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Epilepsy: what works and what doesn't

MagazineDecember 2010 (Vol. 21 Issue 9)Epilepsy: what works and what doesn't

Epilepsy is a disorder of brain electrical activity that results in recurrent seizures

Epilepsy is a disorder of brain electrical activity that results in recurrent seizures. The severity of seizures differs from one person to another. Some people simply experience a momentary 'blank out' (absence, or petit mal, seizures), whereas others lose consciousness and have convulsions (tonic-clonic, or grand mal, seizures).

Yet, despite the obvious symptoms, epilepsy is difficult to diagnose. In 2002 alone, an estimated 92,000 people were misdiagnosed as having epilepsy in England and Wales (Seizure, 2006; 15: 598-605). The economic consequences of such misdiagnoses are huge-the total medical costs may reach up to lb138 million a year-but what's even worse is the impact that a wrong diagnosis can have on an individual's life.

In addition to suffering the social and financial effects (driving restric-tions and the threat of losing one's job, for example), thousands of patients may also be inappropriately receiving potentially harmful anti-convulsant drugs (Eur J Neurol, 2008; 15: 1034-42).
For these reasons, it's vital to always seek a second opinion, and preferably from a specialist practitioner with training and expertise in epilepsy.

Conventional treatments

Treating epilepsy usually involves antiepileptic drugs (AEDs), or 'anti-convulsants'. These drugs don't cure epilepsy, but can prevent seizures by either altering electrical transmissions in the brain or changing the brain's chemicals. Around two-thirds of patients with newly diagnosed epilepsy become seizure-free when treated with AEDs (Epilepsy Curr, 2008; 8: 90-1).

But there's a high price to pay for this efficacy. All AEDs depress central-nervous-system function, and so are associated with sedation, dizziness, ataxia, cognitive and visual disturb-ances, and gastrointestinal symptoms (Am Fam Physician, 2001; 64: 91-9). More worrying, several drugs-including the newer, supposedly safer, AEDs-have been linked to psychiatric side-effects such as suicidal behaviours.

In response to the US Food and Drug Administration (FDA) manda-tory warning labelling for anticonvul-sants in 2008, one study looked at second-generation AEDs, such as gabapentin, lamotrigine, oxcarbaze-pine and tiagabine. All increased the risk of suicide, attempted suicide or violent death: there were 26 suicides, 801 attempted suicides and 41 violent deaths with 297,620 new courses of treatment using an anticonvulsant drug (JAMA, 2010; 303: 1401-9).

Other serious side-effects of certain AEDs include memory loss and other cognitive deficits, Stevens-Johnson syndrome (SJS; a potentially deadly hypersensitivity complex affecting the skin and mucous membranes), liver failure and aplastic anaemia (Arzneim Forschung, 2010; 60: 1-11; JAMA, 2004; 291: 605-14)-not to mention the increased risk of birth defects related to drug exposure in the womb (Lancet Neurol, 2005;4: 781-6). Exposure to lamotrigine, for instance, has been linked to a 10-fold increased chance of being born with a cleft lip or palate, a condition characterized by incomplete closure of the upper lip or roof of the mouth (Neurology, 2008; 70: 2152-8).

In addition, according to the drug companies' own data, AEDs can even make seizures worse (Epilepsy Curr, 2002; 2: 184-5), while 30-40 per cent of patients continue to have seizures despite drugs (JAMA, 2004; 291: 605-14).

Dietary approaches

Fortunately, AEDs are not the only way to manage epilepsy, as mounting evidence suggests that certain dietary changes can help to control seizures.
The most effective method is the ketogenic diet (KD), a high-fat, adequate-protein, low-carbohydrate diet that's been around since the 1920s. In fact, the diet may be even more effective than most of the newer medications currently used to treat epilepsy (Pediatrics, 2007; 119: 535-43).
Following a KD leads to ketosis- increased blood levels of 'ketones'-which controls seizures through an as-yet unknown mechanism. The diet can stop seizures, as well as the propensity to develop recurrent, unprovoked seizures (epilepsy).

In a recent randomized controlled trial (RCT), 38 per cent of children following a KD for three months cut their seizures by more than half compared with only 6 per cent of the controls. Also, 7 per cent of the KD group reduced their seizures by more than 90 per cent compared with 0 per cent of the controls (Lancet Neurol, 2008; 7: 500-6).

In earlier studies, 40-70 per cent of patients on the diet cut their seizure frequency in half, whereas 10-33 per cent became seizure-free. In many cases, their medication was either discontinued or dosages were reduced (Altern Med Rev, 2007; 12: 9-24).

The diet is especially effective in children aged 2-5 years, although older patients benefit, too. In an eight-month trial of 11 adults aged 19-45 years, three patients saw a 90-per-cent reduction in seizures, three others saw a 50- to 89-per-cent decrease, and one had a less than 50-per-cent decrease. Also, all types of seizures responded to the diet (Epilepsia, 1999; 40: 1721-6).

The diet has drawbacks, however. Possible side-effects include gastro-intestinal upset, dehydration, high blood levels of fat and acidity, kidney stones and lethargy (Pediatrics, 2007; 119: 535-43). Supplementing with vitamins and minerals is also necessary to prevent nutritional deficiencies (Altern Med Rev, 2007; 12: 9-24).

But the main problem is that the diet is unpalatable, so it's difficult to stick with it and for parents to administer. Ultimately, its success and safety are best achieved with the close supervision of an experienced health-care team that includes a doctor, dietitian and, often, a nurse.
An alternative to the KD is the Atkins diet. Like the KD, this high-fat, low-carbohydrate diet leads to ketosis, but has fewer restrictions on calories and protein, and so is easier to follow.

Studies in both children and adults suggest that the Atkins diet is as effective as the KD for reducing seizures. In 27 children after six months, there was no difference in seizure reduction between the two diets (Seizure, 2009; 18: 359-64). Also, according to a review of eight studies of the Atkins diet, 45 per cent of patients achieved a 50- to 90-per-cent reduction in seizures, while 28 per cent reduced their seizures by more than 90 per cent. These results are remarkably similar to those seen with the traditional KD (Epilepsia, 2008; 49: 37-41).

A low glycaemic index (GI) diet may also be beneficial for epilepsy. Such a diet allows a more liberal carbohydrate intake than either the KD or Atkins diet, but restricts the type of carbohydrate-containing foods to those that produce relatively small changes in blood glucose levels.

The GI diet was recently put to the test in 76 children, 89 per cent of whom had drug-resistant epilepsy. After a year on the diet, 66 per cent had reduced their seizures by more than 50 per cent, and 42 per cent saw dramatic results in as little as one month. Unlike the KD and Atkins diet, the success of the GI diet appears to be related to low blood glucose levels rather than ketosis status (Epilepsia, 2009; 50: 1118-26).

In general, these diets need to be continued for several years to be effective. Nevertheless, long-term benefits can be achieved even when the diet is followed for only a few months, which suggests that the diets may be neuroprotective (Neuro-therapeutics, 2009; 6: 406-14).

The allergy angle

Many nutritionists believe that food allergies lie at the root of many other-wise inexplicable cases of epilepsy, and there is evidence to bear this theory out. In specific individuals, certain foods have been implicated as causing epilepsy, and the avoidance of such symptom-evoking foods has resulted in a reduction of seizure frequency or complete elimination of seizures (Altern Med Rev, 2007; 12: 9-24).

Also, in a study of 63 children with epilepsy, identification and avoidance of allergenic foods was successful for a significant number of children who had other symptoms suggestive of allergy, such as headaches, abdominal symptoms and hyperactive behaviours. Of these children, 25 became free of seizures and 11 had fewer seizures during the diet therapy. Their other symptoms also disappeared in most cases. However, children who had epilepsy alone did not respond to the diet (J Pediatr, 1989; 114: 51-8).

Another study comparing 72 epileptic children with 202 controls found a significantly higher incidence of allergy to cow's milk among the epileptics. What's more, the epileptics were also more likely to have asthma, thereby offering further support for the allergy-epilepsy connection (Acta Neurol Scand, 2001; 104: 349-52).

A greater prevalence of coeliac disease has also been found in patients with epilepsy compared with their matching controls. Seizures improved in patients with coeliac disease who were put on a gluten-free diet, but only when the diet was started soon after the onset of epilepsy (Altern Med Rev, 2007; 12: 9-24).

These studies suggest that identifying any possible food allergies may have an important role to play in epilepsy, especially if allergies such as asthma and hay fever are also present.

Supplements for seizures

Several nutritional deficiencies are associated with epilepsy, including vitamins B1 and B6, vitamin E, magnesium and manganese, so supplements may be beneficial in some cases. Indeed, there is even a phenomenon known as 'vitamin B6-dependent epilepsy', a condition in which seizures can be completely controlled by giving large doses of vitamin B6.

According to Dr Alan R. Gaby, a specialist in nutritional medicine, "The existence of this relatively rare syndrome raises the possibility that more subtle forms of nutrient dependency occur more commonly. While mildly or moderately increased requirements for vitamin B6 or other nutrients may not by themselves be sufficient to cause seizures, a failure to meet these increased requirements could aggravate an existing seizure disorder" (Altern Med Rev, 2007; 12: 9-24).

In fact, studies have found that supplementation with individual nutrients can reduce the frequency of seizures. In one such study, 24 children taking anticonvulsants (and still having seizures) were given either 400 IU/day of vitamin E or a placebo along with their usual medication for three months. Ten of the children in the vitamin E group vs none in the placebo group reduced their seizure frequency by more than 60 per cent. Moreover, six of these 10 children succeeded in reducing their seizures by 90-100 per cent (Epilepsia, 1989; 30: 84-9).

Other studies suggest that supple-ments of magnesium, manganese and omega-3 fatty acids can help to control seizures. However, certain nutrients-such as folic acid and omega-6 fatty acids-can actually make seizures worse (Altern Med Rev, 2007; 12: 9-24).

In the end, if you decide to pursue this non-drug therapeutic route, make sure that you do so only with the guidance and supervision of a qualified health practitioner.

Joanna Evans

For further information on epilepsy, see WDDTY 14 no 4.

WDDTY VOL 21 NO 3


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