Understanding Epilepsy Seizure Types and Treatment Pathways

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• Focal Seizures Explained
• Generalized Tonic-Clonic Myth
• Absence & Myoclonic Seizures
• Diagnosis & EEG Importance
• Treatment Options Selection
• Medical Second Opinion
• Full Transcript

Focal Seizures Explained

Focal epileptic seizures are the most common type of seizure disorder. Dr. Tracey Milligan, MD, describes these episodes as often involving an alteration in awareness or a unique internal sensation. Patients may experience a dreamlike state, déjà vu, or a feeling that is difficult to articulate. These focal aware seizures can occur while the patient remains conscious of their surroundings.

Another form is the focal impaired awareness seizure. During these events, patients may stare into space and make automatic mouth or hand movements. They are not fully responsive and typically have no memory of the episode afterward. Dr. Tracey Milligan, MD, notes these seizures usually last from 30 seconds to two minutes and can cluster together.

Generalized Tonic-Clonic Myth

Generalized tonic-clonic seizures are the most recognized but least common seizure type. Dr. Tracey Milligan, MD, clarifies that this violent, convulsive event represents a relatively small percentage of cases. Many patients experience focal seizures for years before their first generalized tonic-clonic event, if they ever have one.

This misconception can lead to underdiagnosis. A patient's history of subtle focal episodes often only surfaces after direct questioning about strange sensations or brief lapses in awareness. Dr. Anton Titov, MD, discusses this diagnostic challenge with Dr. Milligan, highlighting the need for thorough patient interviews.

Absence & Myoclonic Seizures

Absence seizures are a generalized type that begin in childhood. Dr. Tracey Milligan, MD, explains that a child will stare into space, sometimes with eyelid flickering or mouth movements. These episodes are brief, lasting only seconds, but can occur hundreds of times per day before the child returns to normal activity.

Myoclonic seizures are another generalized form characterized by quick, jerky movements of the arms. Dr. Milligan shares a case of a college student who dropped objects like a shampoo bottle every morning. These seizures are often triggered by sleep deprivation or alcohol and frequently go unreported until a specialist asks specific questions.

Diagnosis & EEG Importance

Accurate epilepsy diagnosis hinges on determining the seizure's origin point. Dr. Tracey Milligan, MD, stresses the critical question: does the seizure begin in one specific brain region (focal) or involve both sides simultaneously (generalized)? This distinction directly guides all subsequent testing and treatment choices.

An electroencephalogram (EEG) is a cornerstone of this diagnostic process. Dr. Milligan describes how EEG patterns can definitively differentiate between focal and generalized epilepsy. She cites a case where a woman was misdiagnosed with focal epilepsy for her entire life; a review of her EEG confirmed generalized epilepsy, leading to a complete change in her medication regimen.

Treatment Options Selection

Selecting the best epilepsy medication depends entirely on the correctly identified seizure type. Dr. Tracey Milligan, MD, explains that certain medications are effective for focal onset seizures, while others are specifically indicated for generalized epilepsy syndromes. Using the wrong class of medication can be ineffective and may even worsen some seizure types.

Following an accurate diagnosis, the correct treatment can be life-changing. Dr. Tracey Milligan, MD, highlights the patient with generalized epilepsy who became seizure-free for the first time in her life after her medication was switched to one appropriate for her condition. This underscores the profound impact of a precise diagnosis on treatment success.

Medical Second Opinion

Obtaining a medical second opinion from an epileptologist is crucial for complex seizure disorders. Dr. Tracey Milligan, MD, advocates for this step because many seizure manifestations are subtle and easily missed. An epilepsy specialist is trained to ask the specific questions that reveal a complete history.

Modern technology facilitates remote second opinions effectively. Dr. Anton Titov, MD, and Dr. Milligan discuss how digital EEG recordings can be transmitted and reviewed by experts anywhere in the world. This allows patients access to top-tier specialist analysis without the need for travel, ensuring they receive the most accurate diagnosis and optimal treatment plan.

Full Transcript

Dr. Anton Titov, MD: What are the main types of epileptic seizures? How does treatment differ for different kinds of epilepsy? What are the best medications for different types of epileptic seizures?

Dr. Tracey Milligan, MD: There are different types of epileptic seizures. It is very important to know the many different manifestations of epileptic seizures. It is important to think about why somebody has epileptic seizures or why somebody has epilepsy.

I always think about the cause of epilepsy, but I also think about the different types of epileptic seizure. There are some very specific types of epileptic seizures. We know causes for those particular forms of epilepsy.

Dr. Anton Titov, MD: What is an epileptic seizure like? Most people think of a generalized tonic-clonic epileptic seizure. Actually, it is a relatively very small percentage of patients who have a generalized tonic-clonic epileptic seizure.

Dr. Tracey Milligan, MD: It is much more common for patients to have a focal epileptic seizure. They have an alteration in their awareness, or not. A patient may have some sort of internal sensation, like déjà vu. A patient can have a feeling that they have been someplace before or had this experience before.

It could be very difficult for patients to put into words. It could be some sort of funny or dreamlike state. That is one of the most common types of epileptic seizures. They may have those types of epileptic seizures for many years.

Only much later do they have a generalized tonic-clonic epileptic seizure. You may encounter a patient who had a generalized tonic-clonic epileptic seizure. You question them about these prior events. Only that helps to bring previous focal epileptic seizures to attention.

It is very important for patients to be aware of focal epileptic seizures. People have to be aware that epileptic seizures can be these funny episodes. Sometimes it feels as if it is some sort of dream.

There is a dream-like experience that is very familiar to the patient, but it is hard to put into words. We call those episodes focal epileptic seizures. Focal epileptic seizures can occur in patients who are otherwise aware of everything.

Sometimes they have a focal epileptic seizure with impaired awareness. It is a focal impaired awareness epileptic seizure. During those types of epileptic seizures, patients may stare into space. They sometimes make some mouth movements or hand movements.

Patients are staring into space. They are maybe a little bit responsive, but not fully responsive. They don't remember what had just happened. They may be a bit confused. Those episodes are focal aware epileptic seizures. They are called focal impaired aware epileptic seizures.

Such types of epileptic seizures are much more common than the generalized tonic-clonic epileptic seizures.

Dr. Anton Titov, MD: How long do those focal impaired epileptic seizures usually last? Usually, they last one to two minutes. It is not a duration of seconds, but it is a duration of a couple of minutes?

Dr. Tracey Milligan, MD: Yes. Sometimes epileptic seizures last half a minute. They can last maybe a minute or two minutes, or sometimes cluster together. Focal epileptic seizures are common.

Now we know that they begin in a very specific part of the brain. Manifestation of epileptic seizure depends on the part of the brain where the epileptic seizure is coming from.

There are other epileptic seizures that involve both sides of the brain right at the beginning. For example, an absence epileptic seizure. Absence epileptic seizures begin in childhood. They may happen hundreds of times a day.

A child will stare into space. A child will sometimes flicker their eyelids or make some mouth movements. They last seconds and the child is back to normal.

Dr. Anton Titov, MD: But absence epileptic seizures happen hundreds of times a day?

Dr. Tracey Milligan, MD: They happen hundreds of times a day. Those are a type of generalized epileptic seizures. Those are very different than the epileptic seizures that adults have, even if adults also stare into space during an epileptic seizure.

There is another type of epileptic seizure called myoclonic epileptic seizures. Myoclonic epileptic seizures are common. I mentioned that college student in Boston. He presented with a juvenile myoclonic epilepsy.

Those myoclonic epileptic seizures are quick movements of the arms. They typically happen in the morning. One of my patients was a 19-year-old man. He had an epileptic seizure in class. He was sitting in class; he hadn't slept well the night before. He also drank too much alcohol the night before.

He had a generalized tonic-clonic epileptic seizure in the university class. So he was brought to the hospital. I asked him about any myoclonic epileptic seizures. It was the only time he had ever told anybody.

For the past two to three years, he had a strange episode. Every morning, when washing his hair, he dropped the shampoo bottle. You have to ask patients about myoclonic epileptic seizures.

These are quick jerky movements that patients report. They may drop their orange juice in the morning. They may drop the toothbrush. This student dropped the shampoo. Many times, patients will not share that history until you ask them.

Myoclonic epileptic seizures are very brief generalized epileptic seizures. There are many different manifestations of epileptic seizures. It is very important for patients to be aware of these different symptoms.

Generalized tonic-clonic epileptic seizures are the least common of many types of epileptic seizures.

Dr. Anton Titov, MD: Patients see a primary care physician after some events. Patients usually do not see an epileptologist, an epilepsy specialist. But there should be a very high index of suspicion of epileptic seizures of different manifestations. It is important to refer a patient to an epilepsy expert.

Dr. Tracey Milligan, MD: An epilepsy expert can diagnose epileptic seizures correctly. An expert can really find the cause of what is going on with the patient. Yes, absolutely, absolutely. It is so important for patients to be aware of the various manifestations of epileptic seizures.

Every patient can get the proper diagnosis. Then we can select appropriate treatment by careful attention to the patient’s clinical history. We also monitor EEG, of course.

A patient may have a focal epilepsy or a generalized epilepsy. We have to ask important diagnostic questions.

Dr. Anton Titov, MD: Does an epileptic seizure begin in one specific part of the brain? Or does it involve both sides of the brain at once? That leads us to other specific diagnostic tests and to the correct treatment.

Dr. Tracey Milligan, MD: For example, there is a woman who made this box for me. She had been treated for a focal epilepsy her entire life. She actually had a generalized epilepsy. We could tell the difference on EEG.

We then changed her treatment. We used an epilepsy medication that works for generalized epilepsy. She became epileptic seizure-free. She never had an epileptic seizure in her life.

EEG can be transmitted electronically now. Patients could have an EEG and monitoring completed in one part of the world.

Dr. Anton Titov, MD: Then one or several epilepsy experts can review the situation in another part of the world. EEG and other diagnostic tests are sufficient to make the correct epilepsy diagnosis.

Dr. Tracey Milligan, MD: Absolutely! EEGs can be transmitted all over the world. EEG can be stored on digital media. They can be sent via the internet or through other means.

There is the ability to take that information and to get an expert opinion about epilepsy. Many epileptic seizure types exist. Some epilepsy symptoms are difficult to recognize.

Generalized tonic-clonic seizures involve violent shaking of the body. They are less common than more subtle focal epileptic seizures. Every patient with suspected epilepsy must get an expert opinion by a highly qualified epileptologist. It is an epileptic seizure expert.