Epilepsy and Sleep

Epilepsy is a group of over 30 disorders in which abnormal brain activity causes a predisposition to seizures. It affects around 1 in 26 Americans and is the 4th most common neurological disorder, after migraines, strokes, and Alzheimer’s disease.

Epilepsy and sleep have a bidirectional relationship, meaning that poor sleep may trigger epileptic seizures and, at the same time, having epilepsy can contribute to sleep issues.

Learning about this complex relationship can help people with epilepsy understand the impact that this condition has on sleep, know the risks of losing sleep, and empower them to take charge of their health.

Epilepsy and the Brain

The brain consists of nerve cells that communicate through small electrical impulses. These impulses travel throughout the body using chemical messengers called neurotransmitters. Normally, the brain’s electrical activity is relatively orderly.

In people diagnosed with epilepsy, the brain’s electrical activity and connections become abnormal, with sudden bursts of electrical impulses that affect a person’s thoughts, feelings, and actions. There are many types of epilepsy and epilepsy syndromes.

Epilepsy and Sleep

Doctors and scientists have long observed a relationship between sleep and epileptic seizures. Aristotle observed this connection in antiquity, and doctors in the late 19th century recognized that most nocturnal seizures occur close to when a person falls asleep and when they are waking up.

Researchers continue to study many important connections between sleep and epilepsy. Sleep is a valuable tool in diagnosing epilepsy and research continues to explore the impact that sleep has on the timing and frequency of seizures.

Diagnosing Epilepsy

Doctors consider a diagnosis of epilepsy when a person has two or more unprovoked seizures at least 24 hours apart. While epileptic seizures may be related to medical conditions, brain injuries, abnormal brain development, or an inherited genetic condition, most often the cause is unknown.

When a neurologist evaluates a person having seizures, one tool they use is an electroencephalogram (EEG). EEGs are used to detect the presence and location of abnormal electrical activity in the brain, which tells doctors if the abnormal activity is coming from all over the brain or from just from a small part. Neurologists also look for specific patterns of brain activity on EEGs, called epileptiform abnormalities. These abnormal brain waves can appear as spikes, sharp waves, or spike-wave patterns.

Epileptiform abnormalities are more likely to occur during certain types of sleep, particularly during sleep stages involving non-rapid eye movement (NREM) sleep. To increase the likelihood of finding these epileptiform abnormalities during an exam, patients may be asked to sleep during one portion of an EEG.

Epileptic Seizures While Sleeping

Epileptic seizures can occur during any time of day or night. Around 20% of people with epilepsy only have seizures during sleep, while 40% only have seizures while awake and 35% have seizures both while awake and asleep.

One hypothesis about the connection between sleep and seizure activity involves the ways in which electrical activity in different areas of the brain tend to synchronize during NREM sleep. Excessive or hyper synchronization may lead to seizures. Another hypothesis relates to physiological changes associated with circadian rhythms and melatonin production.

Several common epilepsy syndromes involve seizures that occur during sleep.

• Nocturnal frontal lobe epilepsy (NFLE): In people diagnosed with NFLE, almost all seizures occur during NREM sleep. This condition can occur at any age, but most commonly begins in childhood. After waking, people with NFLE may not be aware of nighttime seizure activity.
• Benign epilepsy with centrotemporal spikes (BECTS): BECTS is the most commonly diagnosed epilepsy in children, usually starting between 3 and 13 years of age. Children with this type of epilepsy have 70% of seizures during sleep, usually right after falling asleep or right before waking in the morning.
• Panayiotopoulos syndrome: This type of epilepsy usually appears most commonly in children between 3 and 6 years old. Approximately 70% of seizures occur during sleep with another 13% occurring as the child wakes up. Fortunately, most children with this syndrome have less than five seizures before going into remission.

Other epilepsies that occur primarily during sleep include autosomal dominant nocturnal frontal lobe epilepsy, Lennox-Gastaut syndrome, and epilepsy with continuous spike-wave in sleep (CSWS).

Epilepsy and Sleep Deprivation

Getting the right amount of sleep is important for people with epilepsy. While this link isn’t present in all patients, losing sleep can increase the frequency of seizures in people with epilepsy, including those with no prior history of seizures.

One hypothesis for why sleep deprivation may trigger seizures is related to neuronal excitability. When underslept, neurons in the brain are more likely to produce large changes in electrical activity. In a person with epilepsy, these large changes in electrical activity can become abnormal and lead to a seizure.

Epilepsy and Sleep Disorders

Sleep is vital for mental and physical health. Unfortunately, sleep disorders are common in people diagnosed with epilepsy. There are several types of sleep disorders linked to epilepsy.

• Insomnia: Having difficulties falling and staying asleep is common in people diagnosed with epilepsy, with between 24 and 55% having insomnia. Insomnia in people with epilepsy may be caused by several factors, such as nighttime seizures, medications, and the effects of anxiety and depression.
• Obstructive sleep apnea:  Obstructive sleep apnea (OSA) is a respiratory disorder involving a full or partial collapse of the upper airway during sleep. OSA affects up to 30% of people with epilepsy, which is twice as common as in the general population. This condition can cause snoring, frequent awakenings, and make it more difficult to get a good night’s rest.

Parasomnias are sleep disorders that involve unusual behaviors that occur both before and during sleep, as well as when waking up. Parasomnias can be categorized into three groups: NREM-related, REM-related, and other parasomnias.

Researchers are still untangling the complex relationship between parasomnias and epilepsy. Some forms of epilepsy are difficult to differentiate from parasomnias and many people with epilepsy are also diagnosed with a parasomnia.

• NREM-related parasomnias: This group of disorders includes sleepwalking, sleep terrors, and disorders of arousal. Some types of epilepsy, such as nocturnal frontal lobe epilepsy, mirror arousal disorders and it can be challenging to differentiate between these conditions. Further complicating this dinstinction, arousal disorders are found in the family history of up to a third of patients with nocturnal frontal lobe epilepsy.
• REM-related parasomnias: REM sleep behavior disorder, one type of REM-related parasomnia, involves vocalizations and sudden body movements during sleep. This condition often goes undiagnosed and may occur in as much as 12% of older people with epilepsy.

Epilepsy and Children

Childhood is a time of immense growth and development. Sleep is particularly important during this time, playing a role in everything from growth to learning and memory.

Sleep issues are common in children with epilepsy. In research that compared children with epilepsy to their unaffected siblings, children with epilepsy were found to have a harder time falling and staying asleep, more sleep disorders, and increased daytime drowsiness.

Managing sleep issues is important in children with epilepsy. Sleep-related breathing disorders like OSA are present in 30 to 60% of children with epilepsy, and parasomnias are commonly seen with certain types of childhood epilepsy.

While strategies to improve sleep disorders in children with epilepsy are still being studied, several researchers point to the benefit of parent-based interventions in children with other conditions that affect sleep. Parents of children with epilepsy can benefit from talking with the child’s medical team to customize an approach to treating sleep issues in order to reduce seizures and minimize long-term complications.

Managing Epilepsy

Treatment of epilepsy can help many people manage the frequency of seizures. Treatment most commonly involves medications, called anticonvulsants or antiepileptics. Other therapeutic options include surgery and vagus nerve stimulation, which may help when seizures are not well-controlled with medication.

People diagnosed with epilepsy also benefit from lifestyle changes that help them take charge of their health and potentially reduce seizures. Self-management strategies, like getting enough sleep and making dietary changes, can be an important part of managing epilepsy.

Medications and Epilepsy

Antiepileptic drugs can affect sleep, although it’s often difficult to determine if sleep issues are due to medications or to the physical and social effects of having epilepsy. Side effects of these medications can vary from patient to patient. Some medications may cause people to feel drowsy, while others may cause them to feel more alert.

Doctors may use the potential effects of antiepileptic drugs to benefit patients with sleep issues. For example, doctors may prescribe nighttime use of antiepileptic drugs that cause drowsiness in patients with insomnia. They may prescribe daytime use of antiepileptic drugs with stimulating effects for patients with daytime drowsiness.

Many people with epilepsy wonder if sleep aids can help them get better quality sleep and minimize seizures.  To date, the effect of melatonin on sleep quality in patients with epilepsy is inconclusive. Anyone with epilepsy interested in using sleep aids should talk to their doctor for advice.

Tips for Better Sleep

Losing sleep can affect the mood and quality of life for people with epilepsy. In fact, one of the most common complaints in people with epilepsy is excessive daytime sleepiness. Sleep issues in people with epilepsy are likely due to a combination of factors, including the effects of nocturnal seizures, the side effects of antiepileptic drugs, and the stress and anxiety that often go hand in hand with managing epilepsy and coping with the social stigma.

People with epilepsy can benefit from working closely with their medical team and communicating about any sleep-related issues they’re experiencing. Here are several topics that may be helpful to discuss with a doctor:

• Ask about sleep disorders: Talking to your doctor about a potentially undiagnosed sleep disorder, that if treated, could help you better manage epilepsy.  For example, treating sleep disorders such as OSA may help to reduce seizures by up to 50%.
• Talk about side effects of medications: It’s important for doctors to know if antiepileptic medications are working and if there are any unexpected side effects. Ask your doctor about what side effects you should expect and keep your doctor informed of any side effects you experience.
• Discuss stress and anxiety: Living with epilepsy can transform a person’s life and be both physically and emotionally draining. It’s normal to feel a variety of emotions and for emotions to change. Talking to a doctor, support group, or counselor about your feelings may be beneficial. These professionals can offer support and help you learn to cope with stress and anxiety that can interfere with quality sleep.

While working with the medical team to manage sleep issues, people with epilepsy can also benefit from improving their sleep hygiene. Good sleep hygiene promotes quality rest by focusing on  habits that affect sleep. Here are some tips for improving sleep hygiene:

• Schedule your sleep: Having a consistent sleep schedule helps to ensure that you get the full amount of sleep you need. Make sleep a priority and try to go to bed and wake up at the same time each day, even on the weekends.
• Make a nightly routine: Creating a nightly routine can help your body wind down before bed, setting you up to fall asleep faster. Try setting an alarm for 30-60 minutes before bed to remind you to turn off electronics, dim lights, and practice relaxation techniques.
• Improve daytime habits: What we do while awake can significantly impact our sleep. Try getting a healthy amount of physical activity and natural light during the day, and avoid smoking, alcohol, caffeine, and meals too close to bedtime.