CAUSES OF HEADACHES: EPILEPSY

Epilepsy can be divided into three main types:

Petit mal is characterised by a sudden loss of consciousness lasting for a very short time – perhaps a quarter of a second to a few seconds. These are often called ‘absence seizures’ and during an attack the patient may suddenly stop talking in mid-sentence and then pick up from where he left off. Occasionally the muscles go limp and the patient drops down to the floor. Attacks like this are normally not followed by headaches.

Grand mal epilepsy is what most people normally associate with the idea of somebody who has fits’. A grand mal attack may be preceded by an aura, an overwhelming feeling in which the patient becomes aware that an attack is pending; then he loses consciousness, falls to the ground, and goes into spasm for up to thirty seconds, during which time he stops breathing and goes blue. Then generalised jerking of the limbs begins.

A variant of grand mal epilepsy is Jacksonian epilepsy, in which the twitching starts in one small part of the body, gradually spreading towards the trunk and eventually involving the whole body: consciousness is eventually lost.

After a grand mal fit, the patient is very drowsy, is sometimes confused, often has a generalised headache, and usually wants to sleep off the attack, which he-will probably do quite successfully without any need for interference.

•    Temporal lobe epilepsy can be much harder to recognise, because the symptoms can be quite different. There may be visual hallucinations, which can consist of flashes of light or balls of fire, or even more complicated hallucinatory events. There may be disorders of smell and taste, automatic odd behaviour (such as suddenly undressing in public); occasionally there may be outbursts of aggression, or rage – or even attacks of laughter. Finally, temporal lobe epilepsy doesn’t necessarily progress to a fit.

There is a crossover in symptoms between temporal lobe epilepsy and migraine; sufferers from temporal lobe epilepsy can get severe headaches, preceded by an aura with visual hallucinations – just like migraine. Usually muscular shaking and loss of consciousness gives the clue to the diagnosis, but sometimes a full-blown fit doesn’t occur. Just to make things more complicated, very occasionally a migraine can end with a fit.

Usually the diagnosis of epilepsy is easy to make; either there has been a fullblown fit (grand mal) or else short episodes of loss of consciousness. If there is any doubt, an electro-encephalogram (EEG) may quickly show what is happening by monitoring the electric activity within the brain.

Most people with epilepsy had their first attack before the age of twenty. Why certain people are susceptible is unknown, though a brain injury does predispose to attacks. Sometimes attacks can start out of the blue in adult life, and then go away again within a few months. I suspect that some of these cases are the aftereffects of viral infections in the brain.

Epilepsy usually starts in childhood, but the first fit has to be distinguished carefully from a fit due to meningitis; it’s also important that fits from febrile convulsions (fever) aren’t mistaken for epilepsy, and vice versa. Febrile convulsions are always associated with a rise in temperature and never last beyond the age of seven years. (They never lead on to epilepsy.) On the other hand, epileptic attacks occur out of the blue, unrelated to temperature.

It is unusual for epilepsy to start after the age of twenty. When it does, the doctor has to be careful to make sure that there is no underlying disease causing the epilepsy, such as a tumour. Epilepsy can also arise as a result of abnormal blood vessels stimulating the brain; and from scars in the brain caused by head, injuries, operations, small strokes, and sometimes even strokes following migraine.

The doctor will want to fully investigate a first fit. A young child with a first attack of convulsions needs to be admitted to hospital for a lumbar puncture, to ensure that the fit isn’t due to meningitis. In an older person it’s much easier to be sure that a fit isn’t meningitis, so there isn’t quite the same rush to investigate. CAT scans and MRI scans will help to pinpoint any abnormality which is triggering off the attacks, and can be used when the EEG points to unusual brain-waves. CAT scans and MRI scans are also very useful in adults who have developed epilepsy, where the doctors are particularly concerned that there isn’t an underlying tumour.

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