Heads Up: There's More Than One Type of Seizureby Nancy Fitzgerald Health Writer
Epileptic seizures are like an electrical storm inside your brain. There are lots of different kinds of storms—and many kinds of seizures, too. Those electrical brainstorms can range from the “TV seizures” that knock your lights out and throw you off your feet to a milder storm that’s more like a passing shower—a few seconds of fuzziness, then back to normal. It’s important to know which kind of seizures you’re having because that can help your doctor choose the right treatment. Here’s a guide to seizure types and treatments—and the process from start to finish.
For Best Treatment, Knowledge Is Power
“Everyone who’s had a seizure should have a thorough evaluation,” says Barbara Jobst, M.D., epilepsy program director at Dartmouth-Hitchcock Medical Center in Hanover, NH. See an epilepsy specialist. “We start with magnetic resonance imaging (MRI) and an electroencephalogram (EEG),” Dr Jobst explains. “If medications don’t help, we may admit you to the hospital and take you off your meds to bring on a seizure. Then we do a video EEG showing where in the brain the seizure starts.” A thorough exam can provide clues to what’s causing your epilepsy—from a tumor to scar tissue to misshaped blood vessels.
Epilepsy Comes in Many Varieties
There are hundreds of different kinds of epilepsy, from debilitating cases to types that can be easily controlled. Developmental epileptic encephalopathy, for instance, is a super-severe genetic form that shows up before age 1. With other kinds of epilepsy, seizures can be much milder.
There are two major types—focal and generalized—which doctors classify according to where they begin in the brain. To figure which kind you have, doctors use tools including neurological exams, MRIs, CAT scans, and other imaging tests.
Focal seizures are caused by an electrical instability in a particular spot on one side of the brain—for example, the region affecting speech or movement. Sometimes, though, they take over the whole brain, says Jacqueline French, M.D., chief medical officer of the Epilepsy Foundation. These seizures usually begin after age 35—the older you are, the more likely you are to develop them. “You could be born with it or acquire it along the way,” says Dr French. Let’s look at the different kinds of focal seizures.
Focal Aware Seizures
With focal aware seizures, people never lose consciousness. “They realize it’s happening, and they can remember the details when it’s over,” explains Dr. French. This kind of seizure can play out in many ways, depending on exactly which area of the brain is involved. “If the little piece of your brain that’s being tickled affects your muscles,” says Dr French, “you might experience twitching of your arm or leg. If the piece of your brain affects your thinking ability, you might have an experience of déjà vu. If it affects your emotions, you might experience fear.”
When a seizure involves the parts of your brain that affect your ability to think and remember, you’re having a focal-unaware seizure. That can look different for everyone. “You could be sitting and staring, you could be shaking, you could even be walking or stiffening. It all depends on how the electrical surge is making a path through your brain,” says Dr. French. “[But] being unaware isn’t the same as being unconscious. You may realize a seizure is happening, but your understanding of the outside world fades away. You may be unable to speak because that area of your brain is affected.”
Focal Tonic-Clonic Seizures
These can be scary when they become generalized. Even though they started in one spot, the electrical activity can spread throughout your brain. They can look like the classic seizures you see dramatized on TV or in the movies. They cause you to shake and jerk, roll on the floor, or foam at the mouth. “After it’s all over,” says Dr. French, “the tonic-clonic seizure is the most likely to cause injury because you may hit your head on the ground.” Though it’s often treatable, this is the worst-case scenario for epilepsy.
Unlike focal seizures, generalized seizures, which may have a genetic cause, start with electrical discharges in both sides of the brain. These are the kind of seizures that begin happening in people younger than 35, though once they start, they may continue for a lifetime. There are three kinds of generalized seizures: absence, myoclonic, and tonic-clonic.
Generalized Absence Seizures
With the absence seizure, people stare absently for a few seconds as they experience brief changes in their level of awareness. A 2018 Baylor College of Medicine study compared this type of seizure to an orchestra playing without a conductor. “When the seizure ended, it was like the conductor returned and the musicians play harmoniously again,” says Dr. French. “Your eye might have a dazed look, but you could sit there quietly and nobody would notice.”
Generalized Myoclonic Seizures
Generalized myoclonic seizures are characterized by a sudden, quick body jerk, often in the arm or leg. They only last for a couple of seconds and they can range from a mild twitch to a jerk that’s so forceful it can knock you over or make you throw something that’s in your hand. These seizures don’t usually affect your consciousness, and they often respond well to medication.
Generalized Tonic-Clonic Seizures
These are the dramatic, potentially dangerous seizures that knock you off your feet, and they’re more likely to occur among children, especially kids with developmental delays. “They don’t start happening in your sixties,” explains Dr. French. They’re exactly the same as focal tonic-clonic seizures—the only difference is that they begin in both parts of your brain rather than in one specific region.
Treating Epilepsy With Medication
The first treatment strategy for epilepsy is usually medication. “It doesn’t cure epilepsy,” explains Dr. Jobst. “It suppresses the seizures by reducing excessive electrical activity in the brain.” For most people, medications really help. A study from Columbia University examined their effectiveness, and over the course of a year, as many 79% of patients found relief. For best results, take your medication as directed and report any side effects, like problems with thinking, memory, or fatigue. Your doctor can change the dosage or the medication. Still having problems? Surgery is another option.
Treating Epilepsy With Surgery
On average, says Dr. Jobst, medication controls seizures for 70% of patients. But if you’re among the unlucky 30%, surgery may be an effective treatment for those with focal epilepsy. First, visit a specialized epilepsy center (find one here) for evaluation. When surgeons know where the seizures are happening, they can remove that tissue, using conventional surgery or laser interstitial therapy to remove brain tissue. “These procedures reduce seizures 64% of the time,” says Dr. Jobst.
Treating Epilepsy with Vagus Nerve Stimulation
Starting from your brain, there’s a pair of vagus nerves that carry messages throughout the rest of your body. With vagus nerve stimulation therapy (VNS), a tiny pulse generator, implanted in your chest, sends mild electrical stimulations to help calm the brain activity that leads to seizures.
VNS may take a year or two to kick in, but when it does, it can be very effective. One study showed that VNS therapy led to improvements for 60% of patients, with 8% of them experiencing complete freedom from seizures.
Treating Epilepsy With Diet
Studies show that the ketogenic diet, an extremely low-carb eating program, can help people when medications and surgery don’t work. A 2018 study showed that 13% of patients on the diet were seizure free and 53% saw their seizures reduced by half.
“The ketogenic diet works really well in children because it’s easier to restrict their food,” says Dr. Jobst, “and it works with adults who are able to stick with it. But it’s a very hard diet to follow. You have to go all-in—if you splurge once, the effect might be gone.”
Epilepsy and Depression
Epilepsy and depression often go hand-in-hand. A 2019 study showed that 55% of people with epilepsy also suffer from depression—and depression is linked to an increase in seizures. But a mindfulness-based program called Using Practice and Learning to Increase Favorable Thoughts (UPLIFT), which you can do at home, can help. A study published in 2020 showed that the program significantly reduced the number and severity of seizures that participants experienced. Learn more about UPLIFT here.