Sleepless nights. Exhausted afternoons. Confusion. Memory loss. Trouble with concentration, mood swings and of course, seizures. Which may increase in frequency or severity. Or may even contribute to intractable seizures. It seems like an endless cycle.
For people with epilepsy, sleep problems are a double-edged sword; epilepsy disturbs sleep and sleep deprivation aggravates epilepsy. Plus, the drugs used to treat epilepsy may also disturb sleep.
Studies have shown that 10-45% of people with epilepsy have seizures that occur predominantly or exclusively during sleep, whereas 34% have seizures upon awakening and 21% have diffuse seizures (while both awake and asleep).
Sleep activates electrical charges in the brain that result in seizures and seizures are timed according to the sleep-wake cycle. That sleep-wake cycle is associated with prominent changes in brain electrical activity and hormonal activity, so seizures and the sleep-wake cycle are closely related.
For some people, seizures occur exclusively during sleep. Others have seizures as they are falling asleep or waking up, and still others have seizures randomly spread throughout the day or night. This is especially true for Benign Focal Epilepsy or Rolandic Epilepsy.
When seizures occur during sleep, they may cause awakenings that are sometimes confused with insomnia. Epilepsy patients are often unaware of the seizures that occur while they sleep. They may suffer for years from daytime fatigue and concentration problems without ever knowing why.
Conversely, in the case of Juvenile Myoclonic Epilepsy, seizures rarely or never happen when sufficient sleep is obtained.
The way seizures spread through the brain also seems to differ depending on sleep state. Interestingly, frontal lobe seizures begin during sleep more often than temporal lobe seizures. However, temporal lobe seizures are more likely to spread and result in a convulsion when beginning during sleep, while frontal lobe seizures are not. This discovery could have implications for treatment if better understood.
Despite this, many physicians overlook the potential for treatable causes of sleep disruption in patients with epilepsy. And the outcome is that optimal sleep may not be achieved.
Here are some specific epilepsy disorders that are closely related to sleep seizures…
Frontal Lobe Epilepsy
Temporal Lobe Epilepsy
Juvenile Myoclonic Epilepsy
Epilepsy with Generalized Tonic-Clonic seizures on awakening
Rolandic Childhood Epilepsy with centrotemporal spikes
Interestingly, people progress through different stages of sleep. Most sleep seizures begin during the lighter stages, 1 and 2, and usually happen first upon falling asleep, accounting for about half of the total sleep time. These are times during which the electrical activity of the brain is more synchronized (rhythmic), which is why scientists believe that seizures are more likely to begin during these states.
By contrast, few or no seizures begin during REM sleep, (rapid eye movement, when you have the most vivid dreams). Normally, people cycle through all of these stages several times during the night.
On occasions, nocturnal seizures can be misdiagnosed as a sleep disorder and certain sleep disorders can be misdiagnosed as epilepsy. (Video-EEG recordings can assist with the correct diagnosis.)
But, the most troublesome sleep disorder in people with epilepsy is sleep apnea, in which breathing stops briefly during sleep. Sleep apnea affects at least 2% of the general population. But it’s about twice as common for those with poorly controlled epilepsy than in the general population.
As sleep deepens, the airway becomes blocked. The brain recognizes the resulting lack of oxygen, and the person wakes up (usually with a loud snore) and begins to breathe again. Often the person does not remember waking up, but this cycle is repeated all night long and normal sleep is never achieved. Therefore the person is drowsy most of the time and may be at risk of falling asleep during activities like driving.
It’s especially important to recognize and treat sleep apnea if you have epilepsy. Not only can the lack of sleep make your seizures worse, so can the lack of oxygen getting to your brain during sleep.
You may continue to have seizures (particularly during sleep) even if you take seizure medicines that would otherwise be effective. The good news is that both your drowsiness and seizures should improve if the sleep apnea is treated.
Sedating AEDs may benefit epilepsy patients with insomnia, and stimulating AEDs may benefit epilepsy patients with daytime sleepiness.
Phenobarbital and Klonopin can actually be used as sedatives. Lamictal may cause difficulty falling asleep. (It made me crazy hyper!) Felbatol, may cause insomnia. And medications like Dilantin, Phenytek, Tegretol or Carbatrol decrease REM sleep and therefore may contribute to memory problems.
Other seizure medicines, such as Neurontin and Depakote are thought to have little effect on sleep. And the jury is still out on some of the newest medications, like Trileptal, Keppra and Zonegran.
So what about sleeping pills?
Well, it depends upon your body chemistry. (And your state of mind.) Some people tolerate sleeping pills very well. Others become addicted.
The party line is that almost no sleeping pill should be used for more than two or three weeks. Particularly drugs of the benzodiazepine class, such as Xanax, Valium and Ativan, along with Halcion and Restoril.
Although how Restorial can be considered a sleeping pill is beyond me. I threw up all night and got zero sleep. So everyone is different. Which leads back to the merry-go-round of drugs.
To sleep or not to sleep? To seize or not to seize?
I’m tired of this merry-go-round. (I bet you are, too.) I want to get off. And take a nap.