Monthly Case

Epilepsy with grand mal on awakening | 9-2016

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A 26-year-old female patient suffers at age 18 and 19 years her first and up to now only three generalized tonic clonic seizures. All her seizures manifested within the first 30 min. after awakening in the morning. The patient reported that in those years she had a rather irregular sleep-wake-cycle. EEGs had demonstrated generalized spike-wave-complexes at 3/s. At that time, the correct diagnosis of idiopathic generalized epilepsy had been made. This form accounts for approximately 20% of all epilepsies. The subsyndrome in the current patient is epilepsy with grand mal on awakening.

First choice pharmacological treatment of idiopathic generalised epilepsy is valproic acid. Due to possible malformations and developmental injuries to the embryo during pregnancy (teratogenicity), this drug is generally not administered to female patients with child-bearing potential. The current patient was treated with lamotrigine 100 mg daily, she did not report adverse effects.

Probably due to persisting seizure freedom, the patient did not present in our epilepsy outpatient clinic for 5 years. At age 26, she showed up in our clinic and reported that she had withdrawn lamotrigine some 6 months ago without seizure recurrence. She asked for our advice regarding need for further treatment.

We explained to the patient that idiopathic generalised epilepsies are rather benign conditions with excellent response to pharmacological treatment. In the long run, probability for further seizures decreases. After withdrawal of antiepileptic drugs, more than half of the patients will have seizure recurrence.

As the current patient had a total of only three epileptic seizures and as she has withdrawn the antiepileptic drug based on her own decision, we decided – after 6 months of seizure freedom without pharmacological treatment – to leave her untreated.

This case illustrates that withdrawal of antiepileptic drugs in epilepsy is always an individual decision that considers both biological aspects and patients’ expectations.

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