Epilepsy: Symptoms, Causes & Treatment Options

What Is Epilepsy and How Does It Affect the Brain?

Epilepsy is a neurological disorder characterized by recurrent, unprovoked seizures caused by abnormal electrical activity in the brain. It affects approximately 50 million people worldwide, making it one of the most common neurological conditions. Seizures occur when groups of nerve cells fire excessively and synchronously, disrupting normal brain function.

The brain consists of billions of nerve cells that communicate through carefully controlled electrical signals. These signals allow us to think, feel, move, and perceive the world around us. In epilepsy, this delicate electrical balance is disrupted. Certain groups of neurons become hyperexcitable and fire abnormally, creating a surge of electrical activity that spreads through the brain and manifests as a seizure.

Understanding how epilepsy works begins with understanding the brain's normal electrical activity. Nerve cells communicate by releasing chemical messengers called neurotransmitters. Some neurotransmitters excite neighboring cells to fire, while others inhibit them from firing. In a healthy brain, these excitatory and inhibitory signals are carefully balanced. When someone has epilepsy, this balance is disrupted – excitatory signals overwhelm inhibitory ones, allowing abnormal electrical discharges to occur.

The specific symptoms experienced during a seizure depend entirely on which part of the brain is affected by this abnormal electrical activity. If the electrical storm remains localized to one region, the person may experience unusual sensations, involuntary movements in one limb, or altered awareness without losing consciousness entirely. If the abnormal activity spreads to involve the entire brain, the result is typically a convulsive seizure with loss of consciousness and rhythmic jerking of the body.

Between seizures, most people with epilepsy function completely normally. The brain's electrical activity returns to its typical patterns, and there are usually no ongoing symptoms. However, some individuals with very frequent or severe seizures may experience cognitive difficulties related to the repeated disruption of normal brain activity, or as a result of the underlying condition causing their epilepsy.

Who Gets Epilepsy?

Epilepsy can develop at any age, but the risk follows a distinctive pattern across the lifespan. The condition is most commonly diagnosed during two periods: early childhood (particularly the first year of life) and after age 70. In children, epilepsy is often related to genetic factors, developmental abnormalities, or complications during birth. In older adults, epilepsy frequently develops as a consequence of stroke, dementia, brain tumors, or other conditions that affect brain tissue.

Approximately 0.5-1% of the global population has epilepsy, making it a relatively common condition. In the United States alone, about 3.4 million people live with epilepsy. The condition affects people of all backgrounds, ethnicities, and social classes, though rates may be higher in regions with limited access to healthcare where treatable causes go unaddressed.

What Causes Epilepsy?

Epilepsy has many potential causes, though in approximately 50% of cases, no specific cause can be identified despite thorough investigation. When a cause can be determined, the most common include traumatic brain injury, stroke, brain tumors, brain infections (such as meningitis or encephalitis), developmental abnormalities present from birth, and genetic factors. Understanding the cause, when possible, is important because it can influence treatment decisions and prognosis.

Genetic factors play a role in many types of epilepsy. Some forms are caused by specific gene mutations that directly affect how neurons function. In other cases, genetic variants may increase susceptibility to developing epilepsy following a brain injury or other triggering event. However, having epilepsy generally carries only a small increased risk of passing the condition to children – in most cases, less than 5%.

What Are the Symptoms of Epilepsy Seizures?

Epilepsy symptoms depend on which part of the brain is affected during a seizure. Generalized seizures cause loss of consciousness and convulsions affecting the entire body, while focal seizures may cause localized twitching, unusual sensations, or brief periods of confusion. Many people experience a warning sensation called an "aura" before a seizure.

The symptoms of epilepsy are essentially the symptoms of seizures themselves. What makes epilepsy distinct from an isolated seizure is that seizures recur over time. The nature of these seizures can vary enormously between individuals, but for most people with epilepsy, their own seizures tend to follow a consistent pattern. Understanding the different types of seizures is crucial for accurate diagnosis and effective treatment.

Seizures are classified into two main categories based on where the abnormal electrical activity begins in the brain: generalized seizures and focal seizures. This classification matters because different seizure types respond to different medications, and the distinction affects many aspects of management, from choosing the right drug to determining eligibility for surgical treatment.

Generalized Seizures

Generalized seizures involve abnormal electrical activity affecting both sides of the brain from the very start of the seizure. Because the entire brain is involved, generalized seizures typically cause loss of consciousness. There are several types of generalized seizures, each with distinct characteristics:

Tonic-clonic seizures (formerly called "grand mal" seizures) are the most dramatic and widely recognized type. These seizures have two phases: the tonic phase, during which all muscles stiffen and the person may fall, followed by the clonic phase, during which rhythmic jerking movements occur in the arms and legs. During the tonic phase, breathing may stop temporarily, and the person's lips may turn blue. The entire seizure typically lasts 1-2 minutes. Afterward, the person gradually regains consciousness but often feels confused, exhausted, and may have a headache or muscle soreness. They have no memory of the seizure itself.

Absence seizures (formerly "petit mal") cause brief lapses in awareness lasting 5-15 seconds. During an absence seizure, the person may stare blankly, blink rapidly, or make subtle mouth movements. They do not fall or convulse. These seizures can occur many times per day and are most common in children. After the seizure, the person immediately returns to their previous activity without confusion – they may not even realize anything happened.

Myoclonic seizures cause sudden, brief jerks of a muscle or group of muscles, often affecting the arms, shoulders, or head. Both sides of the body are typically affected simultaneously. The person remains conscious during myoclonic seizures and can describe the experience afterward. These seizures are particularly common in the morning.

Focal Seizures

Focal seizures (previously called partial seizures) begin in one specific area of the brain. The symptoms depend on which brain region is affected. Focal seizures can be further divided based on whether awareness is preserved or impaired during the episode:

Focal seizures with preserved awareness (previously "simple partial seizures") occur when the person remains fully conscious and can interact normally with their environment, though they experience unusual symptoms. These may include involuntary twitching or jerking in one part of the body, tingling or numbness in one limb, visual disturbances such as seeing flashing lights or colors, strange tastes or smells, or emotional sensations such as sudden fear or déjà vu. The person can describe exactly what they experienced.

Focal seizures with impaired awareness (previously "complex partial seizures") cause altered consciousness. The person may appear awake but does not respond normally to their environment. They may stare blankly, make repetitive movements (called automatisms) such as lip smacking, fumbling with clothing, or walking around aimlessly. These seizures typically last 1-2 minutes, followed by a period of confusion lasting several minutes. The person usually has no memory of the seizure.

Focal to bilateral tonic-clonic seizures begin as focal seizures but then spread to involve the entire brain, resulting in a generalized tonic-clonic seizure. The person may remember the initial focal symptoms (the "aura") before losing consciousness.

The Aura: A Warning Sign

Many people with focal epilepsy experience a distinctive warning sensation seconds to minutes before a larger seizure occurs. This warning, called an aura, is actually a focal seizure with preserved awareness that precedes a more extensive seizure. Auras are highly individual – one person might smell burning rubber, another might feel sudden anxiety, and another might see geometric patterns. Learning to recognize one's aura can be valuable, as it may provide time to get to a safe position before a larger seizure occurs.

Can Epilepsy Seizures Cause Brain Damage or Injury?

Most epileptic seizures end on their own within 1-2 minutes and do not cause brain damage. However, prolonged seizures lasting more than 5 minutes (status epilepticus) can be dangerous and require emergency treatment. The greatest immediate risk during a seizure is physical injury from falling or hitting objects.

A common concern among people newly diagnosed with epilepsy and their families is whether seizures cause brain damage. For the vast majority of typical seizures, the answer is reassuring: brief seizures that stop on their own do not damage the brain. The neurons that fire abnormally during a seizure return to normal function once the seizure ends, and there is no lasting injury to brain tissue from an ordinary seizure.

However, this does not mean seizures carry no risks at all. The primary concern during most seizures is the possibility of physical injury. When someone loses consciousness and falls during a tonic-clonic seizure, they cannot protect themselves from impact. This can result in head injuries, bone fractures, dental injuries from jaw clenching, or burns if the seizure occurs near a stove or other heat source. People with frequent, uncontrolled seizures are at ongoing risk for such injuries.

Prolonged seizures are a different matter. When a seizure continues for more than 5 minutes, or when multiple seizures occur in succession without full recovery between them, this is called status epilepticus – a medical emergency. During prolonged seizure activity, the brain's oxygen and energy demands exceed what normal circulation can provide. This can lead to genuine brain injury if not treated promptly. Status epilepticus requires immediate emergency treatment with intravenous medications to stop the seizure.

Long-term Considerations

For individuals with very severe epilepsy characterized by frequent, uncontrolled seizures over many years, there can be cumulative effects on cognitive function. Memory problems and learning difficulties are more common in people with drug-resistant epilepsy who experience frequent seizures. However, it can be difficult to separate the effects of the seizures themselves from the effects of the underlying brain condition causing the epilepsy, or from side effects of seizure medications taken over many years.

Sudden unexpected death in epilepsy (SUDEP) is a rare but serious concern, occurring in approximately 1 in 1,000 people with epilepsy per year, with higher rates in those with uncontrolled seizures. The exact mechanism is not fully understood but is thought to involve disruption of breathing or heart rhythm during or shortly after a seizure. Achieving good seizure control through medication adherence is the most important strategy for reducing SUDEP risk.

When Should You See a Doctor or Call Emergency Services?

Call emergency services immediately if a seizure lasts more than 5 minutes, if the person doesn't regain consciousness after convulsions stop, if another seizure follows shortly after, if breathing is difficult, or if it's a first-time seizure. Contact a healthcare provider if you suspect you or someone in your family has epilepsy based on symptoms described here.

Knowing when to seek emergency care versus routine medical attention for seizures is crucial. The distinction can be life-saving in some situations while avoiding unnecessary emergency room visits in others.

Emergency Situations – Call For Help Immediately

Certain situations following or during a seizure require immediate emergency medical attention. You should call your local emergency number or go to an emergency department if any of the following apply:

• The seizure lasts more than 5 minutes: This may indicate status epilepticus, which requires emergency treatment
• The person does not regain consciousness within a few minutes after the convulsions stop
• A second seizure follows shortly after the first without full recovery in between
• The person has difficulty breathing after the seizure ends
• The seizure occurs in water, raising the risk of drowning
• The person is injured during the seizure
• It is the person's first seizure
• The person is pregnant or has diabetes

Non-Emergency Medical Consultation

If you experience what you believe may have been a seizure but are currently feeling normal, contact a healthcare provider to schedule an evaluation. While not an emergency, any suspected first seizure should be evaluated by a doctor, typically within a few days. Bring someone who witnessed the event if possible, as their observations will be valuable for diagnosis.

If you have established epilepsy and experience a seizure that is different from your usual pattern – perhaps lasting longer, involving different symptoms, or occurring more frequently – contact your neurology provider. This may indicate that your treatment needs adjustment.

How Is Epilepsy Diagnosed?

Epilepsy diagnosis involves a detailed medical history (ideally including witness accounts), neurological examination, EEG (electroencephalogram) to detect abnormal brain electrical activity, and brain imaging with MRI or CT scan to identify structural causes. A diagnosis typically requires at least two unprovoked seizures occurring more than 24 hours apart.

Diagnosing epilepsy can be challenging because seizures are usually over by the time a person reaches medical care, and there is no single definitive test. Diagnosis relies on piecing together clinical history, witness observations, and various diagnostic tests to build a clear picture of what is occurring in the brain.

The diagnostic process typically begins with a detailed medical history. The doctor will ask about what happened before, during, and after the suspected seizure. Because most people have no memory of their seizures, bringing someone who witnessed the event is extremely valuable. The witness can describe movements, duration, responsiveness, and what recovery looked like – all critical information for determining seizure type.

Electroencephalogram (EEG)

An EEG records the brain's electrical activity using electrodes placed on the scalp. This painless test can detect abnormal electrical patterns that suggest a tendency toward seizures. During the test, the technician may ask you to look at flashing lights or hyperventilate, as these can sometimes trigger abnormal electrical activity in susceptible individuals.

A standard EEG lasting 20-30 minutes may be normal even in someone with epilepsy, simply because no abnormal activity happens to occur during the recording. For this reason, longer recordings – including ambulatory (take-home) EEG monitoring or inpatient video-EEG monitoring where brain activity and behavior are recorded simultaneously for days – may be necessary to capture an actual seizure.

Brain Imaging

MRI (magnetic resonance imaging) produces detailed pictures of the brain and can identify structural abnormalities that may be causing seizures, such as tumors, scarring, developmental malformations, or damage from previous strokes or injuries. MRI is the preferred imaging modality for epilepsy evaluation because of its superior detail.

CT (computed tomography) scanning may be used in acute settings, such as after a first seizure in an emergency department, because it is faster and readily available. CT is particularly useful for detecting bleeding or large tumors but provides less detail than MRI.

Neuropsychological Testing

If epilepsy surgery is being considered, or if there are concerns about cognitive function, neuropsychological testing may be performed. A specialized psychologist evaluates memory, language, attention, and other brain functions. This helps locate the seizure focus by identifying functional deficits and establishes a baseline for comparison after treatment.

How Is Epilepsy Treated?

Epilepsy treatment primarily involves anti-seizure medications (ASMs), with over 20 options available. About 70% of people achieve seizure control with medication. For drug-resistant epilepsy, options include surgery, vagus nerve stimulation (VNS), and the ketogenic diet. Treatment is tailored to seizure type, age, and individual factors.

The primary goal of epilepsy treatment is to prevent seizures while maintaining the best possible quality of life. Treatment almost always begins with anti-seizure medications, which are effective for the majority of people with epilepsy. For those who do not respond adequately to medication, other treatment options are available.

Anti-Seizure Medications

Anti-seizure medications (ASMs), also called antiepileptic drugs or anticonvulsants, are the cornerstone of epilepsy treatment. These medications work by reducing the excessive electrical activity in the brain that causes seizures. They do not cure epilepsy but effectively prevent seizures in most people who take them consistently.

More than 20 different anti-seizure medications are available, each with different mechanisms of action, effectiveness for different seizure types, side effect profiles, and drug interactions. Finding the right medication often involves some trial and adjustment. The doctor will consider your seizure type, age, other medications you take, and potential side effects when selecting an initial medication.

It is crucial to take anti-seizure medication exactly as prescribed. Missing doses is the most common reason for breakthrough seizures in people whose epilepsy is otherwise well-controlled. Most people need to take medication regularly, often multiple times per day, and stopping suddenly can be dangerous – it may trigger severe seizures or even status epilepticus.

Common side effects of anti-seizure medications include fatigue, dizziness, and cognitive slowing, though these often improve over time or with dose adjustment. Some medications require monitoring through blood tests to ensure safe levels and to check for effects on liver function or blood counts.

Treatment During an Active Seizure

Most seizures stop on their own within a few minutes without intervention. However, for seizures lasting more than 5 minutes, emergency treatment is necessary. In hospital settings, intravenous medications are used to stop prolonged seizures. For people known to be at risk of prolonged seizures, rescue medications in the form of rectal, nasal, or buccal (cheek) formulations may be prescribed for use at home or school.

Epilepsy Surgery

For people with focal epilepsy that does not respond to at least two appropriate medications, surgery may be an option. Epilepsy surgery aims to remove or disconnect the specific brain region where seizures originate. When the seizure focus can be precisely located and safely removed, surgery offers the possibility of a complete cure – freedom from seizures without needing ongoing medication.

The evaluation for epilepsy surgery is extensive and may take several months. It typically includes prolonged video-EEG monitoring to capture seizures and localize their origin, detailed MRI imaging, neuropsychological testing, and sometimes additional specialized tests. A multidisciplinary team reviews all findings to determine whether surgery is appropriate and safe.

The success rate varies depending on the type and location of epilepsy, but many patients who undergo surgery experience significant improvement. For certain types of focal epilepsy, such as mesial temporal lobe epilepsy, seizure freedom rates of 60-80% are achievable.

Vagus Nerve Stimulation (VNS)

For people with drug-resistant epilepsy who are not candidates for resective surgery, vagus nerve stimulation offers another option. A small pacemaker-like device is implanted under the skin in the chest, with a wire connecting to the vagus nerve in the neck. The device delivers regular mild electrical pulses to the brain via this nerve, reducing seizure frequency.

VNS does not typically eliminate seizures entirely but reduces their frequency and severity in about half of the people who try it. The device can also be manually activated with a magnet when a seizure is felt coming on, which may stop or shorten the seizure.

Ketogenic Diet

The ketogenic diet is a high-fat, very low-carbohydrate diet that can reduce seizures, particularly in children with difficult-to-control epilepsy. The diet changes the body's metabolism to produce ketones, which may have anticonvulsant effects. It requires strict adherence and close medical supervision, including regular monitoring by a dietitian.

While challenging to maintain, the ketogenic diet can be remarkably effective for certain types of epilepsy, with some children becoming seizure-free. Modified versions of the diet, such as the modified Atkins diet and low glycemic index treatment, may be more feasible for some families and adults.

How Do You Help Someone Having a Seizure?

During a seizure: stay calm and time it, protect the person from injury by clearing hard objects nearby, place something soft under their head, loosen tight clothing, and turn them on their side once convulsions stop. Never put anything in their mouth or try to restrain their movements. Call for help if the seizure lasts more than 5 minutes.

Witnessing someone have a seizure can be frightening, but knowing how to respond can help you stay calm and provide appropriate assistance. The most important things to remember are to protect the person from injury and to know when emergency help is needed.

What to Do During a Tonic-Clonic Seizure

When someone experiences a tonic-clonic (convulsive) seizure, follow these steps:

1. Stay calm and time the seizure. Note when it starts. Most seizures last 1-2 minutes.
2. Protect from injury. Clear the area of hard or sharp objects. If standing, gently guide the person to the floor. Do not try to hold them down or restrain their movements.
3. Cushion the head. Place something soft (a folded jacket, pillow) under the head to prevent injury.
4. Loosen tight clothing around the neck to aid breathing.
5. Once convulsions stop, turn the person on their side (recovery position) to keep the airway clear.
6. Stay with them until fully recovered. Speak calmly and reassure them – they may be confused for several minutes.

Helping Someone After a Seizure

After the seizure ends, the person may be confused, tired, or disoriented for several minutes to hours. This post-seizure period is called the postictal state. Stay with them, speak calmly and reassuringly, and let them know what happened. Offer to help them contact someone or get home safely. If they have a seizure action plan or medical ID, follow the instructions provided.

What Is It Like Living With Epilepsy?

Most people with well-controlled epilepsy lead full, active lives. However, some adjustments may be necessary, including medication adherence, avoiding seizure triggers like sleep deprivation, and following driving restrictions until seizure-free for a required period. With proper management, people with epilepsy can work, travel, exercise, and have families.

Living with epilepsy is different for everyone. For many people whose seizures are well-controlled with medication, daily life may be minimally affected. For others with more difficult-to-control epilepsy, the condition may require more significant adaptations. Either way, the goal of treatment is to help people with epilepsy live as normally and safely as possible.

Managing Triggers

Many people with epilepsy find that certain factors make seizures more likely. While triggers are highly individual, some common ones include sleep deprivation, stress, alcohol consumption, and illness. Keeping a seizure diary can help identify personal triggers. Once known, avoiding these triggers – particularly getting adequate sleep – can help reduce seizure frequency.

For a small percentage of people with epilepsy (about 3%), flickering or flashing lights can trigger seizures. This is called photosensitive epilepsy. Those affected may need to avoid strobe lights, certain video games, or other sources of flickering light. Most people with epilepsy, however, are not photosensitive.

Driving and Epilepsy

Driving regulations for people with epilepsy vary by country and state but generally require a period of seizure freedom before driving is permitted. This is typically 6-12 months for a regular driver's license, with longer requirements for commercial licenses. These regulations aim to balance public safety with the individual's need for independence. People with epilepsy should know their local laws and discuss driving with their neurologist.

Employment Considerations

Most people with epilepsy can work in a wide range of occupations. However, certain jobs may be unsuitable if a seizure would pose a risk to the person or others – for example, working at heights, operating heavy machinery, or commercial driving. Workplace accommodations, such as avoiding certain tasks or having someone nearby who knows about the epilepsy, may help. Many countries have laws protecting people with epilepsy from employment discrimination.

Informing Others

Deciding whether and when to tell others about epilepsy is a personal choice. However, it can be valuable to inform close friends, family, colleagues, or teachers so they know how to respond if a seizure occurs. Some people choose to wear a medical identification bracelet or necklace indicating they have epilepsy, which can be helpful if they have a seizure in public.

Is It Safe to Get Pregnant If You Have Epilepsy?

Most women with epilepsy have healthy pregnancies and babies. However, some anti-seizure medications carry risks for fetal development, so pregnancy should be planned with your neurologist. Adjusting medications before conception, taking folic acid supplements, and careful monitoring during pregnancy help ensure the best outcomes for both mother and baby.

Women with epilepsy have valid questions about pregnancy, and the good news is that the vast majority have uncomplicated pregnancies and healthy babies. However, pregnancy in epilepsy requires careful planning and management to minimize risks.

Certain anti-seizure medications, particularly valproate (valproic acid), carry significant risks of birth defects and developmental problems if taken during pregnancy. Other medications are considered safer during pregnancy. Ideally, women with epilepsy should discuss pregnancy plans with their neurologist before becoming pregnant so that medications can be adjusted if necessary. Switching medications during pregnancy is more complicated and potentially risky.

Taking folic acid before and during pregnancy is particularly important for women on anti-seizure medications, as some of these drugs interfere with folic acid metabolism. Higher doses than standard prenatal vitamins may be recommended.

During pregnancy, seizure frequency may increase, decrease, or stay the same. Regular monitoring and sometimes dose adjustments are needed because pregnancy changes how the body processes medications. Most women with epilepsy will be followed by both their neurologist and a maternal-fetal medicine specialist.

Breastfeeding is generally safe for women with epilepsy on most anti-seizure medications. The benefits of breastfeeding usually outweigh the small amounts of medication that may pass into breast milk. Your doctor can advise based on your specific medication.

Frequently Asked Questions About Epilepsy