Keeping a diary of every event, every missed dose and every bad night of sleep is what makes the next appointment useful.

Driving is governed by a seizure-free period set by the licensing rules and counted from your last seizure, and it is worth asking your neurologist to write down the date you become eligible. Swimming alone, working at height and cooking over an open flame are handled the same way, by how long you have been free of seizures.

After a long spell without one, often taken as two to three years, coming off medication can be discussed. It is done one drug at a time over months, with a plan agreed in advance for what to do if a seizure happens during the reduction. Many people stay free of seizures afterwards; some find they return and go back on the tablet that was working. Where two medicines have already failed, the referral for surgical assessment is made early, since years of uncontrolled seizures cost memory, schooling and work.