I'm Dr. Tricia Ting. I'm a neurologist and regional director of the Epilepsy program. I see patients
who have seizures and epilepsy, predominantly. A lot of times people are not sure whether they're
having seizure or not. And doctors will send them if people have had loss of consciousness, blacking
out, even shaking spells, and they're just not quite sure is this a seizure disorder. We usually start
with a clinical visit to our outpatient clinic, again, where I would be able to get some
details of the history around the circumstances of the seizures, what types people are having. Then,
we want to get more information related to brain waves, and we do a study that's noninvasive. We
have electrodes taped to the scalp, and we do an EEG, or electroencephalogram, where we have the
patients lie still and just relax. And, that's how we can look at different rhythms of their brain
and evidence for a seizure disorder which might be abnormal spikes or sharps or other types of
abnormalities of the brainwaves. Once we can figure out what type of epilepsy they have, because there
are many different types, we'll understand what their likelihood is to need medication because a lot of
times we can control seizures with medication and let people lead very normal lives. It's very
natural when I first see patients, maybe with their first seizure, that there's a lot of concern on
many levels. They're wondering what can I expect in my life? Is this a life-threatening type of ailment?
Will I have another seizure where I blackout with no warning, for instance, and what is this
repercussions for my treatment, my lifestyle? Can I have kids? Can I get married? Can I drive again?
So, epilepsy or recurrent seizures is a high impact diagnosis. So, we want to make sure that
we make the right diagnosis. Having a diagnosis of epilepsy today is much more hopeful than we
were decades ago. We have a lot more medications available now that are approved and work very
well. Moreover, these new medicines have a lot fewer side effects, both short-term for tolerability as
well as long-term side effects. Beyond medicines, we also have a lot of options for surgical management
of patients with epilepsy who don't have their seizures controlled with medication. Now, we're able
to, with the high technology we have, really hone in on where the seizures are developing in their
brain. And in many cases, we can offer different kinds of surgery, whether it's respecting that tiny
area of the brain that's not functioning well for them or even implantable devices are now available.
It's highly rewarding to be able to help someone who's been having spells or seizures feel that
they have some control over it. Because, the problem with epilepsy and seizure disorders is the lack of
control, the feeling that you don't know when it's going to hit you. You might be driving. You might be
at work. You might face embarrassment. You might be injured from it. Patients are very thankful because
when they come in they're very anxious and they're worried. And once we've had that consultation and
I can tell them what it is they're experiencing what's our plan of action what's their likelihood
of having control or understanding what's going on, they are much more relieved. And,
they often leave saying thank you for you know explaining things to me and giving me this hope.
Epilepsy is a condition of recurrent seizures that occur without warning and without a reason.
The seizures are actually electrical storms of the brain, and there are many different kinds of
seizures. There are some focal seizures. There are some generalized seizures. People think
very classically of a grand mal, and that's an example of a generalized convulsion where
someone is blacked out. They may shake all over. They may get very stiff and fall down,
hurt themselves sometimes. And, they generally last a few minutes. Other kinds of seizures can
be very subtle and just very brief, a few seconds of blanking out and staring. People might smack
their lips or do some automatic behaviors, but they can be very quiet types of seizures. Yet
still, really impact someone's life. If you were to currently have episodes where you blackout
for 30 seconds at a time, that's still quite an impact on life life and health and safety.
There are many sources or reasons someone might get epilepsy. Often, it can be a small
injury to the brain, whether it's from a stroke or a growth, a tumor, or just something they were born
with like a like a little birthmark on the brain. Why it happened at different times
of life is often a question I get. They'll say okay Dr. Ting, you found a cortical dysplasia
or again like a birthmark on the brain. Why did I not have seizures from birth? Why did I only
have it when I was 20 years old or 30 years old? We know there are a lot of factors that impact
someone's seizure threshold or the likelihood they will have seizures. And, these can be hormonal
or related to stress or general health or fatigue. So sometimes, it takes a perfect storm for someone
who is at some risk for epilepsy. But normally if they're relaxed and not having too much stress,
they won't have a seizure. But, a perfect storm might happen if they have the flu, and they have
their menstrual period. Or they've been up many, many nights in a row for exams, and then they go
out and have a party and drink a little too much alcohol. All these might come together to lower
their general seizure threshold and then to the point that they individually will have a seizure.
The broad categories for epilepsy are focal and generalized, but the types of spells or attacks or
seizures they can have can be highly varied. So, we like to divide them into focal onset versus
generalized onset epilepsy to help us to give the patient a better idea of what medications
and what treatments are available to them and what medicines work best. Because, some
medications may make a generalized onset epilepsy worse and some treatment options
like surgical options are better suited for someone with a focal onset epilepsy
where they have just one area of the brain that starts off their seizures that can be taken out.
Many people can have a single seizure in their life, and usually, they won't have another one.
The problem with treating a single seizure is that you might be wetting someone to have to
take a medication that has toxicity, that has side effects for the rest of their lives and
they may not need it. So someone with epilepsy has recurrent seizures that we wait generally
for a second event to start treating with a seizure medicine to prevent a third or fourth.
Some patients may grow out of their seizures. This is what a lot of people hope for when
they come to see me. These are often for childhood epilepsy that people as they
reach their adolescence may not have any more seizures and don't have to worry about taking
medication. That is often seen in absence epilepsy, for instance, which is a generalized onset seizure
disorder. But, not everybody has that kind of epilepsy. A lot of people have epilepsy that
we call focal onset, and it may be from say a birthmark on the brain or a lesion. Maybe
they had head trauma at one point or stroke. And, these sort of things set up the brain
to have one area of malfunctioning neurons that will continue to fire off. And, it's unlikely for
many of these people that they would grow out of their seizures. So yes, some people have to
take medication for the rest of their lives. But, the good news is that with the current
medications that we have available, newer ones that have been developed, people can live very
normal lives without side effects, without worry of long-term toxicity from their seizure medicine. So,
I tell my patients it's often like taking a high blood pressure medicine if you've been given a
diagnosis of hypertension. It's not that big a deal if you can just continue to take it all the time.
Many women with epilepsy do come to me when they are thinking about getting married or having children
because they're worried that their seizure medicines may affect the health of their baby. And,
that's very natural. Especially since historically, there were traditional seizure medicines that were
known to cause serious birth defects. The good news is currently we have many newer medications that
are safe in pregnancy, that have been followed in big studies at academic centers while looking at
the outcome for many women with epilepsy who are taking some of these newer medicines. And,
we are able to reassure the patients, my women patients, that they can definitely have babies
and be still on their medication. The fear is, you know, I really try to tell them you don't want to
just stop your medication. Because, there is a risk if you were to do that that you would have more
severe seizures, even status epilepticus which is a life-threatening prolonged seizure problem if
you were to just stop your seizure medicines. And, that's not healthy for a baby either or the mother.
For people who have a generalized epilepsy, what we now call generalized genetic, it is
somewhat more hereditary and can be passed in family members. But
even then, the risk remains very low. And often, generalized epilepsies are
very easy to treat, so it shouldn't be the reason people decide not to have children.
The medicines that we're using nowadays are very safe. They've been fully evaluated with
lots of patients taking them, and they're approved by the FDA. They are safer in many
ways than herbal medications they make it from a natural food store because herbal
medications are not vetted in the same way. They're not tested in the same way to show
that they're effective for seizure control and necessarily safe. And often, herbal medicines do
have medicinal effects and can interact with the other medications. So ,it's not without some risks.
There are certain diets available for children and now even adults. In children, there's something
called the ketogenic diet where it's very high fat, very high oil, but no carbohydrates.
It's a very difficult diet, so we really can only manage it in young children. Once people
start living their lives and going out and trying to have an adult life, it's very hard to
maintain that type of diet. So, there's been much work on a modified ketogenic
diet which is almost like a low carb Atkins diet. And, there's some evidence that that is
helpful for seizures. So patients who are interested, I do tell them where they can get
more information about this and explore that possibility. But even with certain diets that
would be more palatable like a South Beach or Atkins diet, there can be side effects to that
like high cholesterol or weight loss. That is something that people have to consider.
An EEG is an electroencephalogram. This is one of our basic tools in the epileptologists' regimen
to look at what kind of seizures someone's having. What it involves is putting electrodes
on the scalp and measuring the brain waves. It's very similar to an EKG that you might
get in a doctor's office or in the emergency department where they put electrodes across
the chest to look at the heartbeat. We do that on the scalp, and it allows us a picture into
the natural brain waves when someone's awake, when they're asleep, and often we're able to see
abnormal spikes and sharps. I tell people it's like a live wire that's kind of going off and
sparking off in their head. It gives me a sense of what their risk of having a seizure might
be. Because if you were not to have those, sometimes our medicines can control that, we
realize that there's a lower risk if those types of abnormalities are not seen on the brainwaves.
Usually, we'll have EEGs done in the very beginning of a diagnosis to get a better understanding,
again, of what kind of seizures someone's having because that impacts our therapeutic choices and
prognosis. After the first one or two, sometimes they need a second or third one if the first
one is not as helpful. Maybe, they didn't fall asleep, or we didn't see any abnormalities. But
generally, multiple tries at it may reveal an abnormality that's very helpful for diagnosis.
Often EEGs are very short, maybe less than an hour long, and it's only a sampling. We'd like
to see a longer period of time, maybe even catch a typical seizure that someone might be having maybe
only when they sleep in the middle of the night. In those cases, we can bring people into our
hospital. We have a specialized epilepsy monitoring unit that allows them to sleep with the EEG on
and specialized nurses to care for them should they have a seizure. And, we may keep them in the
hospital for several days and get a lot more data and information on the types of seizures they're
having, whether they might be surgical candidates if we can figure out exactly what area the brain
the seizures are coming from. And, even try to change their medicines while they're in the
hospital, again, to achieve better seizure control, all while they're being monitored by the EEG.
Well, the monitoring unit is highly beneficial mostly because it allows us a longer sampling
time of someone's brain waves through many states, while they're awake, while they're
asleep, and several days of it. It allows us to pull away some of their medicines. If someone
is having seizures despite being on medication, we can pull off the medication, catch a typical
seizure. Because, sometimes that happens when we pull seizure medicines off. And, again, have
really the gold standard diagnosis for what their attack is. Not everybody who blacks out
has seizures or epilepsy. Some people who black out might have complicated migraines or cardiac
syncope. They might even have stress or panic attacks that really mimic seizures in that
they come without warning, and they blackout. So this helps us because if it's an epileptic
seizure, we would know with the EEG tracing that's going at the same time as their event. And, it's
really hard to do that in the outpatient setting, so we bring them to the hospital.
Once we have a good idea of the diagnosis of someone's seizures after those first
sets of EEG s or even prolonged monitoring in the hospital, we don't always have to do
a regular EEG studies after that. It really depends on how someone's doing. If they take
a turn for the worse, say they went from being seizure free on medication and suddenly spells are
coming back or seizures are returning, we might get another EEG at that point. Or, if
we know what the source of their seizures are, again, if it's a tumor or mass, we can reassess
that with different with a repeat epilepsy EEG study. But, it's not always necessary to be a
yearly or even up every couple year event. It's really as needed based on the clinical picture.
We have many medications that work very well for seizures and to control epilepsy. But sometimes, someone's
seizures just cannot be controlled even if they're on two, three, four medications. And,
that gets very frustrating. They have a lot of side effects, often, and still dealing with
seizures they can't control. We can offer other therapies. These include surgical therapies that,
in some cases, might even cure their epilepsy if we can remove a small part of their brain, that's
what I tell patients, is malfunctioning, is not serving us well, but only causing problems and
causing the seizures, the electrical storms. We would only, of course, remove those small areas
if we can pinpoint it, know exactly where it is, and it's in a removable area. If it's
not removable area or they have multiple sites that we really can't get all the little spots
of problem, sometimes they might benefit from implanted devices. Those are the latest and
newest treatment options in the surgical realm, and we could implant devices so that we don't
have to remove parts of their brain but just shock those areas to deplete the possibility of seizures.
Generally, people are able to drive with seizure disorder if their seizures are controlled and
if their seizures are not happening during the day. There are some patients who for instance
only have seizures when they're sleeping at night. Since they're not driving while
they're sleeping, they may be allowed to have a driver's license and a permit to drive.
But generally, patients have to be seizure-free, on a medication to be able to drive.
I'll usually recommend to my patients that they if they feel it could be helpful for them that they
seek out other patients who are dealing with the same issues. Because epilepsy is a life-changing
type of diagnosis and involves a whole lot of different issues including even just social
stigma. Some people feel like they don't want to share that they have seizure disorder, so it's
helpful to have other patients to talk to. And there are many support groups. Ones I recommend
are available through the Epilepsy Foundation of America and can be found online at epilepsy.com.