Juvenile Absence Epilepsy and Zarontin

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Elljen

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My 12-year-old started Zarontin on Friday morning for juvenile absence epilepsy, so he just finished day 5 of beginning meds. The plan is 10 days of a once-daily dose (a.m.), then begin twice-daily. I know it is VERY early in the process, and it takes time for the meds to build up to a steady state, never mind he's not even at full dose yet.

The thing is, it might be tough to know for sure if it's working, because as it is we've only ever observed a few obvious absence seizures over the past few months. The last one that we knew of for sure was when someone else observed one 12 days ago. We hadn't see once since. Of course, it doesn't mean he hasn't had others that no one saw. He said he doesn't think so, and honestly he usually is aware when he had one (although I'm not sure if that's only because of people's reactions).

Last night he might have had another, but it's hard to tell. I was quizzing him for a particularly tough definitions test. When I gave a definition for one word that he didn't remember, he was trying to think of the answer, and then it might have happened. It was a bit harder than usual to tell. The episode seemed even shorter than usual ones (others were maybe 5-7 seconds tops), and the “entry/exit” points were less distinct in that I couldn't tell exactly when it started and stopped. In fact, I wasn't even sure if he was just thinking or zoned out. He didn't look as out of it as usual. I asked hi about it, and he did think it was a “zone out.” When asked if he heard me (I'd been repeating the definition in a different way), he said yes but said he usually does hear people through a sort of fog (I didn’t know that). So I was bummed he might have had one because I personally hadn't seen him have one in so long even before he started the meds. Anyway, it seemed milder, but I don't know if milder is possible.

Then there's today. This afternoon he had a more clear-cut absence seizure. Very clear when he stopped talking mid-sentence, didn't respond for several seconds, then "came back" and was momentarily confused as if he'd lost his train of thought. It might even have been a bit longer than any previous ones we'd seen but it's hard to tell.

I've never seen him have an absence seizure two days in a row. Doesn't mean he hasn't had them. But I've never seen that. As I mentioned, I hadn't even seen one in a couple of weeks, with the last known one before his diagnosis being about almost two weeks ago.

As I said, I know it's way too early and way too low a dose for me to be expecting results. But it's also disheartening to see more episodes than before he started the meds. Even though I know he might have been having more without our knowledge.

I just, so badly, want this medication to work. I know that's stating the obvious.
 
It may well be too soon to know what your son's "normal" rate of absence seizures is, and as a result too soon to know if the Zarontin is altering the seizure pattern in any way, good or bad. But you should definitely make a note of anything that seems seizure-like, keep track of how often the symptoms occur, and if you observe an escalation in duration, frequency or kind let his neuro know.

The fact that your son can hear you during some of his episodes is atypical and worth noting. They could still be absence seizures, but there's a chance they could be another kind of seizure called a "partial seizure." Zarontin has no effect against (or may even worsen) partial and tonic-clonic seizures, so you should let your son's neuro know of your concerns.
 
Thank you for your response.

That's concerning, if he has been misdiagnosed and is on the wrong meds. Apparently the EEG showed a class response during the hyperventilation portion of the test. Don't those measure different parts of the brain? Would a focal seizure show up differently? The absence seizure response was the only thing found. That said, it was only a 1-hour EEG.

Would there be other symptoms during a focal seizure? We haven't observed anything else. He's just staring. He is a bit of a fidgety kid at times when he's tired or stressed, but he's always been that way and it really does seem much more like when someone is anxious than anything else.
 
Would a focal seizure show up differently?
Focal (partial) seizures can often be too transient or occur too deep in the brain to register during an EEG. They are often diagnosed via a longer-term EEG or video EEG, or even by the symptoms alone. They don't necessarily have a consistent interictal (between seizure) brainwave pattern that would show up on an EEG if the person is not actually in the middle of seizing during the test.

Would there be other symptoms during a focal seizure?
Not necessarily. Focal seizures can manifest as a wide variety of sensory disturbances, but they can also appear as long staring, similar to absences. The primary difference is that the person has greater awareness during the focal seizure.

However, there are atypical versions of both kinds, so it's not always easy to make a definitive diagnosis. For instance, atypical absence seizures have less abrupt onset and offset, more pronounced changes in tone, variable impairments of consciousness, and tend to last longer than typical absences, so that may be what you are observing. And Juvenile Absence Epilepsy also features less severe impairment of consciousness. It's also possible for people to have both kinds of seizures.

For these reasons, there are a lot of unknowns with epilepsy diagnosis treatment. :( Unfortunately, there can be an aspect of trial and error with medications. Fortunately, there are a lot of meds out there to try.

You might also ask your son's neuro about dietary modifications that might help with seizure control. The Modified Atkins Diet has been shown to help with seizure control, particularly with absence seizures. See: http://www.epilepsy.com/learn/treating-seizures-and-epilepsy/dietary-therapies/modified-atkins-diet
 
For my son, the absences are pretty short, maybe 5 -7 seconds at most. With one exception, in which I wasn't 100% sure if he had one, all of them have had a very distinct start and stopping point.

You mentioned that in JAE, there might be "less severe impairment of consciousness." Could that be what's happening here? The neuro diagnosed him with JAE, not CAE.

The problem with all these unknowns, plus starting a new diet, is the upcoming summer camp session. We're exactly 51 days from the start date. It's sleepaway, so we're not there with him. Obviously this is tricky in terms of finding the right meds. The neuro said he can definitely go to camp. And if we keep him home while his other family members and friends go, he will be crushed. I know epilepsy is going to impact his life. He knows it. But this would be taking away something huge, and the message he'll feel would be that epilepsy has taken over and already begun to ruin his life. I can't imagine what that would do to him. I want to send him if at all possible. I just wish time weren't so short.
 
Yes, it could be that the seizures are JAE ones. The diet is a treatment approach to think about for the future, not right now while you're still aiming to get him to camp. :)

If the neuro has signed off on the camp, that's really all you need to know. All seizures are distressing, but absences are in some ways less disruptive than other kinds. He doesn't need you with him 24/7. (Note to CWE members who suffer from absences: This is in no way an meant to minimize your suffering or make assumptions about what kinds of seizures are "better" or worse" to have). It would be nice to have the Zarontin be a quick fix, but if it doesn't seem to be working, don't be afraid to get in touch with the neuro sooner rather than later for guidance and reassurance.
 
I can't tell you how much I appreciate your time and response. His specific diagnosis was the juvenile type.

The extra wrench is that he also suffers from insomnia, and has since he was six. I've struggled with it, too, partially from being OCD (really just O, not C). We wake up and our minds just can't shut off. Thoughts run through them. And it's a slippery slope, because the more it happens, the more we worry about falling asleep, and then the harder it is to sleep.

His insomnia was actually MUCH better all year, until about 10 days ago when it kicked in more than ever. This was before the meds, and after we noticed his seizures. So it's not medicine-related. We've tried pyschotherapy, melatonin (fast-acting and time-release), and (per his previous neuro that he'd seen for it), tiny doses of clonidine. None of that is working. And the neuro said best not to try anything new like Valerian Root or GABA, because he wants to see how the meds work and the more we add, the more it's hard to tell how the meds are going from an efficacy and side effect standpoint.

He recommended biofeedback, but that's not a short-term solution.

The only thing that works is benadryl. HE sleeps through the night then (gave him some for allergies with the neuro's OK but his recommendation to only use as absolutely necessary). However, I know it's not quality sleep on benadryl. I know it's a short-term solution. And I know benadryl isn't great for seizure threshold. My poor boy. I feel so helpless.
 
You're right to be concerned about the insomnia. Fatigue can definitely be a significant factor in lowering seizure threshold (not a primary cause, but a secondary trigger). But it's also wise to not try too many things at once, however tempting. If the med is affecting sleep one way or another you'll want to know.

However, you might ask the doc about environmental modifications (no screen time within an hour before sleep, blackout shades, white noise machines or cds with soothing sounds, etc.) You may have tried all these already of course...

And if/when the doc greenlights a supplement: I occasionally take "supersnooze" to help with sleep. It has small amounts melatonin and valerian, but also magnesium, hops, chamomile, passionflower, calcium, and taurine.

Down the road, you might ask about having a sleep study done (basically an overnight EEG) to see if there are particular phases of your son's sleep that are being affected, and if there are other issues (like sleep apnea) that are contributing.
 
Yes, we've tried all the healthy sleep habits, room darkening shades, removed the nightlight (he didn't think he needed it) white noise. He has also taken a supplement with hops, chamomile, passionflower, and L-theanine. Plus he gets a highly absorb-able form of magnesium daily. Nothing works. It's so frustrating!

My husband and I do want to get a sleep study done. Actually, it's something we wish we'd pursued years ago, even before we spotted any signs of epilepsy. I doubt we'd get him scheduled anytime before camp, although who knows?

We're also thinking of trying biofeedback.

The neuro is out today, but he should get back to me tomorrow.

In the meantime, I feel terrible. This is his worst bout of insomnia ever! At this point, I suspect it's very much psychosomatic. Everyone wakes a bit at night but most people don't wake enough to notice it. I think that every time he's up, it's like, "I'm up! Now I don't know if I'll be able to fall back asleep." So he can't.
 
Don't know if it was the case for your son, but L-theanine can be problematic: It raises the seizure threshold for complex partial seizures, but lowers it for generalized seizures such as absences.

One more thing to try: Focused breathing using the 4/7/8 method. And if psychological stress ends up being a big factor, CBT (Cognitive Behavioral Therapy) might help.

I hope his sleep can get back on track one way or another. Make sure you're taking care of yourself too. :)
 
Interesting. I didn't realize that. I hadn't given it to him every night of the insomnia, but I will take it out just in case.

I forgot about that breathing method. He tried it a couple of years ago and it first helped, but then it stopped. I'll remind him. Hopefully won't trigger hyperventilation issue haha. The problem is sometimes he gets frustrated when something that might work, doesn't. He's such a thinker.

We are open to pursuing a lot of options. I'll try anything!
 
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