Epilepsy, Acute Onset Seizures, and Trigeminal Neuralgia: A Clinical Review

Generalized Onset Seizures

Generalized onset seizures originate in, or rapidly spread to, both hemispheres at once.

• Nonmotor (Absence) Seizures: These are characterized by brief lapses in consciousness. The patient may not even realize the event occurred.
• Motor Seizures: The most prominent is the tonic-clonic seizure. This involves a sudden loss of consciousness and a rigid fall (tonic phase, <1 minute), followed by rhythmic jerking of the musculature (clonic phase, 2–3 minutes), and finally a flaccid postictal state. Other types include myoclonic and atonic seizures.

Exam Tip: In some clinical scenarios, the distinction between focal and generalized onset can only be definitively made using an EEG.

Status Epilepticus and Management

Status epilepticus is a medical emergency. In patients with known epilepsy, the most common cause of status epilepticus is the failure to take prescribed antiepileptic medications.

The initial pharmacological management for status epilepticus involves administering an IV benzodiazepine, immediately followed by fosphenytoin or phenytoin. For pregnant women experiencing myoclonic seizures, levetiracetam is an acceptable and preferred medication.

Acute Onset Seizures

Unlike epilepsy, which is a chronic predisposition to seizures, acute onset seizures are provoked by specific, immediate insults to the brain. Essentially, anything that acutely irritates the brain—either structurally or metabolically—can provoke a seizure.

Common causes include:

• Structural/Traumatic: Traumatic Brain Injury (TBI), acute ischemic or hemorrhagic stroke, subdural hematoma, subarachnoid hemorrhage, cerebral venous thrombosis, brain abscess, and encephalitis.
• Metabolic/Infectious: Meningitis, metabolic derangements (such as electrolyte abnormalities), and eclampsia.
• Substance-Related: Substance ingestion or withdrawal.

Trigeminal Neuralgia

Trigeminal neuralgia is a condition characterized by sudden, intense, electric-shock-like facial pain.

Clinical Manifestations

The pain typically arises on one side of the mouth and shoots toward the ipsilateral (same side) ear, eye, or nostril. These episodes are often triggered by innocuous stimuli such as:

• Touch or movement
• Drafts of air
• Eating

Because of the unpredictable and severe nature of the pain, patients may exhibit behavioral changes, such as barely moving their mouth while speaking to avoid triggering an attack.

Etiology and Management

The most common cause is an anomalous artery or vein compressing the trigeminal nerve.

Pharmacologic Management:

1. First-line: Oxcarbazepine (used off-label) or carbamazepine.
   • Note: If carbamazepine is used, clinicians must monitor serial Complete Blood Counts (CBCs) and Liver Function Tests (LFTs).
2. Second-line/Adjuncts: Phenytoin, baclofen, topiramate, or lamotrigine.
3. Pain Relief: Gabapentin may also be utilized to help relieve the associated pain.