Frontal Lobe Epilepsy Treatment & Management

While a first seizure may not be treated, anti-seizure medications 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 responsive neurostimulation, corpus callosotomy, multiple subpial transections, or vagus nerve stimulation.

While a first seizure may not be treated, anti-seizure medications 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 anti-seizure medications for use in focal 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 anti-seizure medications include phenytoin, carbamazepine, valproic acid, and barbiturates. Newer anti-seizure medications include gabapentin, lamotrigine, topiramate, levetiracetam, zonisamide, oxcarbazepine, pregabalin, lacosamide, clobazam, eslicarbazepine, and brivaracetam.

Approximately 30% of patients with frontal lobe epilepsy will be refractory to multiple medications, and they may require evaluation for resective surgery. Other options include dietary therapy (ketogenic diet or modified Atkins diet), vagal nerve stimulation, or responsive neurostimulation.

Go to Antiepileptic Drugs for complete information on this topic.

Folate therapy

Folate should be added to the anti-seizure medication regimen of female patients of childbearing age to reduce the risk of neural tube defects.

Frontal cortical resection is the most commonly performed extratemporal cortical resection for intractable epilepsy. ^[18] 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.

In a case series of patients with post-traumatic epilepsy, 57% had temporal lobe epilepsy and 35% had frontal lobe epilepsy (FLE). The overall poorer epilepsy surgical outcomes for FLE when compared with temporal lobe epilepsy (similar in post-traumatic and non-traumatic cases) may be related to a larger epileptogenic zone in FLE, with difficult-to-define margins (especially in nonlesional cases), which results in inadequate resection. ^[19]

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. ^[18]

Factors predictive of poor outcome include incomplete resection, tonic seizures, and interictal spikes on follow-up EEG. ^[20]

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. ^[21]

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 convulsions and/or falls. Focal seizures that do not generalize often do not improve and may worsen. With the advent of improved surgical techniques, this procedure is now rarely peformed 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.

Vagus nerve stimulation

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.

Responsive neurostimulation

Responsive neurostimulation (RNS) is a newer device that should be considered when seizure onset is in/near eloquent cortex or bilateral. The device has electrodes implanted in the suspected seizure-onset zones and can be programmed to detect seizures, and then stimulate to abort ictal activity. In one study, patients with frontal lobe epilepsy experienced a median percent seizure reduction of 70%. ^[22]

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.

• This diet is very restrictive and may be difficult to maintain. It may be more feasible for an individual who receives nutrition via a G-tube.

• 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. This diet is not as restrictive and does not require initial fasting, and thus may be better tolerated. Other alternatives to the ketogenic diet include the medium chain triglyceride diet and the low glycemic index treatment. Results have been encouraging, but data on its efficacy specifically for frontal lobe epilepsy are limited. ^{[23, 24]}

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 anti-seizure medications following head trauma has not been demonstrated to reduce the chance of epilepsy development.

Patients with epilepsy, particularly those with intractable epilepsy and frequent seizures, should be counseled regarding the risk of sudden unexplained death in epilepsy patients (SUDEP).

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 anti-seizure medications. 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.