Beyond medication: new advances in pediatric epilepsy
Lawrence W.Brown, M.D., FAAP and MarissaDiGiovine, M.D., FAAP
Despite the development of new epilepsy medications, approximately one-third of pediatric
patients with epilepsy remain medically refractory. While anti-seizure drugs remain
the mainstay of treatment, efforts are underway to expand nonpharmaceutical options
to decrease seizure frequency and improve quality of life.
The following is an overview of some of these advances — from new surgical approaches
and devices to websites and apps.
New types of neuromodulatory devices have been approved to treat epilepsy (as well
as other neurologic disorders). These treatments offer an alternative for medically
resistant patients who often struggle with complex polypharmacy or live with unacceptable
side effects. While these devices may require surgery, intracranial procedures may
not be necessary. Trials also are underway for noninvasive neuromodulatory devices.
Vagus nerve stimulator (VNS) therapy has been available for decades and has been approved
by the Food and Drug Administration (FDA) for patients as young as 4 years of age
with refractory partial-onset epilepsy. VNS therapy has new technology allowing for
a closed-loop system that can detect and respond to increased heart rate (as a presumed
sign of seizure). Pre-planned changes in VNS settings also can be programmed into
the device, thus reducing the need for office visits. Other newer software can monitor
convulsive seizures by correlation with rapid and repetitive changes in body position.
On the horizon for pediatric patients is responsive neurostimulation therapy, which
has been approved by the FDA for adults with refractory, focal-onset seizures with
one or two epileptogenic foci.
This closed-loop, brain-responsive neurostimulation system is designed to prevent
seizures at the source. Electrodes are inserted in the presumed seizure-onset zone
and are attached to a neurostimulator implanted in the patient’s skull, which is stimulated
by ictal activity. The device is programmed using wireless technology, and information
can be uploaded from home. This allows physicians to view patients’ electrographic
data remotely on a secure website and program device settings in person as necessary.
Even more cutting edge is deep brain stimulation therapy, which recently was approved
for adults with refractory epilepsy. It involves placing electrodes in various locations
within the thalamus and other brain structures. This technology has been adapted from
experience with other movement and psychiatric disorders in adults. Initial experience
has demonstrated effectiveness in refractory epilepsy cases that are not amenable
to surgical resection, even those with multifocal epilepsy or without a clear seizure
Durability and cosmetic impact of these devices keeps improving. Battery life is extended,
memory capacity is improved and the size is decreased with each new generation.
Another novel device for epilepsy approved for patients ages 6 and older with generalized
tonic-clonic seizures is a wearable seizure detector. This not only detects generalized
tonic-clonic seizures, but it can be programmed to alert a caregiver that a seizure
has occurred. There are other wearable devices, such as smartwatches with seizure
detector apps, but they have not yet been approved by the FDA.
Apps and websites
Medical smartphone apps and secure websites related to epilepsy are multiplying, whether
the goal is to monitor seizure frequency, send reminders to maintain medication compliance,
provide education, improve patient safety or create an online community for emotional
support. Many of these apps are free.
Electronic seizure diaries can track seizures and side effects. They also can correlate
seizures with menstrual cycles, diet, sleep schedule, etc. Some apps send reminders
to take medications, renew prescriptions or attend appointments, all of which may
be important for the treatment of epilepsy.
Increasingly, these apps can generate reports or can be uploaded to health care providers
or researchers. Some are even able to be integrated into the patient’s electronic
Additionally, patient safety can be advanced by apps that put medical information
on a phone’s lock screen, allow for daily check-ins for those living alone, send emergency
notifications to designated recipients should the patient feel an aura or seizure,
or offer an outline of standard seizure first aid if a bystander encounters someone
having a seizure.
These devices and applications are just a small sample of the many novel ways that
health care can be improved for those with epilepsy; new advances continue to occur
Drs. Brown and DiGiovine are members of the AAP Section on Neurology.