Monthly Case

A 42-year-old male patient reports that he had suffered tonic-clonic generalized seizures without focal signs or symptoms in his 22^nd, 30^th and 36^th year of life. All seizures manifested within 60 min. after awakening and were preceded by very short sleep duration and significantly increased alcohol consumption the night before. Interictal EEGs demonstrated generalized 3/s spike-wave-complexes with maximal amplitudes bi-frontally. This patient unequivocally suffers from idiopathic generalized epilepsy, the specific subsyndrome is epilepsy with grand mal on awakening. Due to typical EEG features, the patient is treated since his first seizure with valproate at a dose of 900 mg daily. After 6 years of seizure freedom, the patient now asks for withdrawal of the antiepileptic drug. As all seizures have been triggered (not: caused!) by sleep deprivation and increased alcohol consumption, we assume a rather low recurrence risk after valproate withdrawal, if the well-known triggers can be avoided. The patient himself suggested that – when sleep deprivation and/or increased alcohol consumption can be anticipated – he takes 900 mg valproate for 2 to 3 day in advance. Due to his individually low recurrence risk, we did not generally oppose this pragmatic approach.

We explained to the patient that for 3 months after the last dose of valproate he will not be allowed driving a car. Even more, due to his individual susceptibility, he will not be allowed driving the days after sleep deprivation and increased alcohol intake.

This case demonstrates that in some patients with idiopathic generalized epilepsy seizures only manifest in the context of well-known trigger factors. From the perspective of classification, these still are unprovoked (in contrast to acute-symptomatic) seizures. To avoid misunderstandings, the term “provoked” should be avoided, instead the terms “facilitated” or “triggered” are recommended to describe the circumstances of seizure manifestation.

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