Prepared By:

Mary Jane M. Balangon

Epilepsy
Epilepsy is a chronic non-communicable neurological disorder that can
affect individuals of any age irrespective of gender.
About 50 million people are affected with epilepsy all over world.
Around 7.6 per 1000 persons have epilepsy during their lifetime.
The estimated proportion of the general population with active
epilepsy at a given period of time is between 4 to 10 per 1000 people.
Epilepsy is a chronic disorder of the brain.
•It is characterized by recurrent
unprovoked seizures at least 2 in the past 12 months
• Recurrent = usually separated by days, weeks or months.
• Unprovoked = there is no evidence of an acute cause of the seizure
(e.g. febrile seizure in a young child).
Seizures are brief disturbances of the electrical function of the brain.
Characteristics of seizures vary and depend on where in the brain the
disturbances first start and how far it spreads
Seizures
Seizures are brief disturbances in the electrical functions of the brain
Seizures are caused by abnormal electrical activity in the brain and are
of two types: convulsive and non-convulsive.
Non-convulsive epilepsy has features such as change in mental status
while convulsive epilepsy has features such as sudden abnormal
movements, including stiffening and shaking of the body. The latter is
associated with greater stigma and higher morbidity and mortality.

Convulsive consists of generalized tonic-clonic movements and mental

status impairment. Non-convulsive status epilepticus is defined as
seizure activity identified on an electroencephalogram (EEG) with no
accompanying tonic-clonic movements(NLM,2022).
 52

EPILEPSY

ASSESSMENT MANAGEMENT
EMERGENCY: Management Protocol and
Assessment & management of acute Special Populations
convulsions 1. Epilepsy
2. Special Populations (women of childbearing age,
Assess if person has convulsive seizures children/adolescents, and people living with HIV)

Assess for an acute cause Psychosocial Interventions

(e.g. neuroinfection, trauma, etc.)

Assess if the person has epilepsy and Pharmacological Interventions

for any underlying causes (by history or
examination)

Assess for concurrent priority MNS

conditions FOLLOW-UP
Why are seizures treated as an emergency?

•Treatment can end seizures or shorten seizure duration, which

limits the damage they can cause.
•Prolonged or repeated seizures can result in brain injury.
•Prolonged or repeated seizures can result in death if not
treated immediately.
•Seizures can be a symptom of a life threatening problem, like
meningitis.

16
 EPI EMERGENCY
PERSON PRESENTS WITH
CONVULSION OR IS
UNRESPONSIVE AND STIFF

CLINICAL TIP:
1
Assessment and management Any sign of head or neck injury?
should occur simultaneously.

KEEP HEAD AND NECK STABLE

2
Check AIRWAY, BREATHING, CIRCULATION (ABCs) Place an intravenous (i.v.) line for medication/
Ensure the person has nothing in their airway, is breathing fluid administration if possible
well and has a stable pulse DO NOT LEAVE THE PERSON ALONE
Check BLOOD PRESSURE, TEMPERATURE and RESPIRATORY RATE DO NOT PUT ANYTHING IN THE MOUTH
Start timing the duration of the convulsions, if possible
FOR A PERSON WITH POSSIBLE HEAD INJURY,
Make sure the person is in a safe place and if possible, put NEUROINFECTION (FEVER) OR FOCAL DEFICITS,
them down on their side to help breathing; loosen any neckties or REFER URGENTLY TO HOSPITAL
clothing around the neck, take off eye glasses, and place something
soft under the head (if available)

EPILEPSY 53
 54
EPILEPSY Emergency

SPECIAL POPULATION: Pregnancy/Post-partum

3
Is the woman in the second half of pregnancy OR
up to 1 week post partum AND has no past history of epilepsy?

SUSPECT ECLAMPSIA

Give magnesium sulphate 10 g

intramuscular (i.m.) 4
If diastolic blood pressure >110 mmHg, GIVE MEDICATION TO STOP CONVULSIONS
give hydralazine 5 mg i.v. slowly (3-4 min).
Repeat every 30 min until ≤ 90 mmHg;
Do not give more than 20 mg total

REFER URGENTLY TO HOSPITAL IF NO I.V. ESTABLISHED IF I.V. ESTABLISHED

Give: Start normal saline administration slowly

diazepam rectally (30 drops/minute)
(adult 10 mg, child 1 mg/year of age) Give glucose i.v.
OR (adult 25-50 ml of 50%; child 2-5 ml/kg of 10%)

midazolam buccally/intranasally Give emergency medication:

(5-10 mg adult, child 0.2 mg/kg) –diazepam 10 mg i.v. (child 1mg/year of age i.v.)
OR
– lorazepam 4 mg i.v (child 0.1 mg/kg i.v.)
 5
Have the convulsions stopped within
10 minutes of 1st dose of emergency medication?

Proceed to EPI 1 (A ssessment)

GIVE 2nd DOSE OF EMERGENCY MEDICATION

6
Have the convulsions stopped?

Proceed to EPI 1 (A ssessment)

REFER URGENTLY TO HEALTH FACILITY

DO NOT GIVE MORE THAN 2 DOSES
OF EMERGENCY MEDICATION

EPILEPSY 55
 56
EPILEPSY Emergency

7
IS THE PERSON IN STATUS EPILEPTICUS?
Convulsions continue after 2 doses of emergency medication, OR
No recovery in between convulsions

SKIP to Step 10
(e.g. convulsions stopped after
second dose of emergency medication
on arrival to health facility) STATUS EPILEPTICUS IS LIKELY
Management should occur in health facility
8
Continue to check AIRWAY, BREATHING, and CIRCULATION (ABCs)
Give oxygen

Monitor need for intubation/ventilation continuously

9
GIVE ONE OF THE FOLLOWING MEDICATIONS INTRAVENEOUSLY

VALPROIC ACID: PHENYOTIN:

20 mg/kg i.v. once up to maximum dose of 1 g, over 30 min 15-20 mg/kg i.v. up to max dose of 1 g, over 60 min
– use second i.v. line (DIFFERENT FROM DIAZEPAM)
PHENOBARBITAL:
PHENYTOIN CAUSES SIGNIFICANT DAMAGE IF
15-20 mg/kg i.v.* up to maximum dose of 1 g, over 100 mg/min
EXTRAVASATES, MUST HAVE GOOD I.V. LINE!
*If no i.v. access, can use i.m. phenobarbital (same dose as i.v.)
 Have the convulsions stopped?

Use one of the other medications (if available) OR

additional 10 mg/kg phenytoin (given over 30 min)
Monitor for respiratory depression,
hypotension, arrhythmia.

10
EVALUATE (AND TREAT AS APPROPRIATE) FOR
UNDERLYING CAUSE OF CONVULSIONS:

– Neuroinfection (fever, stiff neck, headache, confusion)

– Substance use (alcohol withdrawal or drug ingestion)
– Trauma
– Metabolic abnormality (hypernatraemia or hypoglycaemia)
– Stroke (focal deficit)
– Tumor (focal deficit)
– Known epilepsy (prior history of seizures)

Have the convulsions stopped?

REFER TO SPECIALIST
FOR FURTHER DIAGNOSTIC Proceed to EPI 1 (A ssessment)
EVALUATION

EPILEPSY 57
 First action in all cases:
Check ABCs
• Airway
• Breathing
• Circulation

• DO NOT leave the person alone.

• Place in recovery position.
• Make sure NOTHING is in the mouth.
If the person is still unconscious, Recovery position
use the recovery position 1. Kneel on the floor to one side of the person.
Place the person’s arm that is nearest you at a
right angle to their body, so it is bent at the
elbow with the hand pointing upwards. This will
keep it out of the way when you roll them over.
2. Gently pick up their other hand with your
palm against theirs (palm to palm). Now place
the back of their hand onto their opposite cheek
20 (for example, against their left cheek if it is their
right hand).
3. Now use your other arm to reach across to
the person’s knee that is furthest from you, and
pull it up so that their leg is bent and their foot
is flat on the floor.
4. Now, with your hand still on the person’s
knee, pull their knee towards you so they roll
over onto their side, facing you.
• Respiratory rate actually needs to be counted, not estimated, since
trends in respiratory rate become quite important if the person has
recurrent seizures and requires aggressive treatment with multiple
doses of medications, which can suppress the respiratory drive.
Time the duration of the convulsions.
• Make sure the person is in a safe place
– ensure that nothing is likely to fall on them and/or they can’t hit
anything if they convulse.
• If possible place in an I.V. line for medication/fluids.
• Know when to refer – if a person has a head injury, a neuroinfection
or focal neurological deficits then refer to hospital.
Assessment
 58
EPILEPSY Assessment

CLINICAL TIP

EPI 1 Assessment Syncope and pseudoseizures

should be considered during
initial evaluation and in cases of
treatment failure.

COMMON PRESENTATIONS OF EPILEPSY » Syncopal (fainting) spells often

are associated with flushing,
Convulsive movement or fits/seizures
sweating, pallor, and occasio-
During the convulsion: nally a feeling of vision darken-
– Loss of consciousness or impaired consciousness ing prior to an episode. Mild
– Stiffness, rigidity shaking may occur at the end.
– Tongue bite, injury, incontinence of urine or faeces » Pseudoseizures are typically
After the convulsion: fatigue, drowsiness, sleepiness, confusion, associated with a stress trigger.
Episodes are often prolonged
abnormal behaviour, headache, muscle aches, or weakness on
and can involve nonrhythmic
one side of the body
jerking of the body, eyes may be
closed, and pelvic thrusting is
often seen. There is typically a
rapid return to baseline after
1 the episode. If pseudoseizures
are suspected, go to OTH.
Does the person have convulsive seizures?

Has the person had convulsive movements

lasting longer than 1-2 minutes?

Convulsive seizures unlikely

Consult a specialist for recurrent episodes
Follow-up in 3 months
 Has the person had at least 2 of the following symptoms during the episode(s)?
– Loss of consciousness or impaired consciousness – After the convulsion: fatigue, drowsiness,
– Stiffness, rigidity sleepiness, confusion, abnormal behaviour,
– Bitten or bruised tongue, bodily injury headache, muscle aches, or weakness on one
– Incontinence of faeces/urine side of the body

Convulsive seizures unlikely

Consult a specialist for recurrent episodes
Follow-up in 3 months
Suspect
CONVULSIVE SEIZURES

2
Is there an acute cause?

Is there neuroinfection or other possible causes of convulsions?

» Check for signs and symptoms:
– Fever – M eningeal irritation – Metabolic abnormality – Alcohol or drug
– Headache (e.g. stiff neck) (e.g. hypogylcemia/ intoxication or
– Confusion – Head injury hyponatremia) withdrawal

Suspect EPILEPSY

EPILEPSY 59
 60
EPILEPSY Assessment

IS IT A CHILD 6 MONTHS TO SKIP to S EP 3

6 YEARS OLD WITH A FEVER? » EVALUATE & TREAT M EDICAL T
CONDITION
» REFER TO HOSPITAL
IF POSSIBLE FOR HEAD INJURY,
MENINGITIS, AND METABOLIC
Are the convulsions: ABNORMALITIES
– Focal: Starts in one part of the body
ANTIEPILEPTIC MEDICATION
– Prolonged: Lasts more than 15 min
NOT REQUIRED
– Repetitive: M ore than 1 episode during the
current illness » Follow-up in 3 months to
assess for possible epilepsy

COMPLEX FEBRILE SEIZURE

REFER TO HOSPITAL
FOR ADM ISSION

SIMPLE FEBRILE SEIZURE

Look for cause (local Integrated Management
of Childhood Illness (IM CI) guidelines)
Observe over 24 hours
No antiepileptic treatment needed
 3
Does the person have epilepsy? CLINICAL TIP
Ask about:
– How frequent are the episodes?
Has the person had at least two seizures on two – How many in the past year?
different days in the past year? – When was the last episode?

Does not meet criteria for epilepsy

Maintenance antiepileptic medication not necessary
Follow-up in 3 months and assess for possible
epilepsy EPILEPSY
is likely

CLINICAL TIP Asses for underlying cause. Do a physical examination.

Physical examination should include
Are any of the following present?
neurologic examination and evaluate for
any focal deficits; e.g. any asymmetry in – Birth asphyxia or trauma history – Infection of the brain
strength or reflexes. – Head injury – Family history of seizures

REFER TO SPECIALIST FOR FURTHER

EVALUATION OF CAUSE

EPILEPSY 61
 62
EPILEPSY Assessment

4
Are there concurrent MNS conditions?

Assess for other concurrent MNS conditions according to the

mhGAP-IG Master Chart (MC)

Please note persons with EPILEPSY are at higher risk for DEPRESSION, DISORDERS
DUE TO SUBSTANCE USE. CHILDREN AND ADOLSCENTS MAY HAVE ASSOCIATED MENTAL
AND BEHAVIOURAL DISORDERS. SUBSTANCE USE DISORDERS

Go to PROTOCOL 1

IF THERE IS IM M INENT RISK

OF SUICIDE, ASSESS AND
MANAGE before continuing
to Protocol. Go to SUI.
MANAGEMENT
MANAGEMENT:
MANAGEMENT:
PSYCHOSOCIAL INTERVENTIONS
2.1. Psychoeducation
 Provide information on: “What is a convulsion/epilepsy”
and the importance of medication.
 “A convulsion is caused by excess electrical activity in the
brain – it is not caused by witchcraft or spirits.”
 “Epilepsy is the recurrent tendency for convulsions.”
 “It is a chronic condition, but if you take your medicine a
prescribed, in the majority of people it can be fully
controlled.”
MANAGEMENT:
PSYCHOSOCIAL INTERVENTIONS
2.1. Psychoeducation
The person may have several people helping them take
care of their convulsions. Discussthis with the person.
Ask the person to let you know if they are seeing a
traditional or a faith healer, showing respect for this, but
emphasizing the need for being seen at a healthcare facility.
The person should also be informed that medicines and
herbal products can sometimes have adverse interactions, so
the health care providers must know about everything they
take.
MANAGEMENT:
CLINICAL TIP
Seizures lasting greater than 5 minutes are a
medical emergency – one should seek help
immediately.

Most people with epilepsy can have normal

liveswith good adherence to treatment.
 MANAGEMENT:
Provide information on: How carers can manage
convulsion at home.
 Lay person down, on their side, head turned to help breathing.
 DO NOT PUT ANYTHING IN THEIR MOUTH OR RESTRAIN THE PERSON.
 Ensure the person is breathing properly.
 Stay with person until the convulsion stops and they wake up.
Sometimes people with epilepsy know that a convulsion is imminent. They
should lie down somewhere safe if they have that feeling.
Epilepsy is not contagious. You cannot catch the disorder by assisting the person
experiencing convulsions.
MANAGEMENT:
Provide information on: When to
get medical help.
When a person with epilepsy appears to have trouble
breathing during a convulsion, they need immediate
medical help.
When a person with epilepsy has a convulsion lasting
longer than 5 minutes outside of a health facility, they
need to be taken to one.
When a person with epilepsy is not waking up after a
convulsion, they need to be taken to a health facility.
MANAGEMENT:
2.2. Promote functioning in daily activities
and community life
Refer to Essential Care and Practice (ECP) for interventions that
promote functioning in daily living and community life.
In addition, inform carers and people with epilepsy that:
People with epilepsy can lead normal lives. They can marry and have
children.
Parents should not remove children with epilepsy from school.
People with epilepsy can work in most jobs. However they should
avoid jobs with high risk of injury to self or others (e.g. working with
heavy machinery).
MANAGEMENT:
2.2. Promote functioning in daily activities
and community life
People with epilepsy should avoid cooking on open fires and
swimming alone.
People with epilepsy should avoid excessive alcohol and
recreational substances, sleeping too little, or going to places
with flashing lights.
Local driving laws related to epilepsy should be observed.
People with epilepsy may qualify for disability benefits.
Community programs for people with epilepsy can provide
assistance in jobs and support for both the person and family.
MANAGEMENT:
PHARMACOLOGICAL INTERVENTIONS
2.3. Initiate antiepileptic medications
Choose a medication that will be consistently available.
If special population (children, women of childbearing age,
person living with HIV), see relevant section of this module.
Start with only one medication at lowest starting dose.
Increase dose slowly until convulsions are controlled.
Consider monitoring blood count, blood chemistry and liver
function tests, if available.
 MANAGEMENT:
CAUTION!
Check for drug-drug interactions. When used together, antiepileptics may
increase or reduce the effect of other antiepilepticcs. Antiepileptics may also
reduce effect of hormonal birth control, immunosuppressants, antipsychotics,
methadone, and some antiretrovirals.
Rarely, can cause severe bone marrow depression, hypersensitivity reactions
including Stevens-Johnson Syndrome, altered Vitamin D metabolism and
Vitamin K-deficient hemorrhagic disease of newborns.
When possible, avoid use of sodium valproate in pregnant women due to risk
of neural tube defects.
All anticonvulsant medications should be
discontinued slowly as
stopping them abruptly can cause seizure breakthrough.
 EPI 2 Management
PROTOCOL
1
Provide psychoeducation to the person and carers (2.1)
Initiate antiepileptic medications (2.3)
Promote functioning in daily activities (2.2)

Special populations
Note that interventions are different for EPILEPSY in these populations

HIV

WOMAN OF CHILDBEARING AGE CHILD/ADOLESCENT PERSON LIVING WITH HIV

Concern: Risk of antiepileptic medication to fetus/child Concern: Effect of antiepileptic medication Concern: Drug interactions between antiepileptic
on development and/or behavior medications and antiretrovirals

Advise folate (5 mg/day) to prevent neural tube For those with a developmental disorder, When available, refer to specific drug interactions
defects, in ALL women of childbearing age. manage the condition. Go to CMH. for person’s antiretroviral regimen and antiepileptic
medication.
AVOID VALPROATE. For children with behavioural disorder, avoid
phenobarbital if possible. M anage the condition. Valproate is preferred due to fewer drug-drug
CAUTION If Pregnant: interactions.
Go to CMH.
– Avoid polytherapy. Multiple medications in combination
increase the risk of teratogenic effects during pregnancy. AVOID PHENYTOIN AND CARBAMAZEPINE
– If medications are stopped during pregnancy, WHEN POSSIBLE.
they should always be tapered.
– Advise delivery in hospital.
– At delivery, give 1 mg vitamin K i.m. to the newborn
to prevent haemorrhagic disease.

If breastfeeding, carbamazepine preferred to other

medication.

EPILEPSY 63
 PHARMACOLOGICAL INTERVENTIONS

2.3 Initiate antiepileptic medications

Choose a medication that will be consistently available. CAUTION!
If special population (children, women of childbearing Check for drug-drug interactions. When used together, When possible, avoid use of sodium valproate in
age, person living with HIV), see relevant section of this antiepileptics may increase or reduce the effect of other pregnant women due to risk of neural tube defects.
module. antiepilepileptics. Antiepileptics may also reduce effect of All anticonvulsant medications should be discontinued slowly as
Start with only one medication at lowest starting dose. hormonal birth control, immunosuppressants, antipsy- stopping them abruptly can cause seizure breakthrough.
chotics, methadone, and some antiretrovirals.
Increase dose slowly until convulsions are controlled.
Rarely, can cause severe bone marrow depression,
Consider monitoring blood count, blood chemistry and
hypersensitivity reactions including Stevens-Johnson
liver function tests, if available.
Syndrome, altered Vitamin D metabolism and Vitamin
K-deficient hemorrhagic disease of newborns.

TABLE 1: Antiepileptic medications

MEDICATION ORAL DOSING SIDE EFFECTS CONTRAINDICATIONS / CAUTIONS

CARBAMAZEPINE Adults: Common: Sedation, confusion, dizziness, ataxia, Caution in patients with history of blood disorders,
Start 100-200 mg daily in 2-3 divided doses. double vision, nausea, diarrhea, benign kidney, liver or cardiac disease.
Increase by 200 mg each week (max 1400mg leukopenia.
daily). Dose may need to be adjusted after 2 weeks due to induction
Serious: Hepatotoxicity, cardiac conduction of its own metabolism.
Children: delay, low sodium levels.
Start 5 mg/kg daily in 2-3 divided doses.
Increase by 5 mg/kg daily each week (max
40mg/kg daily OR 1400mg daily).

Women who are pregnant or breastfeeding:

Use with caution.

EPILEPSY 65
 EPILEPSY Management
TABLE 1: Antiepileptic medications (cont.)

MEDICATION ORAL DOSING SIDE EFFECTS CONTRAINDICATIONS /

CAUTIONS
PHENOBARBI Adults: Common: Sedation, Contraindicated in patients with
hyperactivity in
TAL Start 60 mg daily in 1-2 children, ataxia, acute intermittent porphyria.
nystagmus, sexual
divided doses. dysfunction,
depression. Lower doses for patients with
Increase weekly by 2.5-5
mg (maximum 180 mg Serious: Liver failure kidney or liver disease.
daily). (hypersensitivity reaction),
decreased bone mineral
Children:
density.
Start 2-3 mg/kg
daily in 2 divided
doses. Increase
weekly by 1-2 mg/kg
daily depending on
tolerance
(maximum 6mg
daily).
MEDICATION ORAL DOSING SIDE EFFECTS CONTRAINDICATIONS / CAUTIONS
PHENYTOIN Adults: Common: Sedation, confusion, Lower doses for patients with kidney or liver
dizziness, tremor, motor
Start 150-200 mg daily in twitching, ataxia, double vision, disease.
two divided doses. Increase nystagmus, slurred speech, nausea,
vomiting, constipation.
by 50 mg daily every 3-4
weeks (max 400 mg daily). Serious: Hematologic
abnormalities, hepatitis,
Children: polyneuropathy, gum
Start 3-4 mg/kg daily in 2 hypertrophy, acne, lymphadeno-
divided doses. Increase pathy, increase in suicidal ideation.
by 5 mg/kg daily every 3-
4 weeks (maximum 300
mg per day).

Women who are

pregnant or
breastfeeding:
Avoid

Older adults: Use lower

doses
FOLLOW UP
 EPI 3 Follow-up RECOMMENDATIONS ON
FREQUENCY OF CONTACT

1 » Follow up should occur

every 3-6 months

REVIEW THE CURRENT CONDITION

Does the person have more than 50% seizure reduction in convulsion frequency?

IF THE PERSON IS NOT IMPROVING ON CURRENT DOSE:

» Review adherence to medications.
» Consider increase in medication dose as needed to
maximal dose if no adverse effects.
» If response is still poor,
– Consider switching medication. The new medication
should be at an optimum dose before slowly discon-
tinuing the first.

» If response is still poor,

– Review diagnosis.
– REFER TO SPECIALIST.
» Follow-up more frequently.

CLINICAL TIP:
» ADVERSE EFFECTS(e.g. drowsiness, nystagmus, diplopia, ataxia)
are from too high doses of medication for the person.
» If there is an IDIOSYNCRATIC REACTION (allergic reaction, bone
marrow depression, hepatic failure), switch antiepileptic medication.

EPILEPSY 67
EPILEPSY Follow-up

2
MONITOR TREATMENT

At every contact:
» Evaluate side-effects of medication including adverse effects » Does the patient have any new symptoms of concern?
and idiosyncratic reactions (clinically and with appropriate laboratory tests Review for any new symptoms of depression and anxiety given
when available). high risk of co-morbidity with epilepsy.
» Provide psychoeducation and review psychosocial interventions. » Is the patient on any new medications that may have interactions?
» Is the person a woman of childbearing age and considering (Many anticonvulsants have interactions with other medications). If so,
pregnancy? If so, consult specialist. consult a specialist.

3
CONSIDER MEDICATION DISCONTINUATION WHEN APPROPRIATE

Has the person been convulsion free for several years?

» Discuss risk of seizure occurrence with person/carer

IF THERE ARE NO PROBLEMS WITH MEDICATIONS (if epilepsy is due to head injury, stroke or neuroinfection,
» Continue at current dose. Correct dosing is lowest there is a higher risk of seizure recurrence off medication),
therapeutic dose for seizure control, while minimizing and risks and benefits of discontinuing medications.
adverse side-effects. » If in agreement, gradually take the person off
» Continue close follow-up and review for possible dis- medication by reducing the dosesover 2 months and
continuation of medications once seizure free for at monitoring closely for seizure recurrence.
least two years.