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EPILEPSY: THE NIGHT THIEFBy Mary Ellen Wells, MS, RPSGT, REEGT, RNCST
Sleep is vital to the health and well-being of all people but
follows a cyclical pattern, and in certain conditions it may be
takes on new meaning for patients with epilepsy. People with
predominately nocturnal. The human circadian rhythm also has
epilepsy are commonly referred to a sleep laboratory because of
a cyclical pattern and oscillates between wake and sleep, and
disrupted sleep. Daytime sleepiness and insomnia are frequent
sleep oscillates between non-rapid eye movement (NREM) sleep
symptoms experienced by patients with epilepsy.1 Other reported
and REM sleep. Epileptic activity is inﬂuenced by sleep stages.
symptoms include poor cognitive performance, memory dysfunc-
In some idiopathic epilepsies, NREM sleep physiologic oscilla-
tion and sleep related breathing issues. Frequently, these symp-
tions and epileptic seizures are generated by the same cerebral
toms are attributed to medications or the underlying seizure
circuitry. Epileptiform activity is facilitated during NREM sleep,
disorder; an underlying sleep disorder is often missed.
and partially inhibited during REM sleep. Certain epileptic
An increase in health problems occurs as a result of untreated
syndromes produce seizures almost exclusively during sleep (e.g.,
sleep disorders across all people, but people with epilepsy can
frontal lobe epilepsy), and some produce seizures almost exclu-
experience additional devastating eﬀects. There is a clear connec-
sively upon awakening (e.g., juvenile myoclonic epilepsy). Sleep
tion between seizures and sleep. Disruption of sleep can increase
architecture is likewise inﬂuenced by epileptic activity. Eﬀects
seizure frequency and severity, particularly in
can include an increase in sleep latency, increase
the case of sleep-disordered breathing. Many
in number and duration of awakenings, decrease
medications used to treat seizure disorders have
in sleep eﬃciency, and reduction or fragmenta-
adverse eﬀects on sleep, which is further intensi-
ﬁed when a sleep disorder exists and is untreated.
All of these eﬀects may lead to uncontrolled
epilepsy and severe disability. It is important to
Seizures are primarily classiﬁed by the area of
note that most of the sleep disorders occurring in
the brain involved. Many factors are involved in
conjunction with epilepsy are treatable.
determining the causes of seizures; causes may
vary depending on age, gender and related medi-
cal conditions. It is important to identify the
Approximately three million people in the U.S.
seizure type, primarily because it may aﬀect the
have epilepsy, and 200,000 new cases of epilepsy
are diagnosed each year, according to the Na-
tional Epilepsy Foundation. A seizure is deﬁned
Seizures are typically classiﬁed in two primary
as “an electrical brainstorm” or abnormal electri-
groups: partial and generalized. Partial seizures
cal activity in the brain with an underlying cause,
aﬀect only a part of the brain at onset. General-
which elicits some change in activity or behavior.
ized seizures are widespread and involve both
Epilepsy is deﬁned as a disorder in which a
cerebral hemispheres simultaneously. Partial
person has a predisposition to having seizures.
seizures may spread to become generalized, just
Rather than being considered a disease, epilepsy
as a single spark can light a ﬁre. Partial seizures
is mainly viewed as a symptom of a disease.
are further broken into categories of simple and
Although there are numerous causes of epilepsy
complex; simple seizures do not alter alertness,
such as a tumor, trauma, infection, and a genetic
whereas complex seizures do have an impact on
disorder, the cause of many cases of epilepsy is
consciousness. The following list is a classiﬁca-
unknown.2 There are many types of epilepsy syndromes, which
have speciﬁc seizure types as well as associated symptoms.
Simple Partial Seizures
As early as the late 1800s, studies demonstrated the strong
These seizures do not impair consciousness
and often begin in
correlation between sleep and seizures. Epileptiform activity
the temporal or frontal lobe. Simple partial seizures are classiﬁed according to the following characteristics:
▪ Motor signs, including postural, versive and phonatory
Somatosensory or special sensory signs, including simple
RNCST, has been in the sleep ﬁeld since
hallucinations such as tingling, buzzing sounds and ﬂashes of
1999 and is a clinical assistant professor
Autonomic signs or symptoms, including sweating, ﬂushing
ences at the University of North Carolina
Psychic symptoms, including déjà vu; cognitive and aﬀective
impairments, such as time distortion, fear, and anger; and structured hallucinations, such as music and scenes
Complex Partial Seizures
Atonic or Akinetic Seizures
These seizures impair consciousness
and often begin in the
A “drop attack” is the term often used to describe an atonic
temporal or frontal lobe. They also may begin as simple partial
seizure, because the event involves a fall without warning. These
seizures (the aura) and evolve to complex partial seizures. Com-
seizures last less than 15 seconds and involve the sudden loss of
plex partial seizures are classiﬁed according to these signs and
muscle tone. Manifestations may include facial drooping, drop-
ping objects and falling. Patients who suﬀer from these episodes often require helmets or other protection to prevent injury.
▪ Impairment of consciousness upon seizure onset
▪ Simple partial seizure onset with evolvement to complex
partial seizure. Symptoms include those of simple partial
Seizures occur most frequently during stage 2 sleep, but they
seizures as listed above, followed by impairment of
also occur during drowsiness and slow wave sleep; they rarely
consciousness. Symptoms also may include automatisms
occur during REM sleep. Many studies have demonstrated that
(involuntary and purposeless movements), followed by
sleep deprivation causes an increase in seizure frequency. Sleep
continuity is disrupted, and daytime sleepiness with increased seizures may occur when nocturnal seizures are more frequent. It
Partial Seizures Evolving into Secondarily Generalized
is also noted that people with epilepsy have a higher incidence of
parasomnias, nighttime awakenings, longer sleep latency, daytime
These seizures occur in three forms, with symptoms described
above. The onset can be a simple partial or complex partial seizure that evolves to a generalized seizure. Or, onset may be a
simple partial seizure evolving to a complex partial seizure, and
Many people with epilepsy are concurrently aﬀected by sleep
ﬁnally evolving to a generalized seizure.
disorders. The relationship between epilepsy and sleep disorders is often misunderstood and may lead to inadequate treatment or
misdiagnosis if not carefully investigated. Whether they occur at
night or during the day, seizures cause sleep disturbances. Many
Typical absence seizures begin and end abruptly, typically
studies show increases in sleep complaints from people with epi-
lasting from ﬁve to 20 seconds and rarely longer than one to
lepsy. Disruptions of the parts of the brain involved in regulating
two minutes. Children older than four years of age are primarily
sleep and how the person is able to recognize and diﬀerentiate
aﬀected; however, seizures rarely persist into adulthood. Ab-
their related sleep and/or wake symptoms may be responsible
sence seizures impair consciousness and may occur many times
for some of the increase in sleep complaints by persons with epi-
a day. They can occur alone, or may include automatisms, atonic
lepsy.1 The hypnogram of patients with seizures typically reveals
symptoms, clonic symptoms, and/or autonomic symptoms. Often
fragmented sleep.6 Sleep deprivation resulting from sleep disor-
the patient will stare blankly, and eye ﬂuttering or eyes rolling
ders increases the occurrence of seizures in patients with seizure
upward may be observed. Posture is often maintained. Typically
disorders and may cause deterioration of seizure control.7,8
the person will have no recollection of the event. NREM sleep
When sleep disorders are properly diagnosed and treated
and hyperventilation are facilitators of absence seizures. Often
in patients with epilepsy, increased seizure control is usually
school-aged children with absence seizures are misdiagnosed
achieved, and quality of life is signiﬁcantly improved. In a study
with attention and behavioral problems.
of 63 epilepsy patients with sleep disorders, 78 percent were referred for obstructive sleep apnea with 71 percent achiev-
ing a positive diagnosis.8 In this study, diagnoses of narcolepsy,
Myoclonic seizures are characterized by rapid, involuntary
insuﬃcient sleep syndrome, and nocturnal seizures also were
muscle contraction. Muscle involvement may be local or general-
found. In addition, ﬁve of nine patients with obstructive sleep
ized. Myoclonic seizures may be related to speciﬁc epileptic syn-
apnea achieved increased seizure control by the use of continuous
dromes or may result from degenerative central nervous system
positive airway pressure (CPAP) therapy and antiepileptic drugs.
diseases, such as encephalitis, renal failure and postanoxic states.
Other studies have conﬁrmed that the frequency of seizures decrease in patients with sleep-related breathing disorders once
Tonic, Clonic and Tonic-clonic Seizures
the sleep disorders are successfully treated.9
Tonic seizures involve ﬂexion or stiﬀening of muscles. Clonic
seizures involve rhythmic ﬂexor spasms usually aﬀecting the en-
tire body. Spasms are brief and violent. Incontinence and apnea
Drugs used to treat epilepsy commonly disrupt sleep (see
may occur. Tonic-clonic seizures combine the characteristics
Table 1), and a comorbid sleep disorder may worsen sleep frag-
of clonic and tonic seizures. Initially a tonic seizure will occur,
mentation. Some antiepileptic drugs are commonly used to treat
typically involving extended legs and semiﬂexed arms. The tonic
certain sleep disorders, such as in restless legs syndrome, REM
phase lasts about 10 to 20 seconds and transforms into a clonic
sleep behavior disorder and periodic limb movements of sleep.
seizure with its rhythmic jerking. The entire seizure lasts from
Sedation is one of the most common side eﬀects of older
one to three minutes. A period of confusion or deep sleep may
antiepileptic drugs, with reports of sedation as high as 70 percent
follow a tonic-clonic seizure. These seizures are common dur-
with Phenobarbital, 42 percent with carbamazepine and val-
ing sleep in certain epileptic syndromes and occur only during
proate, and 33 percent with phenytoin and primidone. Among
newer antiepileptic drugs, sedation rates of 5 percent to 15
percent have been reported for gabapentin, lamotrigine, leveti-
Niedermeyer E, Da Silva FL. Electroencephalography:
racetam, vigabatrin and zonisamide, and 15 percent to 27 percent
basic principles, clinical applications, and related ﬁelds.
for topiramate in placebo-controlled studies. No signiﬁcant
Philadelphia: Lippincott Williams & Wilkins; 2005. p
reports of sedation occurred with tiagabine in placebo-controlled
studies, but 25 percent reported sedation in open-label, long-term studies. Felbamate studies revealed reports of sedation and
Kotagal P, Yardi N. The relationship between sleep and
epilepsy. Semin Pediatr Neurol. 2008 Jun;15(2):42-9.
Baldy-Molinier M, Touchon J, Besset A. Sleep architecture
and epileptic seizures. In: Degen R, Neidermeyer E, editors.
Recognizing sleep disorders in people with epilepsy is a vital
Epilepsy, sleep and sleep deprivation. Amsterdam: Elsevier;
step in guiding treatment, and physicians and technologists must
be aware of the sleep eﬀects of antiepileptic medications, as well
Misulis K, Head T. Netter’s concise neurology. Philadelphia:
as the sleep eﬀects from seizures. In patients with comorbid
sleep disorders and epilepsy, treatment of the seizure disorder alone may not signiﬁcantly improve the patient’s overall health.
Basil C, Malow B. Sleep and epilepsy. In: Guilleminault C,
The person’s sleep may be further worsened, precipitating other
editor. Clinical neurophysiology of sleep disorders. Vol. 6.
health issues. Raising awareness of sleep disorders aﬀecting peo-
Handbook of clinical neurophysiology series. Philadelphia:
ple with epilepsy helps ensure the best possible treatments, helps
decrease disability from seizures and increases quality of life.
Devinsky O, Ehrenberg B, Barthlen GM, Abramson HS,
Luciano D. Neurology. 1994 Nov;44(11):2060-4.
Carney P, Berry R, Geyer J. Clinical sleep disorders, sleep
10. Schweitzer P. Drugs that disturb sleep and wakefulness. In:
and epilepsy. Philadelphia: Lippincott Williams & Wilkins;
Kryger M, Roth T, Dement WC, editors. Principles and
practice of sleep medicine. 4th ed. Philadelphia: Elsevier Saunders; 2005. p. 511.
Bear M, Connors B, Paradiso M. Neuroscience, exploring the brain. 3rd ed. Baltimore: Lippincott Williams & Wilkins; 2007. p 593.
Rocamora R, Sánchez-Alvarez JC, Salas-Puig J. The relationship between sleep and epilepsy. Neurologist. 2008 Nov;14(6 Suppl 1):S35-43.
EVENTS THAT IMPACT QUALITY OF SLEEP (FDA DRUG SHEETS)
Insomnia, sleep disturbances, nightmares, vivid dreams
Somnolence, fatigue, insomnia, sleep disturbances, nightmares
TABLE 1. ANTIEPILEPTIC DRUGS. COMMONLY OBSERVED, ADVERSE EVENTS IMPACTING SLEEP ASSOCIATED WITH USE.
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