Frontal Lobe Epilepsy Treatment & Management

While a first seizure may not be treated, anticonvulsant therapy should be initiated once the diagnosis of epilepsy is established. Many nocturnal episodes with prominent motor manifestations respond extremely well to carbamazepine.

Patients with medically intractable epilepsy should be considered for resective epilepsy surgery. If resective surgery is not possible, other surgical options include corpus callosotomy, multiple subpial transections, or vagus nerve stimulation.

While a first seizure may not be treated, anticonvulsant therapy should be initiated once the diagnosis of epilepsy is established. Many nocturnal episodes with prominent motor manifestations respond extremely well to carbamazepine.

An increasing number of anticonvulsants approved for use in partial epilepsies are available and may be used as monotherapy or in combination.

While monotherapy is desirable, some patients require polytherapy for adequate seizure control. Choice of therapy may be influenced by factors such as tolerability of side effects and interactions with other medications. Older anticonvulsants include phenytoin, carbamazepine, valproic acid, and barbiturates. Newer anticonvulsants include gabapentin, lamotrigine, topiramate, tiagabine, levetiracetam, zonisamide, oxcarbazepine, and pregabalin.

Patients who do not respond to multiple medications may require evaluation for resective surgery. Other options include the ketogenic diet, modified Atkins diet, or vagal nerve stimulator.

Go to Antiepileptic Drugs for complete information on this topic.

Folate therapy

Folate should be added to the anticonvulsant regimen of female patients of childbearing age.

Frontal cortical resection is the most commonly performed extratemporal cortical resection for intractable epilepsy.^[11] Although it is less successful than temporal lobe surgery, advances in presurgical evaluation continue to improve the outcome of frontal resections. Most studies indicate 20-50% of patients become seizure-free, with positive outcomes in up to 70% reported.

Go to Epilepsy Surgery for complete information on this topic.

Postoperative prognosis

Prognostic factors for good long-term outcome following surgery include no history of febrile seizures, neuroimaging detection of a potentially epileptogenic lesion, and focal beta (fast) ictal discharge on scalp EEG.^[11]

Factors predictive of poor outcome include incomplete resection, tonic seizures, and interictal spikes in follow-up EEG.^[12]

In general, the prognosis is best if a lesion is present and can be resected completely along with the adjacent cortex if it is a part of the epileptogenic zone. Usefulness of resecting areas of interictal spiking is controversial. Most recurrences occur early, typically within 6 months of resection.^[13]

Intraoperative electrocorticography has prognostic significance, especially if spikes are continuous or nearly so, as is often the case when cortical dysplasia is present. In these instances, absence of postresection epileptiform activity is a strong predictor of a favorable outcome. Although acute postoperative seizures are compatible with long-term seizure reduction following surgery, early postoperative seizure control is a significant prognostic factor for an excellent outcome.

Besides the risk of cranial surgery, potential complications include motor weakness and behavioral changes.

This procedure is aimed at prevention of bilateral synchrony, thus preventing seizure generalization. Partial seizures that do not generalize often do not improve and may worsen. With the advent of improved surgical techniques, this procedure rarely is done for well-defined frontal lobe epilepsy.

In this procedure, multiple vertical transections are created, thus interrupting the pathways for horizontal ictal spread while preserving projection fibers important for function.

It is performed in some centers, often in conjunction with resection, for epileptogenic zones that overlap with eloquent cortex.

A stimulator is implanted surgically, which provides stimulation of the left vagus nerve at a preset rate, typically 30 seconds every 5 minutes, and also may be activated by a hand-held magnet.

This technique allows for patient self-activation of the device during an aura, which may, in some patients, terminate the seizure. The programmed stimulations may improve seizure control even in patients with no aura, allowing self-activation of the device.

Go to Vagus Nerve Stimulation for complete information on this topic.

Ketogenic diet

This high-fat diet, typically with a fat-carbohydrate ratio of 3-4:1, induces ketosis. Considerations include the following:

• Option for medically refractory epilepsy; most often used for children with symptomatic/cryptogenic generalized epilepsies
• May be difficult to maintain
• Limited experience in adults and in partial epilepsies

Modified Atkins diet

The modified Atkins diet has been under investigation as an alternative to the ketogenic diet in patients with intractable epilepsy. Early reports have been encouraging.^[14]

Frontal lobe epilepsy may be an early or late aftermath of head trauma. Measures should be taken to prevent head injury, including mandatory use of seat belts and bicycle helmets.

Use of prophylactic anticonvulsants following head trauma has not been demonstrated to reduce the chance of epilepsy development.

Neurology/epileptology

Patients with frontal lobe seizures should be evaluated by a neurologist. Patients with medically intractable frontal lobe epilepsy should be considered for referral to a comprehensive epilepsy center.

Psychiatry

Psychiatric or neuropsychiatric consultation may be useful for differentiating between frontal lobe epilepsy and nonepileptic conditions.

Depression is often a comorbid condition with intractable epilepsy.

Patients require frequent office visits during the titration and adjustment phase of anticonvulsants. Examination should include evaluation for excessive nystagmus, tremor, and ataxia. Baseline and follow-up blood testing may be needed.

When seizure free on a maintenance dose of medication, patients may be asked to come for follow-up 1-3 times a year.

Patients who are seizure free for 2-5 years may be considered for a trial of medication withdrawal, depending on the individual case.