Epilepsy is a neurological disorder characterized by recurrent seizures. It affects millions of people worldwide, causing significant challenges in their daily lives. In this article, we will explore the various aspects of epilepsy, including its diagnosis, treatment, and the role of different healthcare platforms in managing this condition. Understanding epilepsy is crucial for providing optimal care and support to individuals living with this condition.
Diagnosis and Treatment at Primary Health Centres:
At the primary health centre (PHC) level, medical officers play a vital role in the initial diagnosis and management of epilepsy. The following steps are typically followed:
Clinical diagnosis: Detailed history is obtained from an eyewitness to identify the presence of epilepsy.
Differentiating provoked seizures: Provoked seizures caused by factors such as fever, acute CNS insult, medications, or metabolic causes are differentiated from epilepsy.
Laboratory investigations: CBC, liver function tests, routine biochemistry, hemogram, lipid profile, and vitamin D levels are conducted to assess overall health and identify potential triggers.
Initiation of treatment: Patients with epilepsy (two or more unprovoked seizures) or those with a single seizure but at high risk of recurrence receive appropriate antiepileptic drugs (AEDs). Treatment is administered at low doses, and patients are educated about potential side effects and the importance of medication adherence.
Lifestyle modifications: Patients are advised on seizure prevention strategies such as regular medication intake, sufficient sleep, avoiding excessive exposure to screens or photic stimulation, maintaining a regular diet, and making healthy lifestyle choices (including abstaining from alcohol).
Referrals and follow-up: Referral of difficult cases to neurologists at higher centers, along with regular follow-up visits, ensures comprehensive management and monitoring of the condition.
Reasons for Referral and Red Flag Signs:
Referral to centers with specialists such as pediatricians, neurologists, or district hospitals may be necessary in the following situations:
Red flag signs: Fever, headache, vomiting, altered sensorium, severe giddiness, or loss of bodily function accompany the seizures.
Progressive problems or rapid appearance of new symptoms.
Recent injury or symptoms occurring after an alcohol binge.
Non-response to adequate dose and duration of medication or serious side effects.
Role of District Hospitals:
District hospitals (DH) play a crucial role in the evaluation and specialized management of referral patients. They maintain communication and provide ongoing support to medical officers at PHCs. The following activities are typically carried out at DHs:
Careful evaluation: Referral patients receive a thorough evaluation, including laboratory investigations such as CBC, liver function tests, antiepileptic drug levels, routine biochemistry, lipid profile, vitamin D levels, and neuroimaging when necessary.
Side effect monitoring: DHs monitor and manage the side effects of AEDs to ensure patient safety and treatment efficacy.
Psychological support: Clinical psychologists provide counseling services for persons with epilepsy, either directly or upon referral from PHCs/UPHCs, to address the psychological impact of the condition.
Medications Recommended for Epilepsy Treatment:
Several antiepileptic drugs (AEDs) are commonly prescribed for epilepsy management. The choice of medication depends on the type of epilepsy and individual patient characteristics. Here are some commonly used AEDs:
Sodium Valproate: Starting dose of 200mg TDS, maintenance dose of 600-2400mg. Side effects may include anorexia, weight gain, nausea, vomiting, tremors, hair loss, PCOS, and thrombocytopenia.
Lamotrigine: Starting dose of 25mg HS, maintenance dose of 100-300mg. Side effects may include sedation, ataxia, dizziness, skin rash, and Stevens-Johnson syndrome (with a lower risk through slow titration).
Levetiracetam: Starting dose of 250mg BD, maintenance dose of 1000-3000mg. Side effects may include somnolence, dizziness, cognitive slowing, and psychosis.
Topiramate: Starting dose of 25mg OD, maintenance dose of 100-400mg. Side effects may include sedation, somnolence, cognitive problems, weight loss, word-finding difficulty, renal stones, and seizure worsening.
Carbamazepine: Starting dose of 200mg BD, maintenance dose of 400-1200mg. Side effects may include sedation, dizziness, ataxia, skin rash, hyponatremia, and seizure worsening in certain situations.
Phenytoin: Starting dose of 100mg BD, maintenance dose of 400-1200mg. Side effects may include sedation, dizziness, ataxia, headache, hyponatremia, skin rash, and gum hyperplasia.
It's important to note that in women of childbearing age, folic acid supplementation of 5 mg/day should be added along with AEDs. Polytherapy and valproate should be avoided in women with epilepsy due to potential risks.
Emergency Management of Status Epilepticus:
In cases of status epilepticus (SE), immediate medical attention and appropriate interventions are crucial. The following steps are typically taken:
Out-of-hospital/home: Buccal/intranasal midazolam is administered with acute repetitive seizures/status. In the emergency room, intravenous lorazepam, midazolam, or diazepam are used.
First-line treatment: Phenytoin is administered at 50 mg/min, with a repeat dose of 20 mg/kg if seizures persist. If contraindicated, intravenous valproate at 25-40 mg/kg or phenobarbital at 20 mg/kg may be considered.
Alternative options: Levetiracetam, lacosamide, or topiramate can be administered via intravenous or nasogastric routes based on the patient's condition and response.
ICU management: In the intensive care unit (ICU), medications such as midazolam, thiopental, propofol, or pentobarbital may be used for seizure control, with careful monitoring through EEG.
Epilepsy is a complex neurological disorder that requires a multidisciplinary approach for diagnosis, treatment, and care. Primary health centers play a crucial role in the initial management of epilepsy, while district hospitals provide specialized evaluation and ongoing support. The choice of antiepileptic drugs depends on the individual patient and the type of epilepsy. Emergency management of status epilepticus requires prompt intervention and the administration of appropriate medications. By understanding the various aspects of epilepsy and collaborating across healthcare platforms, we can improve the quality of life for individuals living with this condition.
Source: Indian Council of Medical Research and Department of Health Research, Ministry of Health & Family Welfare, Government of India.
Epilepsy, classified under ICD 10 code G40, is a neurological disorder characterized by recurrent seizures. It affects millions of people worldwide and can have a significant impact on an individual's quality of life. In this article, we will provide you with essential information about epilepsy, its diagnosis, treatment, and management.