What are Nocturnal Seizures?
Nocturnal Seizure is a type of seizure disorder where a person experiences seizures while sleeping. If the patient experiences more than 90% of seizures when asleep, then the patient is said to have sleep seizures or nocturnal seizures. There are some common types of epilepsy such as frontal lobe epilepsy, which can manifest in a nocturnal state. Nocturnal seizures can occur if the type of epilepsy triggers seizures only when the patient is sleeping or if the patient normally has seizures during that particular time. In the latter case, if the patient remains awake at a time when he/she normally sleeps, then the patient can experience a seizure while awake. In such cases, it is important for the patient to follow proper sleeping habits. Any type of diversion from normal sleep patterns may trigger frequent seizures in patients who are diagnosed with nocturnal seizures or epilepsy, even when the patient is awake. Some patients have exclusive nocturnal seizures, i.e. seizures when sleeping; whereas some patients will have both daytime as well as nocturnal seizures. Around 10 - 40% of patients suffering from epilepsy will experience seizures exclusively or mainly during sleep or when they are sleep deprived.
Nocturnal seizures or seizures while sleeping greatly impact a person’s ability to get a good night's sleep. However, other sleep disorders can also produce similar symptoms, which can be misdiagnosed as nocturnal seizures or seizures while sleeping. This is because sleep disorders and seizures, which occur at night, commonly occur without the patient's knowledge. For correct diagnosis of a true nocturnal seizure, it is important to identify the signs and symptoms of a nocturnal seizure or seizures while sleeping.
Signs & Symptoms of Nocturnal Seizures
Inability to Concentrate: Patient suffering from nocturnal seizure or seizures while sleeping has inability to concentrate on any type of task. Many sleep disorders tend to cause difficulty in focusing and excessive daytime fatigue and true nocturnal seizures greatly reduce the time which is spent in deep sleep and this leads to drastic effects on the patient’s health and lifestyle. In some patients, nocturnal seizures can cause complete inability to function or work during the day.
Involuntary Movement: Nocturnal seizures or seizures while sleeping may cause symptoms of uncontrollable or abnormal movements during sleep. In some cases, the patient wakes up suddenly multiple times without any cause. Some patients suffering from Nocturnal seizures or seizures while sleeping can experience violent thrashing movements in the arms and legs when sleeping. Upon waking up, the patient wakes up disoriented and confused.
Tongue Biting and Incontinence: Nocturnal seizures or seizures while sleeping can cause symptoms of loss of ability in controlling the muscles of the body, which leads to incontinence and accidents in bed. Patient can also have a tendency to bite the tongue. To determine whether the patient is having true nocturnal seizures or another type of sleep disorder, EEG i.e. brain wave activity tests and sleep study are done for correct diagnosis.
Other Symptoms of Nocturnal Seizures or Seizures While Sleeping: Nocturnal seizures can cause other type of symptoms or situations for a patient, such as upon waking up the patient will be having a headache, there can be bed wetting, biting of the tongue, injury to a joint or bone, lightheadedness and muscle weakness/strain. Nocturnal seizures or seizures while sleeping can also produce some strange type of mental behaviors in a patient. In some cases, objects present near the bed will be found down on the floor, or the patient can find himself/herself on the floor after falling down from bed from nocturnal seizures or seizures while sleeping. Children suffering from nocturnal seizures can experience unusual sleepiness, signs of drooling, headache, vomiting and bed-wetting.
Causes & Trigger Factors of Nocturnal Seizures
Nocturnal Seizures or Seizures While Sleeping Caused Due to Sleep Deprivation: Lack of sleep or sleep deprivation is one of the major trigger factors for seizures. Sleep deprivation or losing sleep may trigger seizures. Patients with nocturnal seizures will have daytime drowsiness, which in turn increases the risk of daytime seizures in patients with nocturnal seizures or seizures while sleeping.
Nocturnal Seizures or Seizures While Sleeping Caused Due to Changes in Brain Electrical Activity: Nocturnal seizures are believed to occur due to changes in the electrical activity in the brain in the stages of sleeping and awakening. Many of the times, nocturnal seizures are partial seizures.
Epilepsy: Certain types of epilepsy are shown to be related to nocturnal seizures and these are: Awakening grand mal epilepsy, juvenile myoclonic epilepsy, benign rolandic epilepsy (benign focal epilepsy of childhood), landau-kleffner syndrome (LKS), electrical status epilepticus of sleep and frontal onset seizures.
Fever & Stress: If the patient is having high fever or suffers from excessive stress, then it can also trigger seizures including nocturnal seizures in the patient.
Nocturnal Seizures or Seizures While Sleeping Caused Due to Use of Stimulants: Patients suffering from excessive daytime drowsiness tend to take stimulants, such as coffee to overcome this problem; however, this habit can aggravate seizures, especially if the stimulant is used in large quantities.
Use of Sedatives: Individuals with interrupted sleep or sleeping difficulties may use sedatives, which in turn can aggravate the problem of nocturnal seizures.
Pathophysiology of Nocturnal Seizures
There are many stages of sleep. Most of the nocturnal seizures or seizures while sleeping occur when the patient is in the stage of light sleep, which immediately occurs after falling asleep, before waking up or when waking during the night. This particularly happens in cases of myoclonic seizures, temporal lobe seizures and atypical absence seizures. The mechanism of nocturnal seizures or seizures while sleeping is not clearly understood, however, it is believed that sleep activity can influence seizures. It is thought that the change of state has an influence on the epileptic activity. Many changes also occur during sleep. Some types of seizures also occur primarily at specific times of the sleep cycle.
Our brain waves remain quite constant during wakefulness; however, many changes occur during sleep. When we sleep, the brainwaves get transformed from wakeful state to drowsiness, then to light sleep to deep sleep and then to Rapid Eye Movement (REM) sleep. This cycle gets repeated about 3-4 times in a night. When there is any change or disturbance in this sleep cycle, it results in quite dramatic changes in our brainwaves, i.e. EEG. A person can have nocturnal seizures or seizures while sleeping at any time during this sleep cycle, however, majority of them occur during light sleep, i.e. stage 1 and 2 of the sleep.
The time when the nocturnal seizures or seizures while sleeping more commonly and frequently occur include:
- Early nocturnal seizures or seizures while sleeping which occur during the first or second hour after going to bed or sleep.
- Early morning seizures which occur about one to two hours before the normal time of wakening of the patient.
- Early morning seizures which occur within the first hour or so after the patient wakes up.
- If a patient experiences seizures during sleep, then he/she can also have these seizures during an afternoon nap and they need not be limited to night only.
Changing of Nocturnal Seizures to Daytime Seizures
If the patient has a pattern of having seizures only during sleep and this pattern continues for many years, then the chances of having the seizures during daytime or wakefulness is less. Most of the nocturnal seizures or seizures while sleeping are tonic-clonic, however, patient can also have focal seizures during sleep.
Facts about Sleep & Nocturnal Seizures
- Sleep deprivation is one of commonest triggers for seizures in patients with epilepsy.
- Nocturnal seizures or seizures while sleeping tend to disrupt sleep and increase daytime drowsiness.
- There are some types of seizures, which are more common during sleep, however, may occur in a different manner during day time.
- In some cases, nocturnal seizures or seizures while sleeping can be mistakenly diagnosed as a sleep disorder. In other cases, some sleep disorders can be wrongly diagnosed as epilepsy. Video-EEG recordings help in correct diagnosis of any condition.
- There are certain antiepileptic medications, which can augment patient’s daytime drowsiness and sleeping difficulties.
- Quality of life and better seizure control can be achieved by treating the sleep disorder.
- Patients with poorly controlled epilepsy have double the risk for having sleep apnea than other people.
- Epilepsy can aggravate certain sleep disorders and sleep disorders can aggravate epilepsy.
Diagnosis of Nocturnal Seizures
It is difficult to diagnose nocturnal seizures or seizures while sleeping, as the patient may not be aware that they have a seizure disorder. The involuntary movements of nocturnal seizures or seizures while sleeping may appear as typical movement of a normal sleep to onlookers. People suffering from nocturnal seizures will experience different type of situations upon waking up, such as bed wetting, headache, biting of the tongue, injury to a joint or bone, muscle weakness/strain and lightheadedness.
Some patients may have strange mental behaviors after having nocturnal seizure. Sometimes, objects which are present near the bed will be knocked down to the floor, or the patient himself can fall down and wake up on the floor.
Risks of nocturnal seizures or seizures while sleeping include suffocation, concussion, and SUDEP. It is difficult to assess the duration of the nocturnal seizure.
Nocturnal seizures or seizures while sleeping can also be confused or misdiagnosed with parasomnia, which is a term indicating group of sleep disorders, such as teeth grinding, sleepwalking and restless leg syndrome. A number of factors are evaluated to diagnose epilepsy and nocturnal seizures and these include:
- The age of the patient when he/she started having seizures.
- Whether there is any family history of epilepsy or seizures.
- The type of seizures the patient has.
- What other medical conditions the patient has.
- For diagnosis of epilepsy and nocturnal seizures, the following are done:
- Electroencephalogram (EEG) is done which records images of electrical activity in the brain.
- CT scan or MRI scan is done to look at the structure of the brain.
- A diary or a record should be maintained by the patient of his/her seizure activity.
- If a child or infant is suspected to have nocturnal seizures or seizures while sleeping, then they can be diagnosed by careful monitoring of the child by:
- Watching for signs of nocturnal seizures in the morning, such as headache, unusual sleepiness, vomiting, signs of drooling, bed-wetting or vomiting.
- Using a baby monitor.
- Seizure monitor can also be used which contains features like noise, motion and moisture sensors.
Safety Measures for Patients Suffering from Nocturnal Seizures
- Patient suffering from nocturnal seizures or seizures while sleeping should not use soft, large pillows, as there is a risk of smothering with it and instead sleep without a pillow or use an anti-smother pillow.
- Low bed with padded headboards should be used by the patient suffering from nocturnal seizures or seizures while sleeping and bunks should be avoided.
- It is advisable to place safety mats on the floor beside the bed to protect the patient from any injuries if he/she falls out of bed during nocturnal seizures.
- Heavy furniture should be kept away from the bed to prevent any injury if the patient falls during a nocturnal seizures or seizures while sleeping.
- Wall mounted lamps should be used as they have less safety risks when compared to ordinary study lamps or table lamps, as they can be easily knocked over during an attack of nocturnal seizures or seizures while sleeping.
- One should never smoke while in bed, especially those people who suffer from nocturnal seizures. A smoke alarm and non-flammable bedding should be used.
- Coarse carpets should be avoided, as they can cause friction burns in patient who fall down during a nocturnal seizure. Another option is using a protective mat.
Treatment & Management of Nocturnal Seizures
It is an acceptable fact that lack of sleep or sleep deprivation acts as a trigger factor for seizures and increases the likelihood for seizures. There can be significant interruption or disturbance of sleep due to nocturnal seizures or seizures while sleeping.
The aim of treatment for nocturnal seizures or seizures while sleeping is optimum control of seizures, as they are closely related to sleep. Patients suffering from nocturnal seizures will often have partial-onset seizures and these can be well controlled with medications. So, medication is the first-line of treatment for nocturnal seizures. Medicines, such as anti-convulsants are used to treat nocturnal epilepsy or nocturnal seizures just like other types of epilepsy. The treatment for nocturnal seizures or seizures while sleeping is almost the same as treatment for daytime seizures; however, in some cases the doctor may prescribe a higher dose of antiepileptic medication in the evening. The treatment of seizures and its outcome depends on the type of seizures more than the time of occurrence of the seizures.
Even though the anti-convulsant medicines are effective in treating nocturnal seizures or seizures while sleeping, these medicines can disrupt the patient’s sleeping pattern. This in turn increases the likelihood for epileptic symptoms, as it is important to get restful and undisturbed sleep for patients suffering from nocturnal seizures to decrease the chances of further episodes of seizures and to prevent exacerbation of epileptic symptoms. It is important to maintain good sleep pattern, as it helps in decreasing the epileptic symptoms. So, it is important to find an anti-convulsant medication, which does not disturb the patient’s sleeping structure. This will help in minimizing nocturnal seizures and epileptic symptoms. Some of the anti-convulsant medications, which help in achieving this include: Phenytoin, Phenobarbital, Carbamazepine, Ethosuximide, Valproate, Gabapentin, Felbamate, Lamotrigine, Vigabatrin, Topiramate, Levetiracetam, Tiagabine, Oxcarbazepine and Zonisamide. Oxcarbazepine has the minimum adverse effects on a patient’s sleep pattern. This medicine is also shown to enhance the slow wave-sleep and the continuity of sleep in patients with seizures.
It is important that the patient follow regular sleep habits, especially patients who have sleep related seizures. Patients who are having difficulty in falling asleep can overcome this problem by increasing the dosage of the evening medication, by indulging in calm and restful activities in the evening, by using relaxation techniques, by avoiding stimulants, especially in late afternoon or evening and by behavioral training, which will help in establishing an efficient sleep pattern. It is important that the patient follow a regular sleep routine for which sleep specialists can help.