Epilepsy: New (old) treatment without drugs

Nothing is so hard as watching a child having a seizure.

           –Elizabeth A. Thiele, MD, PhD, professor of neurology at Harvard Medical School

Until recently, when people asked me, “What would I suggest as a non-toxic/non-invasive biofeedback approach for the treatment of epilepsy?” I automatically replied, “A combination of neurofeedback, behavioral analysis treatment, respiration training, a low glycemic diet, and stress management and if these did not work, medications.” I have now changed my mind!

Epilepsy is diagnosed if the person has two or more seizures. About one to two percent of the population is diagnosed with epilepsy and it is the most common neurological illness in children. Medication is usually the initial treatment intervention; however, in about one third of the people, the seizures will still occur despite the medications. In some cases, people -often without the support of their neurologist/healthcare provider–will explore other treatment strategies such as diet, respiration training, neurofeedback, behavioral control, diet, or traditional Chinese medicine.

It is ironic that one of the tools to diagnose epilepsy is recording the electroencephalography (EEG)– brain waves–of the person after fasting while breathing quickly (hyperventilating). For some, the combination of low blood sugar and hyperventilation will evoke epileptic wave forms in their EEG and can trigger  seizures (hyperventilation when paired with low sugar levels tends to increase slow wave EEG which would promote seizure activity).
If hyperventilation and fluctuating blood sugar levels are contributing factors in triggering seizures, why not teach breathing control and diet control as the first non-toxic clinical intervention before medications are prescribed. This breathing approach has shown very promising clinical success.  (For more details  see the book, Fried, R. (1987). The Hyperventilation syndrome-Research and Clinical Treatment. Baltimore: The Johns Hopkins University Press).

Self-management should be the first clinical intervention and not the last. Similarly, neurofeedback– brain wave biofeedback–is another proven approach to reduce seizures. This approach was developed by Professor Maurice B. Sterman at UCLA and was based upon animal studies. He demonstrated that cats who were trained to increase sensory motor rhythm (SMR) in their EEG  could postpone seizure onset when exposed to a neurotoxin that induced seizures. He then demonstrated that human beings with epilepsy could equally learn to control their EEG patterns and inhibit seizures. This approach, just as the breathing approach, is non-toxic and reduces seizures.

Underlying both these approaches is the concept of behavioral analysis to identify and interrupt the  chained behavior that leads to a seizure. Namely, a stimulus (internal or external) triggers a cascading chain of neurological processes that eventually results in a seizure. Thus, if the person learns to identify and interrupt/divert this cascading chain, the seizure does not occur. From this perspective, respiration training and neurofeedback could be interpreted to interrupt this cascading process. Behavioral analyses includes all behaviors (movement, facial expressions, emotions, etc) which can be identified and then interrupted. As professors Joanne Dahl and Tobias Lundgren from Uppsala University in Sweden state, The behavior technology of seizure control provides low-cost, drug free treatment alternative for individual already suffering from seizures and the stigmatization of epilepsy.

Until recently, I would automatically suggest that people explore these self-control strategies as the first intervention in treatment of epilepsy and only medication for the last resort. Now, I have changed my mind. I suggest the ketogenic diet as the first step for the treatment of epilepsy in conjunction with the self-regulation strategies—medication should only be used if the previous strategies were unsuccessful.

A ketogenic diet  has a 90% clinical success rates  in children–even in patients with refractory seizures. This diet stabilizes blood sugar levels  and is very low on simple carbohydrates, high in fat,  some protein, and lots of vegetables (a ratio of 4 grams of fat to 1 gram of carbohydrates and protein). In adults, the success rates drops to about 50%. The lower success rate may be the result of   the challenges in implementing these self-regulatory diet approaches. As Elizabeth A. Thiele, MD, PhD, professor of neurology at Harvard Medical School points out, dietary therapy is the most effective known treatment strategy for epilepsy. Even though, ketogenic diet is the most effective therapy, it is less likely to be prescribed than medications—there are no financial incentives; there are, however, many financial incentives for prescribing pharmaceuticals.

These lifestyle changes are very challenging to implement. They need to be taught and socially supported. Just telling people what to do does not often work. It is similar to learning to play a musical instrument.  The person needs step by step coaching and social support which is an intensive educational approach. To learn more about the research underlying the ketogenic diet as the first level of intervention for epilepsy, watch Professor Thiele’s presentation from the 2012 Ancentral Health Symposium, Dietary Therapy: Role in Epilepsy and Beyond.