Treatments for Epilepsy
There is currently a revolution underway in epilepsy treatment, with more options available each year. At Mount Sinai, we believe in tailoring the treatment plan to your individual needs. During consultation, we discuss all of the available possibilities to determine the best fit for you.
Medications for Epilepsy
There are currently more than 20 medications that are approved by the U.S. Food and Drug Administration for treatment of epilepsy. No medication has been proven better at controlling epilepsy than any other. At Mount Sinai, we have extensive experience matching the right medication or combination of medicines to each patient to maximize efficacy and minimize side effects. Sometimes we select a medication because it will help manage a person’s seizures and help with another problem the patient is experiencing, such as migraine headaches.
Controlling seizures is only part of our goal. We want to improve overall daily life for people with epilepsy. Because we take side effects seriously, we always ask if a patient is experiencing fatigue, weight gain, dizziness, or low mood. In addition, we look for silent side effects, like low bone density. For woman of childbearing age, we offer the medications that are safest in pregnancy.
Surgery for Epilepsy
About 30 percent of people with epilepsy will continue to have seizures despite taking anti-seizure medications. If a person does not have full seizure control, an appointment to discuss other options might be helpful. We understand the thought of epilepsy surgery can be anxiety provoking, so our team—as well as our other patients who have undergone surgery—is available to discuss all your questions and concerns. Epilepsy surgery is often the best chance for a cure.
The multidisciplinary epilepsy surgery team at Mount Sinai includes epileptologists, neurosurgeons, neuropsychologists, and radiologists. After we discuss all surgical decisions as a group, the neurosurgeon and epileptologist directly involved in a patient’s care will then make recommendations during a family meeting.
The pre-surgical work-up may include many components, such as a consultation, video electroencephalogram (EEG), neuropsychological testing, detailed imaging studies, pre-surgical clearance, and a Wanda test (a procedure in which each hemisphere of the brain is tested separately for language and memory functions).
We are leading experts in minimally invasive techniques and offer every surgery available in the country, including the following:
- Stereotactic electroencephalography (SEEG): The SEEG is a diagnostic procedure that captures seizures via electrodes in the brain tissue to get more detailed information on where seizures begin. During the admission, we lower medications to capture seizures. We implant electrodes in the operating room while the patient is asleep. Incisions for the electrodes are tiny, and we shave a dime-sized amount of hair. The admission may last about one week. Recovery from the procedure is about two to three weeks.
- Resective surgery: During this procedure, we surgically remove the area of the brain responsible for starting the seizures. We use all of the above pre-surgical tests to ensure that the surgery will not cause neurological problems. We do not remove essential areas of the brain
- Laser interstitial thermal therapy (LITT): Once we have identified a seizure focus, some people are candidates for laser ablation. This procedure involves the surgical placement of a small, heated electrode while the patient is in an magnetic resonance imaging (MRI) scanner so that we have a live image of the exact location and extent of the ablation. The incision for this is tiny, and we shave a dime-sized amount of hair. Most patients leave the hospital the next day. Two to three weeks should be allowed for recovery.
- Responsive neurostimulation (RNS/NeuroPace): If a patient’s seizures are coming from more than one location or are located in an area of the brain that is necessary for functioning, an RNS device is an excellent option. We insert a neurostimulator into the skull and insert two or more connected electrodes into the brain to monitor for seizures. When the electrodes recognize seizure activity coming from brain tissue, they alert the neurostimulator. The neurostimulator then sends out a counter current to stop the seizure before symptoms occur. This device is like a “pacemaker for the brain.” The incision for the device is usually C-shaped and above the ear. Once implanted, it is invisible underneath the hair. We shave a small amount of hair over the incision. The hospital stay for this procedure is usually two to three nights, and there is a two- to three-week recovery period.
- Vagus nerve stimulation (VNS): We implant this electrical stimulator device under the chest muscle (similar to a heart pacemaker) with the wire tunneled under the skin and ending in the neck on the vagus nerve. Epileptologists program the stimulator to give a series of intermittent and ongoing stimulations to the nerve at various strengths and frequencies.
Diet to Treat Epilepsy
Multiple studies have shown the effectiveness of the ketogenic diet and modified Atkins diet for the treatment of epilepsy. Both The Modified Atkins Diet (MAD) and ketogenic diet are high fat and low carbohydrate diets that are proven to reduce the incidence of seizures in children and adults with epilepsy. About half of the people who start and maintain these diet therapies will see a >50% improvement in seizures. Under supervision of a registered dietitian and in close coordination with the epilepsy physicians- we can help people choose, initiate, and maintain the diets safely.
- Ketogenic diet: The ketogenic diet is a high-fat, low carb diet used to treat epilepsy in children. Meals are typically weighed on a gram scale. The diet has a ratio of fat to non-fat of 4:1, 3:1 or 2:1. For certain types of epilepsy, like epilepsy caused by glucose transporter type 1 deficiency syndrome, the ketogenic diet is first-line therapy.
- Modified Atkins diet: The modified Atkins diet is a high-fat, moderate protein and low net carbohydrate diet. It differs from the ketogenic diet in that protein intake is liberalized. Typically, people on the modified Atkins diet do not use a scale. This diet is easier socially as it allows a person to eat more easily at a friend’s house or at a restaurant.
The marijuana plant has hundreds of compounds, but two of the most important are THC and cannabidiol (CBD). The CBD component is thought to help with seizure control. Currently, there are studies underway to help us understand the effectiveness of CBD. In New York State, medical marijuana is allowed for a variety of conditions, including epilepsy. CBD is delivered in the form of an oil, an oral capsule, or via vaporization.
At Mount Sinai, our epileptilogists are registered practitioners in The New York State Medical Marijuana Program, and we can help people with epilepsy enroll.
To better understand the memory difficulties common in epilepsy, we recommend neuropsychological testing, which helps us find out about a person’s strengths and weaknesses in order to tailor appropriate therapies. Often, the memory and attention difficulties that adults and children with epilepsy face can get better through a process called cognitive remediation. Cognitive remediation can teach a person with epilepsy strategies and exercises that will help improve areas of weakness. At Mount Sinai we offer both group and individual cognitive remediation sessions.