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.
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.
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.
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 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.
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).
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.
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.
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.
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.
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.
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:
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: