Epilepsy is one of the most frequently encountered severe neurological disorders, characterized by a heightened risk of recurring epileptic seizures. In the U.S. alone, around 1.2% of the population suffers from this condition, according to data from 2015. However, 80% of all cases of this disorder worldwide are reported in developing, rather than in developed countries. Epilepsy has been recognized and recorded since the beginning of documented history. Many different interpretations have been noted about the identification, causes, and treatments of this disorder since it was first thought to be a spiritual condition, but a particular social stigma around people with epilepsy persists even today. In the past, having epilepsy marked one as a target of shunning and often imprisonment; people with this disorder were seen and treated the same as those who were mentally ill or criminally insane. Others would avoid drinking from the same bowl as them and generally steer clear of all contact with individuals affected by epilepsy. In some countries, although not nearly as bad as in history, the stigma still prevails – in some parts of China, epilepsy is an acceptable justification of marriage denial, while many cultures still hold onto the claims that epilepsy-affected people are haunted. Such an excluding popular opinion can lead people to hide or deny their condition in fear of judgment, resulting in serious risk to their health due to lack of treatment, and increased mortality risk commonly due to falls, incidents, and status epilepticus.
Due to their symptoms and the stress they regularly face, people who have epilepsy often have a comorbid condition such as migraines, anxiety, depression and a palette of sleep disturbances like nocturnal seizures, insomnia and sleep apnea. We will cover more about the relationship between epilepsy and sleep, as well as how to manage some common difficulties, but not before we dispel some myths and misconceptions about epilepsy.
What is Epilepsy?
Epilepsy is a chronic neurological condition which characteristic feature is recurring seizures that range from short and barely detectable to long-lasting and severe. It doesn’t mean that only people with epilepsy have seizures – about 10% of Americans will experience one at some point in their lives. A seizure can signify any sudden, different behavior of a person with symptoms like shaking, zoning out, limb jerking, loss of consciousness, etc.
What makes an epileptic seizure distinctive from others is its electric discharge from the brain and lack of traceable underlying cause. It means that only a seizure that isn’t a consequence of some reversible condition and isn’t caused by extremely low blood sugar, substance abuse or withdrawal, etc. counts as an epileptic seizure. Depending on their varying symptoms and duration, as well as in which area of the brain they occur, epileptic seizures are classified into three categories:
- Focal onset means that the seizure started in one side of the brain. Focal onset aware seizure is a type where the person is conscious and aware of what’s happening. Focal onset impaired awareness means that the individual is awake but confused and not fully aware of their seizure.
- Motor symptoms of focal onset type may include tonic spasming, clonic simultaneous muscle jerking, myoclonic twitching, atonic limp muscles, epileptic spasms (when body repeatedly contracts and extends) and some automatic repetitions like hand rubbing, clapping or chewing.
- Non-motor symptoms would include changed cognitive ability, emotional state, thinking, feeling hot or cold, etc. A complete absence of movement, known as behavioral arrest, is also possible.
- Generalized onset signals that the seizure started simultaneously in both brain hemispheres, or groups of cells from both sides. It includes seizure types such as tonic-clonic, absence and atonic seizures.
- Motor symptoms falling under this category may include sustained clonic jerking movements, brief myoclonic jerking or twitching muscles, limp or weak (atonic) muscles, tonic tense muscles, and epileptic spasms.
- Non-motor symptoms are commonly called typical or atypical absence seizures and may include myoclonic twitching of a specific area of the body such as the eyelids.
- Unknown onset refers to a seizure whose onset region isn’t known, as it occurred when nobody else was present to witness it or during one’s sleep. A diagnose of the unknown onset might later be changed into generalized or focal onset as the case is examined and more information is gathered.
- Motor seizures are usually reported as epileptic spasms and tonic-clonic seizures.
- Non-motor seizures mostly involve behavioral arrest.
Tonic-clonic seizures start with tonic limb contractions, their extension and arching the back. It lasts for up to 30 seconds and is followed by a simultaneous clonic shaking of limbs. After such a seizure, it may take a person around 30 minutes to get back into their normal state. This period is called the postictal state or phase. Tonic-clonic seizure is a less common type than often assumed, accounting for only 10% of all epileptic seizures. Clonic seizures involve simultaneous, rhythmical motion or one or both sides of an individual’s body. Tonic seizures cause a person’s muscles to become rigid, and the person might fall if they were previously standing. Along with the atonic type, one of the shortest seizures. Atonic can also cause a person to fall over, but their body muscles become limp unlike in tonic seizures. Myoclonic seizures involve brief twitching of a body part, and the person is aware while that’s happening. However, since it rarely appears alone, it isn’t classified under the “aware” category.
An individual needs to experience at least two seizures that happen more than 24 hours apart and aren’t provoked by another condition to be diagnosed with epilepsy. The cause of this disorder can be environmental, genetic-related or in many cases, both. The exact cause is unknown in over 60% cases. Severe trauma, stroke, and tumors are some known environmental factors. In developed countries, at risk of epilepsy are the elderly and children, while developing countries have far more cases of occurrence in adolescents and young adults.
The cure for epilepsy doesn’t exist. That is to say, one’s possibility of having seizures cannot be treated as the exact root of their disorder isn’t known. However, preventing or lowering the chance of one triggering seizures is possible with the use of anti-epileptic drugs (AED). Treatment with these medications can put one’s seizures completely under control, but finding the right pill or combination of pills can sometimes take a while. Side-effects of AED often include sleep disturbances.
Epilepsy and Sleep Issues
The relationship between sleep and epilepsy is complex. Sleep and sleep deprivation can both contribute to or trigger seizures, while some sleep disturbances might mask the symptoms of nocturnal seizures. These, in turn, can also interfere with the diagnosis of some sleep disorders, which could potentially deal a whole lot of damage, as the real issue would not be treated, and the misplaced therapy for the mistakenly diagnosed condition could make matters even worse. Some common issues between sleep and epilepsy are as following.
- Seizures during daytime have been linked with a worsened quality and a fragmented structure of sleep the same night. Besides that, medication commonly used to treat epilepsy may disrupt sleep as well, resulting in excessive daytime sleepiness and an insufficient amount of sleep.
- The electrical activity in one’s brain during light NREM stages can trigger a nocturnal seizure.
- Sleep disorders that might comorbid epilepsy also have a negative impact on both sleep and epilepsy symptoms and may spur seizures, not to mention adding a bonus difficulty for a person to handle, making them less happy and functional as a result.
- Children who experience sleep deprivation due to nocturnal seizures or insomnia are more likely to underperform at school. Not only that, but according to numerous studies, their parents are regularly sleeping less as well, even as low as 4 hours a night, proportionally to the problematic nights their child has. Children with epilepsy, in general, have an increased risk of developing ADHD (attention deficit hyperactivity disorder) due to the stress of epilepsy and lack of sleep.
Nocturnal seizures occur during sleep and affect over 45% of people with epilepsy who experience seizures exclusively at that time. This type of epileptic seizures is most common in children, with the incidence rate estimated to be around 60%.
People who only have epileptic seizures in daytime are more likely to have worsened sleep than unaffected people, but a more specific problem arises when recognizing the presence of a nocturnal seizure, as most people will not realize that it’s what woke them up from sleep. Confused or in pain from teeth grinding and tensing muscles, they will often assume the issue lies within sleep itself, guessing at maintenance-type insomnia or a similar disorder instead. If somebody else is present when such an episode happens, they might notice the shaking, jerking or hear a noise, but even then it isn’t guaranteed that epilepsy will appear first on the list. Sleep disorders like periodic limb movement or sleep bruxism are known to feature similar symptoms, and it would not be hard to mistake one for the other. Interestingly, if nocturnal seizures happen regularly enough, a secondary sleep disorder might actually develop, but the root issue remains the same.
If you suspect any of these conditions, you should ask your doctor to order polysomnography for you. This laboratory sleep study done overnight works by tracking your brain wave activity, eye movements, heart rhythm, breathing, movements of your limbs and more. Licensed specialists are required to be present the whole time, and they will be sure to get the picture if you have epilepsy, a sleep disorder or something else entirely. If you aren’t sure about this yet, try writing a sleep diary for a minimum of two weeks. Be as precise as possible about your nightly experiences, as well as how you feel during the day. If somebody else lives with you, ask them to keep track as well. The more details you manage to remember, the easier it will be for your doctor to potentially single out the exact problem. The smallest, seemingly irrelevant note could prove crucial for understanding the condition you are dealing with, even if you already have a diagnose.
Nocturnal seizures typically take place in the light sleep (stage 1 or 2) and prevent one from reaching the REM phase and slow wave sleep, which happen later during the night and are the most restorative stages. It significantly reduces sleep quality, and the individual might wake up tired, with impaired memory functions, cognitive ability, response time or other essential bodily functions. Sleep deprivation is known to cause irritability and emotional stress, which, along with excessive tiredness, ranks high on a seizure trigger list from a large study. That is to say that nocturnal seizures have a good chance of indirectly causing daytime seizures as well.
About one-third of people who live with epilepsy also have undiagnosed sleep apnea. Obstructive sleep apnea (OSA) is a treatable sleep-related breathing condition that causes partial or complete airway obstruction during one’s sleep. When untreated, it can majorly disrupt sleep and result in sleep deprivation, which does nothing to help prevent seizures, as we previously established. The most effective treatment for this disorder is Continuous Positive Airway Pressure (CPAP) therapy. The method is simple: the CPAP machine draws in air, humidifies it and sends it directly into a mask that the patient put on before going to sleep. In patients with epilepsy and OSA, CPAP therapy has been shown not only to treat OSA but also to improve seizure control.
OSA risk group includes older people as well as those who are overweight. People with epilepsy should note this because many of the AED list weight gain as a side-effect.
Epilepsy alone can cause a lot of troubles to an individual who has it. Even in good attempts to improve their condition, one’s sleep can suffer. In the other direction, good and bad sleep can both exacerbate seizures, but insufficient sleep can cause many further complications as well, including sleep disorders and some other conditions – children with epilepsy are more likely to develop ADHD. Treatment for all of these conditions can be efficient if correctly diagnosed. As confusing as that might be, there are things to do and make it easier, such as keeping a sleep (and daytime) log, doing polysomnography and other necessary tests. In addition to that, we would note that healthy sleep hygiene, diet, exercise, and stress management are all key factors to ensure seizures, as well as sleep disorders, are under control.