Epilepsy

Clinical assessment

Diagnosis based on history of characteristic recurrent seizures (detailed description from patient/witness is crucial). Requires excluding provoked seizures (e.g., due to fever, acute illness, metabolic disturbance, toxins). Consider epilepsy if ≥2 unprovoked seizures.

Investigations

• Complete medical and mental health assessment.
• Electroencephalogram (EEG): Useful especially for absence and focal seizures, but a normal EEG does not exclude epilepsy. (RR/NR level).
• Neuroimaging (CT/MRI brain): To look for structural causes (tumors, stroke, malformations) - often at H/RR/NR level.
• Blood tests (glucose, electrolytes, calcium, renal/liver function) to rule out metabolic causes or assess for comorbidities/drug effects.
• Lumbar puncture if infection suspected.

Diagnostic criteria

Clinical diagnosis based on history of at least two unprovoked seizures occurring more than 24 hours apart, or one unprovoked seizure with clinical/EEG/imaging findings indicating a high probability of recurrence. Exclude acute symptomatic seizures.

Non-pharmacological management

• First Aid for Acute Seizure: Ensure safety (protect from injury, move away from danger like fire), DO NOT restrain, DO NOT put anything in mouth. Place in recovery position (on side) after convulsion stops if unconscious. Stay with the person. Seek help if seizure prolonged.
• Psychosocial support for patient and family.
• Health education about epilepsy, seizure triggers, medication adherence, safety precautions (e.g., swimming, driving restrictions).
• Address associated comorbidities (e.g., intellectual disability, behavioral problems).

Pharmacological treatment

• Status Epilepticus (Seizure >5-30 min or multiple seizures without recovery): MEDICAL EMERGENCY. Ensure ABCs. Check blood glucose (give IV Dextrose if low/unknown - Adult: 50% 1ml/kg; Child: 10% 5ml/kg). Give IV Diazepam 10mg slow IV (Child: 0.2mg/kg IV) OR Rectal Diazepam 10mg (Child: 0.5mg/kg rectal). Repeat after 5-10 min if seizure persists. If unresponsive: Give IV Phenobarbital 10-15mg/kg slow IV infusion (monitor BP/respiration closely) OR IV Phenytoin 15-18mg/kg slow IV infusion (use good IV line, monitor ECG/BP). Refer urgently if status persists.
• Chronic Epilepsy (Long-term management): Start with single Anti-Epileptic Drug (AED), low dose, titrate slowly. Aim for lowest effective dose to control seizures. If first AED fails, switch to another monotherapy. If two monotherapies fail, refer to specialist (H/RR). Consider stopping AEDs gradually after 2 years seizure-free (discuss risks/benefits).
• Choice of AED (Examples based on UCG):
• - Generalized Tonic-Clonic/Focal: Carbamazepine (Adult: start 100-200mg/d, maint 400-1400mg/d; Child: start 5mg/kg/d, maint 10-20mg/kg/d, divided doses) OR Phenobarbital (Adult: start 1mg/kg/d, maint up to 3mg/kg/d; Child: start 2mg/kg/d, maint up to 6mg/kg/d, once daily PM). Valproate is alternative for >2yrs. Phenytoin also option (Adult: start 150-200mg/d, maint 200-400mg/d; Child: start 3-4mg/kg/d, maint 3-8mg/kg/d).
• - Absence Seizures: Valproate or Ethosuximide (Child >6y: start 500mg/d, usual 1-1.5g/d; Child <6y: start 250mg/d, usual 20-40mg/kg/d, divided doses).
• - Caution: Avoid phenobarbital/phenytoin in children with intellectual/behavioral issues (use Carbamazepine/Valproate). Refer pregnant women with epilepsy to specialist.
• Follow specific Ugandan treatment algorithms/guidelines.

Monitoring

Monitor seizure frequency, type, duration. Monitor for AED side effects (drowsiness, rash, ataxia, gum hyperplasia, blood abnormalities - specific to drug). Follow up monthly until stable, then every 3 months. Monitor adherence. Consider AED levels if poor control or toxicity suspected (often specialist level).