A 55-Year-Old Woman With Epilepsy

Amit Verma, MD: Today we are going to discuss the case of a married 55-year-old woman who is employed as a kindergarten teacher. She has no family history of epilepsy, and there is no history of head injuries or febrile seizures. There is no smoking history, no alcohol use, and no illicit drug use. She experienced her first generalized tonic-clonic seizure 5 years ago. She was seizure-free for 4 years with no medications, and about 1 year ago, the patient had another convulsive seizure. Although her physician prescribed her an antiepileptic medication, she refused to take it.

Six months ago, the patient had 2 convulsive seizures within 5 weeks, which prevented her from driving. She was seen by an epileptologist who performed an EEG [electroencephalogram], which showed left focal temporal spike wave disorder consistent with left temporal lobe epilepsy with secondary generalization. The epileptologist discussed treatment options based on patient preferences, including wanting to be seizure-free and to be able to drive with only once-daily dosing. The patient was prescribed perampanel, 2 mg once a day at night for 1 month to assess and titrate. It was also suggested that she keep a seizure diary. The patient was seen 4 weeks later for follow-up. She had no seizures and was tolerating the medication well. The dose of perampanel was increased to 4 mg a day. She has subsequently been seizure-free for 6 months at 4 mg perampanel and was able to return to driving.

This is a fairly typical patient who we see in the adult epilepsy clinic. This is a 55-year-old woman who has no risk factors for development of epilepsy and had her first seizure at the age of around 50 years old. As with most patients who have their first seizure, she was not prescribed seizure medication. Then with the second seizure, she was prescribed an antiepileptic medication, but she initially refused to take it. She subsequently had further seizures, and a work-up at that point demonstrated focal left temporal lobe epilepsy. She was then prescribed antiepileptic medication, which she decided to take, and she became seizure-free on perampanel at 4 mg per day and was able to return to driving. 

It’s not unusual for patients who have a single seizure to not be treated with antiepileptic medication, especially if their work-up and testing at that point is normal. It’s not unusual for patients, even after they’ve had their second or third seizure, to resist taking medication because they’re often not convinced that they have epilepsy, and they’re concerned about the adverse effects of medication. Beyond that, a lot of the time, patients are concerned about a potential diagnosis of epilepsy that might impact them for years to come. This is a pretty typical case that we see in the clinic.