First time epilepsy seizures. Treatment options and advise

[how241]

I am asking for help for my 39 year old son who lives in Pattaya.  Two days ago he had several seizures, first time ever.  From Google they seem to be of the tonic-clonic type.  He never had anything like this before. He plays a lot of sports and seemed to be very healthy.  There is no family history of epilepsy.  His Thai wife took him to the Pattaya City hospital where they did a CT brain scan and other tests.  All tests results were normal.  He doesn't drink alcohol but does smoke a Lot of pot- Cannabis-marijuana. The hospital will discharge him tomorrow. I don't know yet what medications they will give him. He has no medical insurance but I am able to help him pay for treatments.  Is there any better doctors he should see ???  Can anyone who has experience with this offer any suggestions ??  As he is a USA citizen, would he be better off going back to the USA for treatment.  Thanks for any help or info.  

[RanongCat]

Have UK friend who had seizure age 28. Never again from that time.

[Stocky]

My wife suffers tonic-clonic seizures. It's intermittent triggered by a stressful situation on top of worry and poor sleep. Seizures started in her teens after an accident causing a blow to the head. She has had bad reactions to most epilepsy medication so has leant to manage by recognising the symptoms and using sleeping tablets if missing sleep, and or sedative if worried or stressed. She's not had a seizure now for over ten years. There was no family history of epilepsy.

 

I wish your son well.

[retarius]

If he has good insurance in the US which allows him to see specialists without going through a gatekeeper, I would send him back home and get a full work up, accurate diagnosis and treatment. In my experience you can get almost anything here that is available in foreign markets. There are some good English speaking neurologists and private hospitals here in Thailand that will do appropriate testing and diagnosis and usually the cost for the initial consults are quite inexpensive (what can be outrageously expensive are the treatment costs, but you can always say you will source the treatments yourself). A lot depends on how much you need to spend to go to the US, and stay there to have the treatment plan set up.

I have not been involved with the epilepsy market for some time, but some new treatments came available in the US in the 1990s. I'm not sure after that, perhaps a new generation of medicine has become available since. 

[Sheryl]

5 hours ago, retarius said:

If he has good insurance in the US which allows him to see specialists without going through a gatekeeper, I would send him back home and get a full work up, accurate diagnosis and treatment. In my experience you can get almost anything here that is available in foreign markets. There are some good English speaking neurologists and private hospitals here in Thailand that will do appropriate testing and diagnosis and usually the cost for the initial consults are quite inexpensive (what can be outrageously expensive are the treatment costs, but you can always say you will source the treatments yourself). A lot depends on how much you need to spend to go to the US, and stay there to have the treatment plan set up.

I have not been involved with the epilepsy market for some time, but some new treatments came available in the US in the 1990s. I'm not sure after that, perhaps a new generation of medicine has become available since. 

Agree with the above should the seizures recur or other symptoms emerge. In interim, suggest he see either of these doctors in Bangkok, bringing with him all records from Pattaya City Hospital including the CT scan on CD.:

 

https://www.bumrungrad.com/en/doctors/Sikawat-Thanaviratananich

 

https://www.bumrungrad.com/en/doctors/Kanokwan-Boonyapisit

 

Consultation will run a few thousand baht. Tests would be extra but since he already has CT may not involve too much (EEG though will be essential if not already done).

The main priority is to rule out possible underlying causes. The diagnosis of epilepsy (as opposed to seizures from other causes) is in part one of exclusion. I would not rely on what was determined by the doctors he has seen so far.

 

As it has so far been only one seizure, if the EEG and neuro exam is normal and no underlying cause has been found, neurologist  might opt to wait before starting him on meds,   as sometimes these are a one-off event. In fact about half of people will not have a second episode (speaking of those without underlying known cause). Those who do, will usually have it within 2 years of the first.

 

If it turns out he has epilepsy which requires medication ), there are a wide range of medication options, both newer and older drugs (newer is not necessarily better). I would not worry about that at this stage. The priority is to (1) rule out underlying causes and (2) if ruled out, determine, based on EEG findings, neuro exam and history, whether to start treatment or take a wait and see approach first. With no history of head trauma or family history of epilepsy, if EEG and neuro exam are normal the latter is likely advice but see what recommended neurologist advises.

 

It is also possible it is due to something he ingested. While cannabis itself will not cause seizures, local product can contain insecticides which might and as you mention he regularly uses cannabis this has to be considered a definite possibility.

 

For future reference, for general medical problems in Pattaya best to go to one of these:

 

Pattaya Memorial Hospital

Bangkok Pattaya Hospital

Pattaya International Hospital

Phyathai Sri Racha

Samitivej Sri Racha

Bang Lamung Hospital (government)

Chonburi Regional Hospital (main government hospital, in Chonburi town)

Queen Sirikit Naval Hospital in Sattahip

 

For something specialized and acute (i.e. needing immediate treatment) I would narrow that down to:

Pattaya Memorial Hospital

Bangkok Pattaya Hospital

Phyathai Sri Racha

Samitivej Sri Racha

Chonburi Regional Hospital (government hospital, in Chonburi town)

 

As PIH , Ban Lamung and Queen Sirikit are smaller and do not have every type of specialist on hand daily.

 

 

[Deserted]

Don't assume because  he has had seizures he has epilepsy. I have had 26 of them and don't have that condition, its usually caused by misfirings in the brain, which can be caused by many things.

 

You can buy Dilantin in many pharmacies, its not expensive. Take them.

[Sheryl]

6 minutes ago, Deserted said:

Don't assume because  he has had seizures he has epilepsy. I have had 26 of them and don't have that condition, its usually caused by misfirings in the brain, which can be caused by many things.

 

You can buy Dilantin in many pharmacies, its not expensive. Take them.

OP do not, under any circumstances, let your son self treat like this. Can do considerable harm.

 

BTW epilepsy by definition is misfiring in the brain not secondary to a known structural or metabolic cause.  Amyone who has had multiple (let alone 26) seizures in the absence of such causes, by definition has epilepsy.

 

 

[Deserted]

Depends on the context, massive head injuries and brain surgery can cause them, which is what I had.

[how241]

16 hours ago, Sheryl said:

OP do not, under any circumstances, let your son self treat like this. Can do considerable harm.

Dear Sheryl,  thank you VERY much for your detailed answers.  You are a  true blessing and have helped out thousands of people. I have been following you for 12 years and I am always impressed by your knowledge and complete answers to all questions.  I will make an appt. with the Bangkok hospital so he can get a complete work-up and rule out any underlying causes.  Thanks again for all the Great assistance you offer to members of this forum.  

[swm59nj]

Seizures could be caused by anything.  
I suggest you go to Bumrungard Hospital in Bangkok.  During my three years living in Bangkok I had excellent care there. 
And Sheryl gives excellent recommendations regarding doctors. 

[Dirk Z]

The first seizure can be the last or the beginning of a life long condition. There are different kinds of epilepsy each requiring a tailored approach for diagnosis and treatment. There are certainly neurologists in Thailand competent enough to take care of this problem, they have been listed, so in my opinion there is no need to seek help in the US. But in spite of all good intentions a forum like this is certainly not the place. Take this from this MD.

[Siamjim]

around 10yrs old to my mid 40s had attacks often usually in public, very embarrassing too. took DILANTIN daily after 16 yr...did help lower attacks 

[how241]

On 8/20/2023 at 10:43 PM, Sheryl said:

The main priority is to rule out possible underlying causes. The diagnosis of epilepsy (as opposed to seizures from other causes) is in part one of exclusion

My son went to Pattaya Bangkok hospital today.  He had an EEG done.  They want to do an MRI in a few days.  They prescribed  KEPPRA 500 mg, 2x daily.  The EEG conclusion says:  36 minute EEG is suggestive of a mild diffuse encephalopathy.  Also evidence of a cortical dysfunction in the right fronto-centro-temporal.  No epileptiform discharges or EEG seizures.  The post-ictal EEG is considered.    Report doctor: Yod Pinroj

I have no idea what this all means.  He might consider a second opinion at the Bangkok hospital you recommended previously. 

He first went to Pattaya Memorial hospital and they could not do the EEG and recommended he go Pattaya Bangkok hospital.   Thanks again for all of your info and help. 

[Sheryl]

4 hours ago, how241 said:

My son went to Pattaya Bangkok hospital today.  He had an EEG done.  They want to do an MRI in a few days.  They prescribed  KEPPRA 500 mg, 2x daily.  The EEG conclusion says:  36 minute EEG is suggestive of a mild diffuse encephalopathy.  Also evidence of a cortical dysfunction in the right fronto-centro-temporal.  No epileptiform discharges or EEG seizures.  The post-ictal EEG is considered.    Report doctor: Yod Pinroj

I have no idea what this all means.  He might consider a second opinion at the Bangkok hospital you recommended previously. 

He first went to Pattaya Memorial hospital and they could not do the EEG and recommended he go Pattaya Bangkok hospital.   Thanks again for all of your info and help. 

He might like to  hold off on medication until he has seen recommended doctor in Bangkok. (Assuming he has not had any further seizures and feels OK). 

 

They are saying his EEG is consistent with having had a recent seizure and does not show any current signs of seizure activity or hyperexcitability (which is factor in epilepsy).  In fact brain electrical activity is somewhat depressed, which can happen post seizure and also in conjunction with some drug use/medication -- not cannabis but sleep meds, anxiety meds etc.  Less often this can be associated with onset of other neurological diseases. 

 

When he goes to Bangkok he should bring full EEG report and actual print out. Also very important he be completely frank with the doctor about all drug use whether recreational or medicinal. 

 

 

 

[Lorry]

1 hour ago, Sheryl said:

Also very important he be completely frank with the doctor about all drug use whether recreational or medicinal. 

This is a common reason for first-time seizures in Pattaya, the most common drug being alcohol. 

The problem with being frank with the doctor is that the doctor might be frank with the insurance. Better check before.

[Sheryl]

37 minutes ago, Lorry said:

This is a common reason for first-time seizures in Pattaya, the most common drug being alcohol. 

The problem with being frank with the doctor is that the doctor might be frank with the insurance. Better check before.

Per OP, he is uninsured

[PPMMUU]

He should stop using marijuana as it is a possible cause of the seizure. If another seizure happens after abstaining from marijuana, he should visit the same hospital again for further investigation and a treatment plan. Only consider going to another hospital if there is no other option. And please, refrain from purchasing and taking Dilantin without a doctor's prescription.

[how241]

2 hours ago, Sheryl said:

He might like to  hold off on medication until he has seen recommended doctor in Bangkok. (Assuming he has not had any further seizures and feels OK). 

Sheryl,  thanks for again for your excellent advise.  My son feels fine and hasn't had any more seizures. My son will hold off on taking the meds.  and will not do the MRI until he has seen  Asst.Prof.Dr. Sikawat Thanaviratananich, in Bangkok.  This doctor has incredible qualifications and I feel confident that he will devise the correct treatment plan.  FYI:  those KEPPRA 500 mg pills where extremely expensive.  Something like 600 baht a pill.  I was not with him at the time as I would have told him to get them at a local pharmacy.  I know hospitals mark-up pill prices a lot.  Thank you

[how241]

On 8/20/2023 at 10:43 PM, Sheryl said:

It is also possible it is due to something he ingested. While cannabis itself will not cause seizures, local product can contain insecticides which might and as you mention he regularly uses cannabis this has to be considered a definite possibility

I was wondering if there is some place that could test this cannabis to determine if it has been sprayed with pesticides.  This cannabis was a cheap brand,  low quality and not grown indoors. 

'IF'  this cannabis tests as contaminated then that might be the direct cause of his seizure and there would be no need for further testing.  Maybe I am just grasping for a quick easy fix ??  My son has an appt. on Monday to see the recommended Bangkok doctor.  Should he bring with a sample of this cannabis or should he get it tested somewhere Before he goes to the Bangkok doctor ??

[Sheryl]

Not easily arranged and wouldn't really tell you much even if tested negative as quality can vary batch to batch and even within a batch..

 

For sure they usually use pesticides growing this stuff as thry do with all produce grown outdoors unless specifically organic (and even then pssticide gets in from rain run off). 

 

He would do best go stop the cannabis but if he won't then at least stick to higher end brands, organic or hydroponic grown. Mighg be able to get more specific recommendations in our Cannabis sub-forum. 

 

The doctor is not going to test the stuff but may know if this has been happening to others so he should bd sure to mention that he had been using this and cheap brand.

 

Also your son should specifically ask the doctor if he can safely take a "wait and see"  approach rather than start meds now. Thai doctors often assume patients want medication and will be dissatisfied if not given hhem (because indeed milost Thais feel that way).  He should clearly explain ftom the start that he is seeking a second opinion and prefers not to go on long term medication unless really necessary. 

 

Indeed if this was due to pesticide or other toxic ingestion it may not recur. For that matter  even if not, might not recur.  At least half the time with idiopathic(not due to other disease or identifiable cause)  seizures  they go not. And if they do it will usually be within 2 years. 

 

[how241]

12 minutes ago, Sheryl said:

Also your son should specifically ask the doctor if he can safely take a "wait and see"  approach rather than start meds now.

Thank you Very much for your detailed answer and excellent advise.  I will pass this along to him. 

I hope the doctor agrees that a 'wait and see' approach is the way to go for now.  Thanks again, take care. 

[how241]

2 hours ago, Sheryl said:

Indeed if this was due to pesticide or other toxic ingestion it may not recur. For that matter  even if not, might not recur.  At least half the time with idiopathic(not due to other disease or identifiable cause)  seizures  they go not. And if they do it will usually be within 2 years.

Interesting :   The Secret “Spice”: An Undetectable Toxic Cause of Seizure

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3726077/

[how241]

On 8/24/2023 at 9:24 PM, Sheryl said:

  At least half the time with idiopathic(not due to other disease or identifiable cause)  seizures  they go not. And if they do it will usually be within 2 years. 

 

Hello Sheryl,  My son  went to the Bumrungard Hospital  today and saw Dr. Sikawat Thanaviratananich.  He  looked at the MRI that my son had done at Pattaya Bangkok hospital, which didn't show anything special.  He said that he could/should do a 'spinal tap' to further rule out things. He advised that he continue on the KEPPRA 500 mg, for at least 2 years and then decide whether or not to continue this medication.  He also suggested that he start the 'Keto' diet next month . My son has felt fine for the past week,  no further seizures. I am surprised and disappointed that he doesn't seem to want and take the wait-and-see approach. I do not like what I have read about this KEPPRA 500 mg side effects, considering that many people never get another seizure and are taking this medication for nothing.  I am certainly in no position to question or challenge this doctors recommendations but from what little I have read I would think that a wait-and-see approach would be best. .  I wasn't there with him during the doctors visit so I don't know exactly what was said.  I definitely replayed your points about asking for a second opinion and Not wanting to start medication unless he thought it was absolutely necessary. Your thoughts please.    Thank  you very much. 

Edited August 28, 2023 by how241
updated

[Sheryl]

Has to be his decision. Did he specifically ask the doctor about a "wait and see" approach? Did the doctor give a reason against it?

[how241]

37 minutes ago, Sheryl said:

Has to be his decision. Did he specifically ask the doctor about a "wait and see" approach? Did the doctor give a reason against it?

Yes, he said he did ask the doctor about a "wait and see" approach?  I'm sure the doctor gave him reasons why he was against this  but I'm not so sure if my son completely understood them.  There seems to be no one clear certain way to handle this.  Two doctors have said he should be on the meds. so it will have to be his final choice. Thanks very much for your help and time. 

[Sheryl]

5 hours ago, how241 said:

Yes, he said he did ask the doctor about a "wait and see" approach?  I'm sure the doctor gave him reasons why he was against this  but I'm not so sure if my son completely understood them.  There seems to be no one clear certain way to handle this.  Two doctors have said he should be on the meds. so it will have to be his final choice. Thanks very much for your help and time. 

Not having been party to the discussion with the doctor there is no way I can comment on  his recommendation.

 

Where I can help is the medication cost. Levitiracetam (Keppra) can be bought over the counter at a pharmacy (much cheaper than hospital) and there are also less coslty locally made brands of the same thing as follows: 

 

Kelep 500

Lacetam 250/500

Letta

Levacore

 

 

 

[how241]

9 hours ago, Sheryl said:

Not having been party to the discussion with the doctor there is no way I can comment on  his recommendation.

 

Where I can help is the medication cost. Levitiracetam (Keppra) can be bought over the counter at a pharmacy (much cheaper than hospital) and there are also less coslty locally made brands of the same thing as follows: 

 

Kelep 500

Lacetam 250/500

Letta

Levacore

 

 

 

Thanks again for all of your help.  I really appreciate the time and effort you spend to assist people.   Take care.