Dr. Alan Ettinger Answers Questions about Diagnosing Epilepsy


Ask the Expert: Diagnosis with Alan Ettinger, MD

EttingerDr. Alan Ettinger, Chief of the Division of EEG and Epilepsy at the North Shore-LIJ Comprehensive Epilepsy Centers, continues the Ask the Expertseries by answering your questions about diagnosing epilepsy.

To view past episodes of this series, click here.

Audio: Dr. Ettinger discusses diagnosis



The following questions were answered by Dr. Ettinger for Episode 3, "Diagnosis":



I have, at the age of 63, been diagnosed with left temporal lobe activity. On and off, since my 20's, I have had bouts with anxiety. Was this from the epilepsy?

The relationship between epilepsy and anxiety is complex and may relate not only reactions to have a seizure but intricate biological connections. It is important that your doctor not only address the epilepsy but also address your anxiety symptoms and what can be done for it. A psychological health professional may be helpful in assisting as well.


I'm 42 years old and 2 years ago I started to have seizures. A neurologist said that I was epileptic and now another says that I am not, that I have non-electrical seizures. I don't understand can you help and tell me the difference?

It would be important for you to ask the doctors specifically what they mean by “non-electrical seizures”. One possibility is what is called psychogenic non-epileptic seizures which refer to episodes that resemble and feel like epileptic seizures but are more akin to the mind playing tricks on the body. It is important to treat these as one would treat any illness but the treatments are different than for epilepsy.



I was born with epilepsy and grew out of it. Why would I get it back after 30 some years?

This is difficult to answer without knowing the details of your individual history. We do indeed see from time to time individuals whose seizures stopped for a period of time and then recur. The explanations for this are often unclear.

Alternatively, a person can develop new problems affecting the brain that could cause seizures independent of the earlier history. Your physician needs to perform a complete evaluation that may include imaging of the brain.



I was diagnosed with epilepsy around age 7. I had about one seizure a month and it was over once I hit puberty (around age 13).

Now, at 22, I have been sleeping when I vividly feel I'm having a seizure, and then I wake up and feel fine. This has happened to me two or three times. The last time it happened was yesterday, while I was taking a nap right before I had to go to work. While it was happening (my dream or the real thing) I vividly remember thinking that I could swallow my tongue and trying to stick it out since I couldn't move. I think I tried to open my eyes, but after I woke up I couldn't remember my eyes being open. After waking up I also checked to see if I had saliva on my face.

When I had my seizures when I was little I would foam at the mouth, so the fact that my face was dry made me think I wasn't having a real seizure? Still, it all seems so real.

As soon as I got to work yesterday I was very irritable and emotional. I couldn't concentrate on what I was doing (tears just kept coming down my face, and I felt like a jerk for getting irritated with people since I'm usually smiling and easy to get along with) I don't know if I was feeling this way because a seizure actually took place, or because I was upset that I could be having seizures again.

So, my question is as follow: Can I really be having seizures again? Can epilepsy resurface? Will a neurologist be able to tell me what is going really going on?

These complicated symptoms may be best addressed at a comprehensive epilepsy center where tests such as the continuous video-EEG monitoring can be performed to pinpoint what is going on. If they are seizures, it would not be uncommon to have what are termed “post-ictal” changes in mood. The first priority is to clarify what is going on.



I recently had a black out situation (or so I thought). I totaled my car by driving head on into a tree, going 60 mph coming home from work. I had a CT scan, MRI, and EEG following the car accident and they all came out normal.

A few weeks later, I had a seizure coming home from dinner with family. After having an actual seizure, some of the similarities from the accident came back to my memory, ex. the strange look of the road as I drove home. It looked like I was looking through a fish bowl. I lost consciousness during the accident but once I hit the tree, I became alert and somewhat aware and confused. When I had the seizure, I stared at my mom in the car and looking at her was the same way, a fish bowl affect.

I was told I became combative and it took four EMTs to get me into the ambulance. I don't remember going through the seizure, obviously, but I was very confused once I awoke and partially remember what I did that day. Even to this day I don't remember much. The doctors don't know yet what is going on but no one has put me on any type of anti-seizure medication to prevent another seizure from occurring. I was told I cannot drive for at least 6 months nor can I work due to my occupation. I don't know if this is epilepsy.

I am hoping you can give me some information or direction so I find out what is going on. What sort of questions should I be asking my physicians to get a clearer answer?

So sorry to hear about these terrible events you have experienced. This history is certainly compatible with seizures (and the term epilepsy simply means recurrent seizures). Post-seizure combative behavior is a well-recognized phenomenon. You can get an organized list of questions to review with your doctor by downloading a form from www.epilepsylongisland.com.



I'm a 38 year old female who is diagnosed with complex partial seizures. I have been on tab. lamotrigine 175 mg/day for the last 10 yrs. My seizures are well controlled, but I suffer from confusional state, lasting for 1-10 minutes. (1 episode every 2-3 months.)

Additionally, I suffer from premenstrual migraine and mood disorders in which I have severe anxiety, irritability, crying spells, sleep disturbances and lack of confidence. Such mood disorders last for 2-4 days.

My questions: 1. What is the best treatment option? 2. If I add tab. valparin sodium 200mg/day, as per my neuron-physician's opinion, shall I make any alterations in dose of lamotrigine? 3. Which drug can I take for immediate relief for migraine? 4. Which drug can I take for immediate relief for mood disorders? 5. Is there any relation between premenstrual syndrome, migraine and interictal dysphoria?

This is a complicated situation and naturally, your doctor should give you specific advice on all of these issues. A few ideas that come to mind that you can use in your discussion include the fact that one seizure every 2-3 months doesn’t sound like great seizure control and therefore vigorous attention needs to be given to achieving even better control. Sometimes epilepsy surgery is indicated. Otherwise, there are a whole host of medication options. Valproate can have some mood stabilizing benefits while lamotrigine may also have some antidepressant properties. Valproate may be useful in that it addresses both epilepsy and migraine but it has a list of potential side effects that you should review with your doctor.



I am22 years old and was diagnosed with epilepsy a year ago. It was never really explained how or why I had it just that I did. Also, my EEG came back normal but I had another seizure recently. Do you have any advice for me?

I have found that even when seizures are brought under control, one of the most disconcerting aspects of epilepsy is when a cause cannot be found. This situation is actually quite common. In some cases, a genetic cause plays a role. Sometimes we need to take heart in the notion that even if the cause is undetermined, the prognosis for controlling the seizures is very good. In looking for a cause, it is essential that a good quality MRI of the brain be performed.



I'm 43 and have six month old twins. I have SLE and my epilepsy, which got worse during pregnancy and is still quite bad. I have roughly three seizures a week (bad ones). I had EEG and MRI scans which were okay. I take 1400mgs of Tegretol daily. I also take predisolone.

Can you give me advice on what to try to control my seizures? With twins I'd be grateful for any advice.

If your seizures are continuing at three per week, it would be important for you to undergo a comprehensive epilepsy evaluation, one which a specialty epilepsy center typically offers. In that context, you would be able to get a thorough evaluation which may include a more extended duration EEG, and a review of all potential treatment options.



My daughter was diagnosed with epilepsy five years ago. After an EEG and MRI her doctor advised her to discontinue the medicine, which she used for almost 3-1/2 years.

Since off the medication, she was married (just last year) and now has a 1 month old baby. Over the last 2 weeks she had seizures and went unconscious for half an hour. We reported the incident to her doctor who said it is due to weakness and not Epilepsy. How can we be sure?

This must have been very frightening for all. If I had to speculate, the doctor may be suggesting that the episode of loss of consciousness was due to fainting and not the abnormal electrical discharges of epilepsy. In any event, it would be very important to clarify with the doctor and if doubts remain, I am always an advocate of second opinions.



After 12 years of having symptoms and repeated visits to neurologists, I have been diagnosed with a simple partial seizure disorder (due to a vascular malformation). The neurologist has prescribed Keppra, but after reading numerous articles and online reports from users, I am afraid to take it because of the side effects—particularly those affecting mood and depression.

I have been an RN for 27 years and presently am a researcher at a local university. Therefore, I am not totally ignorant when it comes to health care matters. However, this is "freaking" me out. I have never been one to take much medication and I would greatly appreciate your input.

My own experience, research and review of the literature suggests to me that Keppra is usually very well tolerated. It appears that most who develop mood problems from this drug are those who suffer from an underlying mood problem at baseline. If this is not the case for you, the chances are better that you would not incur this issue.



Iwas just told, at age 60, that I have had seizures and I need some support as I have become so afraid of this all.

We used to think of epilepsy as a childhood disease but in fact, as people are living longer and healthier into later years, the rate of epilepsy in this age-group is actually climbing quite high.

The good news is that many who develop epilepsy in later years will find that their seizures are very easily controlled with medications. Yet, as we become more sensitive to side effects of medications when we get older, it is important to find the right antiepileptic treatment. I would address these issues with your doctor and would strongly encourage you to contact your local Epilepsy Foundation affiliatefor information and programs that could be very supportive.



My sister-in-law is in her mid 30's and was just diagnosed with epilepsy. Is it normal to be diagnosed so late in life? She doesn't seem to be worried about depression or mood disorders now, but what can I do to help her if these do arise?

The main issues are to perform a thorough evaluation looking for a potential cause, especially a good quality MRI of the brain. Mood issues are one of a number of important subjects for her to discuss with the doctor.

For a more complete list of discussion topics, you can download a form from www.epilepsylongisland.com.



I am a 32 year old female from West Texas, and started having seizures this January. I was diagnosed with SLE in May. I am having seizures that get progressively worse, and are at their meanest right before my menstrual cycle. I have tried Dilantin, Depakote, Topamax, and I am currently taking 2000mg Keppra a day. The Dilantin and Depakote made my liver enzymes go up. I also have a history of Migraines, since the age of 8. My current Neurologist is at his wits end with this whole situation, as am I. The seizures started out as absence, and have progressed to complex partial. I have no history of head trauma, and both MRI/MRA and CT scan come back clean. I am a full time student in Nursing/Molecular Pathology, and work as a tech in the ICU of the local hospital. I really need help. I feel doomed.

I am sorry to hear about all these difficulties you are incurring. I strongly recommend that you be seen at a specialty epilepsy center where potentially curative epilepsy surgery is sometimes appropriate, or where other options such as the vagal nerve stimulator, or antiepileptic drug trials may be offered. Both migraines and epilepsy exacerbations have been commonly tied to the hormonal changes that occur with the menstrual cycle and there may be some additional therapeutic strategies that can be utilized in such situations. I would not despair as I am sure there are many things that can be tried.



I have seizures/blackouts. I started having the seizures in '95. An MRI showed that I have a triangle shaped spot on my right side of the brain. But now it shows nothing and shows nothing on an EEG. What are the possible causes of my problem?

This is a bit difficult to answer without being intimately involved in your evaluation. A few ideas to discuss with your doctor is what does he believe the original MRI was showing. Sometimes a variant of the MRI procedure called MRS in that spot can help clarify a lesion.



I'm not sure if I have epilepsy. No doctor can tell me what is wrong with me. From time to time I encounter a situation where I can not differ what is present time and if I'm sleeping and dreaming. I am obviously awake and can do most of my normal work duties but it is as if my sub-conscious is alive and it's difficult for me to concentrate. This occurs once every two months. Also, there are the times when I can hardly recollect what just happened. My doctor thinks that stress leads this on.

Could you please just let me know if you have had any such cases before? It is very frustrating to know that you have something that no doctor or any other person has ever heard of before. I'm desperate because this affects my social life and I don't want to do anything or go anywhere.

I would recommend discussing with your doctor the possibility of undergoing a more extending monitoring of brainwave activity called video-EEG. In this procedure, commonly performed at specialty epilepsy centers, the EEG runs for several days which is more likely to capture evidence of epilepsy or ideally would capture the actual episodes. A video camera captures the simultaneous behavioral changes you may have during an episode.

Your situation is actually not unusual and is typical of the diagnostic challenges faced by specialists in the field.



I was diagnosed with bipolar 1 disorder on September 26, 1998. Also, it was noted that I had blackouts during manic episodes. My question is this: a few months ago I had a seizure for the first time in years, could it be due to the change in the mood stabilizer from Depakote to Lamictal? And both of my neurologists are having trouble figuring out the cause of the seizures, could the seizures be a precursor to the bipolar disorder or vice versa?

Certainly, if you have an underlying seizure disorder, it is possible that a switch in medications was related to a breakthrough seizure. If you did not have a prior epilepsy history, the chances of this switch causing a seizure would be much lower.



I have seizures at night; I disarrange the covers on my bed. I don't know I'm having them. My family tells me. I some times am confused. In the morning and other times I'm not but the meds I'm on doesn't work. Doesn't show my blood is absorbing them. Why is that?

It sounds like you have a difficult to control seizure disorder which warrants a comprehensive epilepsy evaluation, often best performed at specialty epilepsy centers. Unfortunately, as many as 20-30% of seizures do not respond adequately to medications but the good news is that there are many non-medication treatments that can be very helpful and may even offer a cure.



A friend of our family has a wife who has seizures. A few months ago she developed amnesia. She is 23 years old but thinks she is 16. She has 3 kids and says that she can't take care of them at all because she is 16 and doesn't know how to change a diaper or even see to their basic needs. Do you think her memory will ever come back or do you think she could be faking the whole thing? Her husband is having to work many hours a week plus take care of all the children’s needs. It is really taking its toll on him.

This is a rather unusual story and really warrants a detailed neuropsychological and neuron-psychiatric evaluation. My best advice is to encourage them to pursue these assessments.



I am 28 yrs. old. I have grand mal seizures. I have had a total of 3 seizures over a 6 yr period. Each time I was not medicated. After the first seizure, I was put on tegretol with no seiqures after 2 yrs so I was weaned off and seizure free for 3 months. I then had one small and one grand mal seizure so I went back on tegretol until I got married. Then I was switched to Keppra and have been on Keppra for one and half years. My husband and I are thinking about starting a family. I have never had a seizure while being medicated or any symptoms. What would your recommendation be for treatment for me before and during pregnancy? Should I go off medications again or should I stay on Keppra or would you recommend another medication?

Only your physician who has the intimate details of your prior seizures and associated testing can convey the best summary of the risks and benefits of staying or going off medications. The safety profile of Keppra in pregnancy has been relatively safe but the number of women entered into pregnancy registries is quite limited so our conclusions are also tempered by limited data.



I have syncope and had an episode the other day. I think it might have been a seizure. I want to tell you what my symptoms were and see if it was a seizure.

One of the most common diagnostic challenges that a physician faces is the attempt to distinguish a fainting episode (which is due to temporary insufficient blood flow to the brain) from an epileptic seizure. Distinguishing these two entities requires taking a detailed medical history for which it is invaluable to get as much detail from you and any witnesses of the event, as possible. Testing of the heart rhythms and brainwave testing are sometimes requested to further clarify the diagnosis. Sometimes, despite all best attempts to come to a conclusion, the diagnosis may remain unclear.



What causes epilepsy when there is no genetic history of epilepsy in my family? I am 47 and was diagnosed recently, 7-24-07. I was put on Topamax 50 mg(with a step up to that from 25 to 50). I don’t understand a whole lot about this please help me understand.

Genetics is only one of many potential causes of epilepsy. In essence, anything that affects the brain can cause epilepsy. However, it is not uncommon that a specific cause cannot be determined. Any new onset seizure disorder warrants a thorough evaluation exploring all potential causes. MRI of the brain is often performed to exclude structural abnormalities that can give rise to seizures.