The role of nonpharmaceutic conservative interventions in the treatment and secondary prevention of epilepsy

Nonpharmacologic conservative treatments receive too little attention. Depending on the clinical condition of the patients, they may be used alone or in conjunction with other therapies. Their target is the single seizure rather than the epileptic condition as such. They belong mainly to one of three domains. NONSPECIFIC PREVENTION OF SEIZURES: The first step is the identification of factors facilitating the occurrence of seizures. In the second step, strategies to control these factors are developed. Most common are disturbances of the sleep-wake cycle, especially reduction of sleep. Patients should follow a regular sleep schedule with deviations of not >2 h. Sometimes a sleep calendar is helpful. Night shifts are not compatible with seizure prevention in these cases. Sleep disturbances as a facilitating factor of seizures are particularly common in juvenile idiopathic generalized epilepsies, in which their avoidance is in many cases an indispensable part of the therapeutic regimen, along with appropriate drug treatment. They are the most common precipitating factor in adolescents and adults with a first epileptic [mostly generalized tonic-clonic (GTC)] seizure. In these instances, their avoidance is central to the secondary prevention of epilepsy developing from the single seizure, whereas the prescription of antiepileptic drugs (AEDs) is rarely effective. Other nonspecific facilitators of seizures include uncontrolled use of alcohol and extraordinary stress. Patients must learn how to cope with stressful events. SPECIFIC PREVENTION OF SEIZURES: In reflex epilepsies, specific precipitants of seizures are the targets of interventions. Thus, most patients with primary reading epilepsy begin to have, with prolonged reading, perioral reflex myoclonias, which enable them to stop reading and thus to avoid a GTC seizure. In photosensitive patients, seizures are often precipitated by television. These can be avoided by viewing from a distance and using a remote control, small screens in a well-lit room, and preferably with a 100-Hz line shift. Environmental flicker stimulation often comes unexpectedly, and it is advisable that the patients always wear sunglasses in brightly lighted surroundings. Polarized glasses seem to be more protective than plain sunglasses. If the patient has only photically induced seizures, treatment by specific prevention alone may be sufficient, but if spontaneous seizures also occur, drugs must be given in addition. ARREST OF SEIZURES: Focal seizures that develop sufficiently slowly to leave the patient time to react may be interrupted by "countermeasures." These, again, may be nonspecific (acting by relaxation, concentration, or a combination of both) or specific. The latter are individually tailored, based either on spontaneous experiences of the patient or on the anatomy of ictogenesis. Seizure propagation is blocked when a major part of the neurons involved is activated and not recruitable for spread of the epileptic discharge. Seizure arrest rarely is used alone but usually in combination with partially successful pharmacotherapy.

Primary reading epilepsy: therapeutic efficacy of clonazepam in one case

Primary reading epilepsy is a rare form of reflex epilepsy, in which reading is the specific stimulus evoking attacks. The authors report a case of an 18-year-old man who since the age of 17 presented myoclonic jaw jerking provoked exclusively by reading. In one episode, in which reading was not interrupted, jerks were followed by a generalized convulsive seizure. EEG with routine activating procedures was normal, while EEG recorded during reading showed bilaterally synchronous paroxysmal small-voltage spikes, more prominent in frontocentral regions, coinciding with jaw myoclonus. Complete clinical seizures control and EEG normalization were achieved with clonazepam 2 mg daily in a 24-month follow-up.

Reading and language-induced epilepsy

Primary reading epilepsy
Primary reading epilepsy usually begins when the person is between 12 and 25 years old. In this condition, seizures are provoked only by reading, and people do not have seizures at other times. Usually, while reading, the person’s jaw clicks or jerks and, if she keeps reading, she may have a generalized tonic-clonic seizure. Other seizure types may also occur. People with this syndrome often have a family history of epilepsy, and cases of reading epilepsy that run in families have been reported. Primary reading epilepsy may be a specific form of language-induced epilepsy (see below).

Secondary reading epilepsy
Secondary reading epilepsy is very similar to primary reading epilepsy, except that people with this condition may also have unprovoked seizures.

Language-induced epilepsy
In language-induced epilepsy, stimuli such as writing, typing, listening to speech, singing, or reciting may trigger seizures. People with this syndrome have jaw jerks with abnormal EEG activity.

Some symptomatic epilepsies may also result in reading- or language-induced seizures.