Prognosis:

General Outlook for Patients with Epilepsy

Most patients can control their seizures with a single drug and stop drug treatment completely
after 2 years without seizures. In fact, patients who respond well to an anti-epileptic drug
(AED), have a better chance for remaining seizure-free in the future. In general, patients who
do not have good control with medications are more likely to have difficulty with epilepsy
treatment.
Injuries and Accidents
Injuries from Falls. Because many people with seizures fall, injuries are common. Although
such injuries are usually minor, people with epilepsy have a higher incidence of fractures
than those without the disorder. Epilepsy patients who take the drug phenytoin have an even
higher risk, since the drug can cause osteoporosis.
Household Accidents. Household environments, such as the kitchen and bathroom can be
dangerous places for children with epilepsy. Parents should take precautions to prevent
burning accidents from stoves and other heat sources. Children with epilepsy should never be
left alone when bathing.
Driving and the Risk for Accidents. Being unable to drive is an extremely distressing and
severe component of epilepsy. Drivers with well-controlled epilepsy are not at a high or
unacceptable risk for automobile accidents. Uncontrolled epilepsy, however, poses a high
risk. Needless to say, seizures can be very dangerous if they occur while a person is driving.
Studies have reported that more than a fourth of drivers with uncontrolled epilepsy had a
seizure-related accident at some time. Many of these accidents resulted in injuries to the
patient or others.
Certain factors can help predict who may safely drive:
A long duration between seizures (seizure-free for 6 months or more)
Having few seizure-related accidents
Having a reliable pre-seizure warning sign, such as an aura
Accidents while Swimming. Swimming poses another danger for people with epilepsy,
particularly those with tonic seizures, which can cause the diaphragm to expel air quite
suddenly. People with epilepsy who swim should avoid deep and cloudy water (a clear
swimming pool is best), and always swim with a knowledgeable, competent, and experienced
companion or have a supervisor on site.
Survival Rates
Epileptic patients who are cured have a normal lifespan. Their long-term survival rates are
lower than average if medications or surgery fail to stop the seizures. The lower survival rate
is partly due to a higher-than-average risk for death due to accidents and suicide. The specific
cause of the seizure may also contribute to fatalities.
There is a very low risk for sudden death in patients with epilepsy. Although the causes of
such events are not fully known, doctors suspect heart arrhythmias in many cases.
Effects of Epilepsy in Children
Long-Term General Effects. In general, the long-term effects of seizures vary widely
depending on the seizure's cause. The long-term outlook for children with idiopathic epilepsy
(epilepsy of unknown causes) is very favorable. One study reported that 68 - 92% of these
patients were seizure-free after 20 years. Another study reported that they had a survival rate
no different from children without these seizures.
Children whose epilepsy is a result of a specific condition (for example, a head injury or
neurologic disorder) have higher mortality rates than the normal population, but their lower
survival rates are most often due to the underlying condition, not the epilepsy itself.
Effect on Memory and Learning. The studies on the effects of seizures on memory and
learning vary widely and depend on many factors. In general, the earlier a child has seizures
and the more extensive the area of the brain affected, the poorer the outcome. Children with
seizures that are not well-controlled are at higher risk for intellectual decline.
Social and Behavioral Consequences. Learning and language problems, and emotional and
behavioral disorders, occur in a significant number of children with several of the partial
epilepsy syndromes. These children perform worse on behavioral tests than do other children.
Whether these problems are caused by the seizure disorder and anti-seizure medications or
are simply part of the seizure disorder remains unclear.
Effects of Epilepsy in Adults
Effect on Mental Functioning in Adults. The effects of adult epilepsy on mental functioning
are not clear. More research is needed in this area, as results have been contradictory.
Psychological Health. About 25 - 75% of adults with epilepsy show signs of depression.
People with epilepsy have a high risk for suicide, particularly in the first 6 months following
diagnosis. The risk for suicide is highest among people who have epilepsy and an
accompanying psychiatric condition such as depression, anxiety disorder, schizophrenia, or
chronic alcohol use. Antiepileptic drugs (such as carbamazepine,
gabapentin,topiramate,valproate, and many others) can increase the risk of suicidal thoughts
and behavior. [For more information, see Medications section in this report.]
Overall Health. Many patients with epilepsy describe their overall health as "fair" or "poor,"
compared to those who do not have epilepsy. People with epilepsy also report a higher
frequency of pain, depression, anxiety, and sleep problems. In fact, their overall health state
is comparable to people with other chronic diseases, including arthritis, heart problems,
diabetes, and cancer. Treatments can cause considerable physical effects, such as
osteoporosis and weight changes.
Effect on Sexual and Reproductive Health
Effects on Sexual Function. There have been studies suggesting that up to two-thirds of
patients with epilepsy experience sexual disturbances, including erectile dysfunction in men.
Causes of these problems may be emotional, medication induced, or a result of changes in
hormone levels:
Epilepsy in childhood may cause disturbances in hormones regulating puberty.
Persistent seizures in adults may be associated with other hormonal and neurologic
changes that contribute to sexual dysfunction.
Negative emotions due to epilepsy can reduce sexual drive.
Medications may be responsible for many of these cases, although newer drugs may
reduce this problem.
Epilepsy and Pregnancy
Studies have been conflicting on the effects of fertility from epilepsy, but most suggest that
fertility rates among women with epilepsy are lower than among women in the general
population. A number of factors, including anti-epileptic drugs (AEDs) or social factors such
as marriage at an older age, may contribute to this lower rate. Certain AEDs, particularly
valproate, disrupt ovulation and menstruation by increasing male hormone levels and weight
and causing polycystic ovaries.
Preparing to Become Pregnant. A woman should visit her doctor at least 3 months before
becoming pregnant to talk about risks of medications and the possibility of making any
changes.
A woman who has been seizure-free for 2 or more years may attempt to discontinue
drugs under her doctor ' s supervision.
If she has not been seizure-free, she should continue medications but try to reduce
them to a single drug, if possible. (Again, under a doctor ' s supervision.)
If a woman taking antiseizure medications has an unplanned pregnancy, there may be
no point in switching medications right away, since the effects of the drugs last for 10
weeks. However, she should notify her doctor immediately.
Folic acid is recommended for all pregnant women, and women with epilepsy should
talk with their doctor about taking folic acid supplements at least 3 months before
conception as well as during the pregnancy.
Effect of Pregnancy on Seizure Frequency. The frequency and intensity of seizures vary
widely in women with epilepsy. About 25% of pregnant women with epilepsy face an
increase in events, and the risk is highest in those who have more than one seizure per month
prior to becoming pregnant. In most cases, however, there is no change at all. Some pregnant
women even have a decrease in seizures. The risk is lower in women who experience less
than one seizure in the 9 months prior to becoming pregnant.
The following conditions may contribute to an increase in seizures during pregnancy:
Nausea and vomiting (vitamin B6 and antihistamines may help with nausea)
Fluid retention
Higher estrogen levels
Psychological and emotional stress
Medication noncompliance from fear of side effects
Problems with sleeping
Changes in absorption of anticonvulsants
Anti-epileptic drug levels are monitored at least three times during the pregnancy, more often
if seizures are occurring or levels are not normal. Dosage levels should be adjusted
accordingly.
Effects of Epilepsy on the Pregnant Patient and the Fetus. Women who become pregnant
have a risk for uncontrolled seizures and birth defects from antiseizure medications. In
studies of women who were carefully monitored, however, 95% of pregnancies (which is
close to normal) had favorable outcomes.
Isolated seizures do not appear to pose any adverse effects to the mother or the unborn child,
but repeated seizures and status epilepticus can lead to great dangers. In one study, the effect
of epilepsy on complications during pregnancy was the same as in non-epileptic women
except for a higher rate of premature deliveries (8.2% in the women with epilepsy).
Drugs Used During Pregnancy. Some types of anti-epileptic drugs (AEDs) can increase the
risks for birth defects, especially when taken during the first trimester of pregnancy. Expert
guidelines advise that pregnant women use the most effective medication for their type of
epilepsy at the lowest dose possible to control seizures. They should also have their doctors
take blood tests during pregnancy to monitor their drug levels.
The fetus should be carefully monitored with ultrasonic evaluation and sometimes
amniocentesis (visual tests and examination of the fluid in the womb for birth defects and
other fetal problems).
In general, research indicates that 90% of women who take AEDs will give birth to healthy
children. Still, doctors recommend that women of child-bearing age use a drug other than
valproate if possible.
The risk for malformation is higher when more medications are used. For example, there is a
3% risk of birth defects with women who use one anticonvulsant. The risk increases to 20%
when four drugs are used.
Birth Defects Associated with Medication. The most common birth defects related to anti-
epileptic drugs are:
Cleft lip or palate (risks from lamotrigine, phenobarbital, phenytoin, valproate
especially when taken during the first trimester).
Genital or urinary abnormalities (risk from most standard drugs).
Neural tube defects (NTD) in the skull or spinal column (risk of 2% with valproate
and 1% with carbamazepine). These complications are most often due to lower folic
acid levels caused by both pregnancy itself and antiseizure drugs. Folic acid
supplements can help prevent this problem.
Mental impairment (known risk with phenytoin and valproate; inconclusive in
carbamazepine and phenobarbital).
Heart defects (risk from phenobarbital, phenytoin, valproate).
Many antiseizure drugs also cause a deficiency in vitamin K clotting factors that increases the
risk for hemorrhage in the newborn. Treatment with vitamin K during the last month of
pregnancy and a single dose given to the newborn is recommended.
Labor and Delivery. Seizures occur during labor and after delivery in a small percentage of
women with epilepsy. The following labor complications are more common among pregnant
women with epilepsy: Vaginal bleeding, anemia, and preeclampsia (extremely high blood
pressure in the third trimester). If seizures occur during labor, they are generally treated
intravenously with benzodiazepines or phenytoin. If tonic-clonic seizures, absence seizures,
or status epilepticus occur, a cesarean section may be appropriate.
Postnatal Care
Monitoring the Infant. The infant should be thoroughly examined for any birth defects. Also,
if the mother was given phenobarbital or primidone while pregnant, the infant should be
monitored for up to 8 months to see if withdrawal symptoms develop. Drug dosages will also
need to be adjusted for the mother after delivery.
Breast-feeding. Women on most AEDs typically can nurse their babies, since usually only a
small amount of the drug enters the breast milk. The lowest levels are with phenytoin and
valproate. (Ethosuximide and possibly levetiracetam are exceptions and should be avoided
when a woman is breast-feeding. Women taking phenobarbital are also usually advised not to
nurse.) A mother should watch for signs of lethargy or extreme sleepiness in her infant,
which could be caused by her medication.
Resources
www.epilepsyfoundation.org -- Epilepsy Foundation
www.aesnet.org -- American Epilepsy Society
www.aan.com -- American Academy of Neurology
www.ninds.nih.gov -- National Institute of Neurological Disorders and Stroke
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