I am 29, male with recurrent seizures. How do I manage them?

Question

Hello doctor,

I am a 29-year-old male who has been experiencing recurrent seizures for the past four years, and my neurologist has diagnosed me with epilepsy. My seizures are usually generalized tonic-clonic, lasting two to three minutes, followed by confusion and fatigue for several hours. On average, I get about one seizure every two months, even though I am taking Sodium valproate 500 mg twice daily.

My recent EEG showed epileptiform discharges in the temporal lobe, and the MRI of my brain revealed a small left temporal lesion. I also have a history of depression, with my PHQ-9 score at 16, and I often feel hopeless after a seizure episode. My recent blood tests showed mildly elevated liver enzymes (ALT 62 U/L), which my doctor suspects may be due to medication.

My fasting blood sugar is normal at 92 mg/dL, and electrolytes are within range. I once had a seizure while crossing the road, which made me very anxious about my safety, and since then, I have avoided traveling alone. My family is worried because I recently had a seizure that resulted in a shoulder dislocation. Could you please guide me on how best to manage epilepsy in my case, especially with depression and medication side effects, and whether advanced options like surgery, VNS, or a change in drug therapy would help me get better control?

Please advise.

Answer 1

Hello,

Welcome to icliniq.com.

I understand your concern.

The fact that you are still experiencing seizures every two months despite being on Sodium valproate tells us one thing clearly: your epilepsy is not optimally controlled. Our goal is zero seizures, or as close to that as we can possibly get.

Currently, you are taking 500 mg twice daily, which is often a starting or moderate dose. For many adults, we may need to increase the dose to achieve better seizure control, but we must carefully balance this with potential side effects.

Elevated liver enzymes (ALT) are a known, though usually mild, side effect of Valproate. We will need to monitor this closely, but in many cases, it is manageable. However, Valproate can also worsen depression and cause fatigue, which directly impacts overall health and well-being. Because of these factors, a medication adjustment or change is likely necessary.

We have over 20 different anti-seizure medications available today. Considering your depression, we would aim to avoid drugs that may worsen your mood. Fortunately, there are several excellent options that are either mood-neutral or can even support emotional well-being, which we can discuss further.

Your PHQ-9 score of 16 indicates moderately severe depression, and this is critical. Depression and epilepsy are closely linked; seizures can make depression worse, and depression can lower your seizure threshold, making seizures harder to control. We need to treat both conditions aggressively. You cannot effectively manage your seizures if you ignore the depression.

We need to integrate a mental health approach into your overall treatment plan.

Cognitive behavioral therapy (CBT) has strong evidence for helping both depression and the anxiety related to seizure triggers.
If we decide to start an antidepressant, we would carefully select one that is safe to use with anti-seizure medications and does not lower the seizure threshold. This is a delicate balance, best managed together by your neurologist and a psychiatrist.

Please feel free to reach out at any time if you have questions or need guidance. I am always here to support you.

Thank you.