Head injury, poor antenatal care and stroke common causes of epilepsy in Nigeria —Dr Iwuozo

Dr. Emmanuel Iwuozo is a Consultant Neurologist at the Benue State University Teaching Hospital, Makurdi. In this interview with Sade Oguntola, he speaks about how best to prevent and treat cases of epilepsy in Nigeria. Excerpts:

What are studies on epilepsy saying about its prevalence across the geopolitical zones?

Epilepsy is a common chronic non-communicable neurological condition or disorder of the brain characterised by unpredictable seizures. It has great social impact on the affected individuals and their families. Epilepsy accounts for 0.5% of the global burden of diseases, with about 70 million people affected worldwide, and most of them in sub-Saharan Africa, including Nigeria.

Research on epilepsy in Nigeria shows that prevalence is not evenly distributed across the six geopolitical zones, although the exact ranking varies depending on the study design, years covered, and regions sampled.

A study by Watila and his colleagues reported the overall prevalence of epilepsy in Nigeria to be 17.7%. According to their study, the prevalence in four geopolitical zones was North Central 0.47%, Southeast 14.7%, Southwest 14.25%, and South South 21.73%.

Researchers have suggested several possible explanations why prevalence rates differ between zones. This includes differences in access to healthcare and diagnostic services; rural–urban disparities; variation in risk factors such as birth complications, central nervous system infections, head injuries, and untreated childhood illnesses; as well as environmental and socioeconomic differences.

Why is it that epilepsy is more in children than adults? What causes epilepsy in Nigeria?

Epilepsy is more common in children, as the prevalence is 11.85% in adults and 36.09% in children. The higher prevalence of epilepsy in children has been attributed to the higher frequency of the common causes of epilepsy among the children’s population. The causes of epilepsy in Nigeria may be related to poor antenatal or perinatal care, leading to prolonged or obstructed labour with subsequent birth asphyxia. Others are febrile seizures, during which the child develops seizures when they have a fever from infections like malaria within the age of 6 years and may subsequently develop seizures spontaneously even without any fever-causing illness. Also, head injury from vehicular or motorcycle accidents or assault can be a reason for epilepsy. Previous brain infections like meningitis, encephalitis, brain tumors, stroke, and family history of epilepsy in first-degree relatives can increase the risk.

Epilepsy is often associated with witchcraft, curses, and contagion, leading to social exclusion and stigma. Can you explain if this is true?

This is completely false. Epilepsy is purely a brain disease that manifests in myriad ways depending on the part of the brain affected. However, due to the misconception that the illness could be a result of a curse, witchcraft, spiritual attack, or demonic possession or contracted from the saliva or urine of affected persons. This makes sufferers and caregivers seek help from prayer houses, mallams, or herbalists without respite. The unpredictability of the seizures in the public could lead to stigma and discrimination and the possibility of keeping the sufferer away from other people.

Q: What gaps do we have regarding diagnosis and treatment of epilepsy in Nigeria?

The two major gaps in epilepsy care in Nigeria are diagnostic and treatment gaps. These gaps significantly affect the quality of care for individuals with the condition. Regarding the diagnostic gap, there is a dearth of neurologists, paediatric neurologists, neuropsychiatrists, or epileptologists who are trained in recognising and making diagnoses of epilepsy. Aside from this, there is the lack or non-availability of diagnostic facilities like electroencephalography (EEG) and magnetic resonance imaging (MRI), which are essential in making the diagnosis and determining the appropriate treatment approach. There is also the problem of the treatment gap, which describes the proportion of people with active epilepsy who do not receive or cannot access appropriate antiseizure medication. In Nigeria, this has been reported to be about 70-75%.

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What challenges do parents of children with epilepsy face in Nigeria?

Parents of children with epilepsy in Nigeria face numerous challenges, including the lack or inaccessibility of specialist healthcare services, inability to procure anti-seizure medications, stigma, discrimination, and misconceptions about epilepsy. As a result, these parents keep the children away from public places. They prevent them from going to school or playing with their friends or neighbours. These challenges can significantly impact the quality of life for both the children and their families.

A study said that early intervention after the first seizure may prevent long-term epilepsy and associated cognitive deficits. Can you explain? How best can the decline in learning and memory associated with epilepsy be averted in children?

Patients with epilepsy will require urgent and early intervention to control the seizures. This is because repeated uncontrolled seizures can cause irreversible brain damage. This is more so in children, especially during the period of their brain development. Irreversible brain damage can lead to cognitive problems like forgetfulness, apathy, irritability, aggression, lack of attention, and concentration, etc. Also, some of the medications used in the treatment of epilepsy can affect memory. It is imperative to commence epilepsy treatment early and to select the best antiseizure medication for each person, considering their peculiar problems.

Patients with epilepsy face many challenges, but perhaps the most difficult of all is the unpredictability of seizure occurrence. Experts say, therefore, one of the most commonly reported triggers for seizures is stress. If this is so, why?

Epilepsy triggers are those factors that could make someone who is predisposed to have recurrent seizures develop it spontaneously. Stress is a common trigger, but others are febrile illness, starvation, lack of sleep, excessive exposure to screens, alcohol use, use of substances like tramadol, etc. During stressful events the brain is made to release stress hormones like cortisol and adrenaline, which causes brain cell excitability, leading to seizures.

What are the common traditional and spiritual healing practices you encounter in the care of people with epilepsy?

Common traditional and spiritual healing practices I have encountered in the course of my practice as a neurologist include the use of herbal concoctions, and occasionally, they compound anti-seizure medications into them. They also do spiritual cleansing and healing, which may involve prayers, wearing chains or bangles to ward off evil spirits, casting out evil spirits, using holy water, drinking water from prayer beads, etc. Sometimes it may involve rituals like making cuts or scarifications on the skin and applying herbal remedies, cow dung, etc.

Are there specific diets or diet modifications helpful for the control of seizures in individuals with epilepsy?

In the management of persons with epilepsy a balanced diet is usually recommended. However, some patients with particular forms of epilepsy may require a ketogenic diet, which is a diet rich in high fat and low carbohydrates. Other dietary measures may include the modified Atkins diet, which is a restrictive high-fat, low-carbohydrate diet, and in addition to a low glycemic index diet with moderate fat and protein and slow-absorbing carbohydrates.

Can individuals outgrow epilepsy? Can victims live normal lives, marry, and have children?

Yes. Some people can outgrow epilepsy, but it depends on the type of epilepsy and the underlying cause. For example, certain childhood epilepsy syndromes, such as childhood absence epilepsy and some forms of benign childhood focal epilepsy, often improve significantly or disappear during adolescence.

People whose seizures are caused by a temporary condition (such as a past infection or injury that has healed) may eventually stop having seizures. Other forms of epilepsy, especially those linked to structural brain abnormalities, genetic conditions, or certain adult-onset epilepsies, may persist throughout life. Doctors generally consider epilepsy to be “resolved” if a person has remained seizure-free for many years (typically at least 10 years) and has been off anti-seizure medication for a substantial period (often at least 5 years). However, this does not guarantee seizures can never return.

Whether someone can safely stop medication should always be decided with a neurologist, since stopping anti-seizure drugs too soon can increase the risk of seizure recurrence.

It is important to note that individuals with epilepsy can live a normal life, go to school, work, marry, and have children. Epilepsy can be controlled with drugs called anti-seizure medications. All that is required is for them to adhere to the appropriately prescribed anti-seizure medications.

It is said that epilepsy cannot be cured, but the seizures can be controlled. How true is this? What are the treatment options for epilepsy?

Currently, there is no cure for epilepsy, but effective treatments are available that can help control seizures for most individuals with epilepsy. The seizures can be controlled in over 70% of persons with epilepsy using appropriate antiseizure medications. Other treatment options include the use of dietary therapy like ketogenic, modified Atkins, and low glycemic index diets. There is also the option of neurostimulation, like vagus nerve stimulation, deep brain stimulation, and epilepsy surgery, in a few patients with drug-resistant epilepsy.