Adolescent Epilepsies

Adolescence is a time of dramatic change in growth, physical maturation, hormonal milieu, emotional state, and social development. Epilepsy is one of the most common neurologic disorders in adolescents. In actuality, adolescence represents the second peak period for epilepsy onset, with the first occurring during early childhood. Pubertal changes, the potential for pregnancy, driving, rebellious behavior, alcohol and drug use, acceptance of diagnosis, medication compliance, independence, self-esteem, and even employment represent potential issues during the adolescent years that may impact or be impacted by seizure control and appropriate management.

Quality treatment of epilepsy in adolescents requires a rational and holistic approach to therapy that must include appropriate knowledge of epilepsy and epilepsy syndromes common to this age group, the spectrum of efficacy and potential adverse effects of antiepileptic drugs (AEDs), and many psychosocial factors that must be considered for each individual patient. New-onset epilepsy is common to adolescence, especially with the idiopathic or genetically determined generalized epilepsy syndromes that arise during this time period. These generalized epilepsies, with the most common being juvenile myoclonic epilepsy and juvenile absence epilepsy, have overlapping clinical features and genetic origins as well as similar electroencephalographic findings. There is also a group of heterogenous, more severe, and devastating epilepsy syndromes that commonly begin during adolescence that are collectively referred to as progressive myoclonus epilepsies that characteristically include myoclonus and progressive neurologic decline. These disorders are discussed in this issue and include Unverricht-Lundborg disease, Lafora disease, juvenile-onset neuronal ceroid lipofuscinosis, sialidosis (cherry-red spot myoclonus), dentatorubral-pallidoluysian atrophy, and myoclonic epilepsy and ragged-red fibers.

Special considerations must be applied to adolescent females, as hormonal changes associated with the menstrual cycle may impact seizure control and management, and as they become women of childbearing age with a potential for pregnancy whereby the impact of AED therapy on the fetus also warrants consideration.

Alternative therapies should be considered for adolescents with epilepsy who are refractory to AED therapy. Epilepsy surgery for intractable patients provides the best overall potential for complete seizure control for patients who are medically refractory. Even though surgical treatment will obviously not be an appropriate option for all individuals, it is recommended that all patients who have not experienced seizure control in response to two or more AEDs should at least be referred to a comprehensive epilepsy surgical center for appropriate evaluation and consideration. If surgery is not an appropriate option for an individual, knowledge gained from the comprehensive evaluation may contribute to better understanding of the individual's disorder, and may provide information that may help direct better therapy.

The adolescent may also present with other paroxysmal events that are nonepileptic in nature but must be evaluated and differentiated from epileptic seizures. These nonepileptic spells occur very commonly during adolescence and include both psychiatric and nonpsychiatric conditions such as migraine, syncope, movement disorders, sleep disorders, and psychogenic nonepileptic seizures. The adolescent with true epilepsy is at risk for many psychological, psychiatric, and behavioral comorbidities, and a comprehensive team approach to epilepsy care is preferable if available.

The impact of epilepsy on the quality of life of the adolescent is potentially tremendous. Physicians who provide care and management for teenagers with epilepsy should be fully aware of the multifaceted, associated issues common to this age group that extend far beyond simple medication management. Increased awareness and knowledge of these associated issues will help physicians provide better care for their patients and achieve the primary goals of therapy: seizure freedom and maximized quality of life.