#257 Carpe Diem: Seizure Basics for Primary Care

February 22, 2021 | By Beth Garbitelli

Seize control of your differential for epilepsy! This week, we review the basics of seizure work-up and management with our esteemed guest  Dr. Sara Dawit @DrSaraDawit a board-certified neurologist who is an Assistant Professor of Neurology and Neurophysiology Fellow at  The Mayo Clinic, Arizona Campus. Dr. Dawit takes us through rapid response to witnessed seizure, how to approach first-time seizures and adult-onset seizure disorders, gives us some facts about non-epileptic seizure disorders, and describes how to approach medication management in epilepsy!

Hungry for more seizure information? Don’t miss The Cribsiders recent episode on pediatric seizures!  They cover the full spectrum from febrile seizures all the way to status epilepticus with Dr. John Gaitanis, a pediatric neurologist who specializes in care for children with epilepsy.

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Credits

• Producer: Paul Williams MD, Beth Garbitelli
• Writer and Infographics: Beth Garbitelli, Sara Dawit MD
• Cover Art: Kate Grant  MBChB DipGUMed 
• Hosts: Matthew Watto MD, FACP; Paul Williams MD, FACP   
• Editor: Cyrus Askin MD (written materials); Clair Morgan of nodderly.com
• Guest: Sara Dawit MD

Sponsor: ACP’s MKSAP18

MKSAP® is the most trusted resource for lifelong learning and Board prep for internal medicine physicians and residents. Learn more at www.acponline.org/curb2021.

Sponsor: Green Chef GreenChef.com/90curb

Sponsor: Indeed Indeed.com/INTERNALMEDICINE

Sponsor: VCU Health CE

The Curbsiders are partnering with VCU Health Continuing Education to offer FREE continuing education credits for physicians and other healthcare professionals. Visit curbsiders.vcuhealth.org and search for this episode to claim credit.

Time Stamps*

*Note: Time Stamps refer to ad free version. 

• 01:00 Intro, disclaimer, guest bio
• 03:25 Guest one-liner
• 06:20 Picks of the Week*
• 10:35 Case from Kashlak
• 12:20 Responding to seizure in real time
• 19:30 Defining seizures
• 24:20 Syncope versus seizure
• 26:50 Seizure subtypes; intact awareness during seizure
• 32:30 New onset adult seizures
• 39:42 Non-epileptic seizures
• 45:00 Seizure recurrence; Initiating medication
• 46:00 Medication choice
• 49:50 Monitoring patients who are on seizure medication
• 51:20 Dietary management for seizures, ketogenic diets
• 54:25 Seizure precautions
• 57:290 Lifestyle counseling
• 59:00 Comorbid mood disorder and seizure 
• 1:03:10 Other primary care considerations for seizure
• 1:05:30 Outro

Seizure Basics for Primary Care Pearls

1. Witnessing a seizure? Don’t put something in their mouth and don’t try to restrain the person. Most seizures resolve in a couple of minutes.  Dr. Dawit recommends that a patient experiencing a 1st time seizure should receive an urgent evaluation at the emergency department.
2. If possible, take video of the seizure episode, as it can be very helpful for neurologists to review the videos, especially if the patient experiences more than one type of spell. 
3. Non-epileptic events are a common seizure mimic. However, approximately 10-20% of people can have both epileptic seizures and non-epileptic events co-occurring (Kutlubaev et al, 2018).
4. An app that has been validated by seizure experts for selecting an anti-seizure medication (monotherapy) is EpiPick.Org. You can input age, comorbidities, and other information and it can help you with medication options with starting doses.
5. Dr. Dawit recommends checking anti-seizure medication levels and routine labs (CBC & CMP)  at least annually. If a patient is on carbamazepine or any of the p450 inducers, it is recommended to check vitamin D levels and supplement as indicated, as these medications are associated with adverse effects on bone metabolism (Zhang et al, 2020).
6. Patients with seizure disorders have a higher risk of comorbid mood disorders and a higher risk for suicide. Screen regularly and manage mental health conditions with medication and therapy as indicated. (Expert Opinion)

Seizure Notes 

Definitions

Seizures are transient paroxysmal events that involve alteration of consciousness and brain function with motor, sensory, autonomic, and psychic manifestations.  Pathophysiology of seizure involves abnormal electrical discharges (Angus-Leppan, 2014). 

Seizures are classified as either focal or generalized, based on electrical activity and whether or not its onset can be localized to a specific region of the brain. Focal seizures begin in one region of the brain, whereas generalized seizures simultaneously involve all regions of the brain (Gavvala et al, 2016). Focal seizures are further classified by awareness (see this post by Epilepsy Foundation). 

The most common type of generalized seizure is the classic tonic-clonic seizure, which is also referred to as a grand mal seizure or a major motor seizure. 

Epilepsy is a chronic neurological disorder with recurrent seizures. The definition requires 2 unprovoked seizures more than 24 hours apart, or 1 unprovoked seizure with a higher risk of recurrence (60%), or a diagnosis of an epileptic syndrome (ILAE, 2014). The risk of recurrence can be further determined by identified structural brain abnormality or abnormal electroencephalogram (EEG).  One in 26 people develop epilepsy in their lifetime (Epilepsy Foundation). 

Drug-resistant epilepsy is a subtype of epilepsy that does not respond to medication therapy. The International League Against Epilepsy defines drug-resistant resistant epilepsy as “failure of adequate trials of two tolerated and appropriately chosen and used antiepileptic drug schedules (whether as monotherapies or in combination) to achieve sustained seizure freedom.” This definition aims to avoid unnecessary delay in evaluation for additional therapeutics, such as curative epilepsy surgery. 

Seizure Rapid Response

Always check your own pulse! The key is to stay with the person until awake and alert, as well as keep them in a safe physical space. Lay the patient on their side if possible and as always in medical emergencies, assess the ABCs (airway, breathing, circulation).  Move any harmful objects, or anything that may interfere with breathing. If you can, start timing the seizure. Check if there is a medical ID. Additionally, have a low threshold for calling 911.  Don’t put something in their mouth and don’t try to restrain the person. Most seizures resolve in a few minutes.  Dr. Dawit recommends that a patient experiencing a first time seizure should receive an urgent evaluation at the emergency department. 

If possible, take video of the seizure episode, as it can be very helpful for neurologists to review the videos, especially if the patient experiences more than one type of spell (expert opinion). 

Building the Differential

“Any type of stereotyped event should raise concern for seizure” says Dr. Dawit. The differential diagnosis for seizure is broad. Dr. Dawit classifies common categories as neurological, cardiologic, and other.  Cardiac mimics can include dysrhythmias, dysautonomia, syncope. Neurological mimics include movement disorders, sleep disorders such as cataplexy, migraine, stroke, transient global amnesia, and transient ischemic attacks. Additional common etiologies include panic disorder, psychogenic non-epileptic events, and vestibulopathy. A detailed clinical history is important. 

Questions to consider include frequency, aura symptoms, symptoms before and after an event, evolution of symptoms, recollection of events, medication history, physical injury, risk factors such as head trauma, recreational drug history, prior central nervous system infection, developmental history, family history, seizures in childhood, prior neuroimaging and electroencephalogram (EEG) diagnostics. Epilepsy risk factors include family history, prior febrile seizures, and concussion trauma (Gavvala et al, 2016). In differentiating syncope, it can be helpful to include questions on provocation of the event (ie: from pain, from exertion, post-prandial, vasovagal, post-micturition-related), cardiac history, and other associated symptoms. Alcohol and substances may lower seizure threshold. Additionally,  medications such as clozapine, cephalosporins, fluoroquinolones, bupropion, and tramadol can precipitate a seizure in vulnerable individuals (Gavvala et al, 2016). 

Seizures can manifest in a myriad of ways. Some people have seizures where they retain awareness. Other people can have seizures where they start with awareness then lose it. Alternatively, there are people who lose awareness at the start. Seizures with intact awareness can occur depending on the involvement of the limbic system. 

Different seizure phenotypes are associated with unique presentations and neuroanatomy. For example, occipital lobe epilepsy will involve visual symptoms, while temporal lobe epilepsy may invoke a sense of deja vu (or jamais vu) in the patient or the patient may experience automatisms, such as chewing or lip smacking. Frontal lobe epilepsy can have a hyperkinetic presentation. 

Work-Up

Dr. Dawit says, “obtaining an EEG and neuroimaging are important steps in the seizure evaluation for an adult.”  Choosing an EEG monitoring period is similar to cardiac monitoring, in that sampling a longer period of time may capture more events.  A typical routine EEG is approximately 40 minutes. If you’re really suspicious of seizure after an initial negative EEG, then a longer EEG monitoring period e.g. 24-48 hour ambulatory monitoring can be useful (Gavvala et al, 2016).  “Additionally,  patients can be referred to epilepsy centers and epilepsy monitoring units for longer continuous video EEG monitoring” says Dr. Dawit. Early referral to a neurologist or an epilepsy specialist is recommended. 

For evaluation of a first-time seizure, patients are advised to go to the emergency department as soon as possible so they can get expedited evaluation and neuroimaging to rule out structural etiologies such as a brain tumor, which can cause seizure.  Infectious causes of seizure may also need to be assessed.  

It is Dr. Dawit’s expert opinion that neuroimaging is warranted with any first-time seizure.  If the patient is set up with an outpatient evaluation, a brain MRI with a seizure protocol can be helpful. Dr. Dawit mentions it is helpful to add this to an order to obtain more detailed imaging of the temporal lobes.

Non-epileptic Events can Co-exist with Seizures

Non-epileptic events (formerly known as pseudo-seizures) are a subtype of a functional neurological disorder.  Patients with non-epileptic events will have paroxysmal events that appear convulsive and epileptic, but without the expected cortical electrical activity. The gold standard for diagnosis is capturing an event while the patient has continuous video EEG to evaluate cortical activity. Approximately 10-20% of people have both epileptic and non-epileptic seizures co-occuring (Kutlubaev et al, 2018).

It is estimated that up to 20% of persons referred to epilepsy clinics are experiencing non-epileptic seizures (Benbadis et al, 2000). “Patients experiencing them are not faking them and they are very real events. Early diagnosis and treatment is important,” says Dr. Dawit. The mainstay treatment is cognitive behavioral therapy. 

Dr. Dawit advises that sharing this diagnosis with a patient involves emphasizing that there is no abnormal electrical activity and that there is effective treatment available. 

Treatment Modalities for Seizure

Medical therapy seeks to reduce seizure frequency and improve quality of life. The decision to initiate medicine is a shared decision. It is always appropriate to refer a patient to a neurologist or epileptologist when having questions about the best treatment options or evaluation. Additionally, curative epilepsy surgery may be an option in selected patients. 

“Selecting an anti-seizure medication is highly personalized, considering the patient’s co-morbidities and preference,” says Dr. Dawit. Common typical anti-seizure medications include lacosamide, levetiracetam, and lamotrigine.  A new app that was recently validated by experts for selecting an anti-seizure medication is EpiPick.Org. This tool allows you to input age, comorbidities, and other information, and provides medication considerations with starting doses.  Consider comorbidities when addressing seizure.  Migraine, depression, anxiety, neuropathy can be co-treated with certain medications.  Some common dual diagnosis modalities include lamotrigine for co-morbid bipolar disorder and topiramate for co-morbid migraine. 

Epilepsy Management Considerations

Dr. Dawit recommends checking seizure medication levels and routine labs (CBC & CMP) at least annually. Check vitamin D levels and supplement as indicated in patients on carbamazepine or any of the p450 inducers, as they’ve been associated with adverse effects on bone metabolism (Zhang et al, 2020).  Older medications for seizure like phenytoin require more monitoring and can have potential long-term side effects. It is reasonable to consider a newer antiseizure medication to reduce any side effects. 

In terms of non-pharmacologic options for management, ketogenic diets may be useful (D’Andrea Meira et al, 2019). However, the patient will need counseling with a dietician and regular assessment of ketosis. Dr. Dawit says ketogenic diets usually do not replace medications, but it is something a patient can try under the guidance by their healthcare team. In pediatric patients,  there have been indications that ketogenic diets can reduce seizure: one meta analysis showed 16% of pediatric patients became seizure free on a ketogenic diet, 32% had a >90% reduction in seizures, and 56% had a >50% reduction (Zupec-Kania et al, 2008).  Limited data is available regarding the efficacy of ketogenic diet in adults;  results have been less conclusive and diet abandonment is common  (Liu et al., 2018).  

Persons with epilepsy have higher risk of comorbid mental health conditions such as depression and anxiety. Depression or anxiety is seen in 20 to 50% of patients with epilepsy, per the Epilepsy Foundation. Additionally, those with seizure disorder are 3.5 to 5.8 times more likely to die from suicide (Newell, 2019).  Dr. Dawit strongly recommends screening and management of mood disorders in patients with epilepsy. 

Counseling on Seizure Precautions

There are many considerations and strategies to improve the quality of life for people with epilepsy. “Everyone has a seizure threshold, so I counsel patients on seizure precautions, first aid, and common triggers that can lower the threshold,” says Dr. Dawit. Common triggers include sleep deprivation, alcohol, substance use, antibiotics, stress, and others.  Some precautions include no unsupervised swimming, and wearing a helmet for activities such as bicycling, skateboarding, or horseback riding.  Patients should also be supervised around any type of water, including tubs, pools, spas, and the ocean. “Another area of concern is the kitchen, for instance while cooking over a hot stovetop,” says Dr. Dawit. Avoidance of ladders is recommended. Patients can purchase epilepsy safe pillows (more on this from Epilepsy Foundation). It is also important to understand and discuss one’s state-specific driving laws and regulations, as the episode-free time frame varies. “People can also get seizure first aid certification training at Epilepsy.com. This website and the Epilepsy Foundation are excellent resources,” says Dr. Dawit. 

Links

1. Born a Crime by Trevor Noah
2. Mayo Clinic’s Guide to Stress Free Living
3. Mank on Netflix
4. Open by Andre Agassi 
5. The Last Dance on Netflix
6. EpiPick.org
7. Dawit S, Drazkowski J. The evaluation of nonepileptic paroxysmal events. In: Cascino GD, Sirven JI, Tatum W, editor(s). Adult Epilepsy. 2nd ed. Chapter 8. Wiley-Blackwell; 2020.
8. Dawit S, Crepeau AZ. When Drugs Do Not Work: Alternatives to Antiseizure Medications. Curr Neurol Neurosci Rep. 2020 Jul 9;20(9):37. doi: 10.1007/s11910-020-01061-3. PMID: 32648170. https://pubmed.ncbi.nlm.nih.gov/32648170/
9. Sirven JI. Management of Epilepsy Comorbidities. Continuum (Minneap Minn). 2016 Feb;22(1 Epilepsy):191-203. doi: 10.1212/CON.0000000000000268. PMID: 26844737. https://pubmed.ncbi.nlm.nih.gov/26844737
10. Noe K. Counseling and Management of the Risks of Living With Epilepsy. Continuum (Minneap Minn). 2019 Apr;25(2):477-491. doi: 10.1212/CON.0000000000000708. PMID: 30921019. https://pubmed.ncbi.nlm.nih.gov/30921019/
11. Drazkowski J. An overview of epilepsy and driving. Epilepsia. 2007;48 Suppl 9:10-2. doi: 10.1111/j.1528-1167.2007.01392.x. PMID: 18047592. https://pubmed.ncbi.nlm.nih.gov/18047592
    
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Goal

Listeners will learn how to evaluate seizure in patients, develop basic treatment strategies, understand evaluation for first seizure

Learning objectives

After listening to this episode listeners will…  

1. Define seizure and subtypes, epilepsy, and nonepileptic seizures
2. Review prevalence of seizure and seizure disorders
3. Formulate a basic evaluation of first adult seizure with knowledge of seizure mimics
4. Review primary care considerations for patients with epilepsy
5. Comprehend dosing, management, side effects, and long-term strategies for seizure therapy
6. Counsel patients on lifestyle modifications for seizure

Disclosures

Dr. Dawit reports no relevant financial disclosures. The Curbsiders report no relevant financial disclosures. 

Citation

Garbitelli E, Dawit S, Williams PN, Askin C, Watto MF.  “#257 Carpe Diem: Seizure Basics for Primary Care”. The Curbsiders Internal Medicine Podcast. http://thecurbsiders.com/episode-list February 22, 2021.