Epileptology and sleep disorders
This domain tests classification, semiology, emergency treatment and the everyday pharmacology of epilepsy, plus the recognition and scoring of the major sleep disorders. Expect seizure semiology vignettes and EEG-based questions.
Classification (ILAE 2017)
- Onset: focal, generalised, unknown. Focal seizures are further divided by awareness (aware versus impaired awareness) and by motor versus non-motor onset; focal-to-bilateral tonic-clonic seizures are recognised.
- Aetiology: structural, genetic, infectious, metabolic, immune, unknown.
- Generalised types include absence, myoclonic, tonic-clonic, tonic and atonic.
Semiology clues
Temporal lobe: epigastric rising aura, déjà vu, automatisms, postictal confusion. Absence: brief staring, 3 Hz spike-wave, no postictal confusion. Juvenile myoclonic epilepsy: morning myoclonus, photosensitivity, often lifelong treatment. Frontal lobe seizures are brief, nocturnal, hypermotor and often have little postictal confusion.
Status epilepticus
Convulsive status is defined at 5 minutes. First line: benzodiazepine (lorazepam 4 mg IV, or midazolam 10 mg buccal/intramuscular). Second line: levetiracetam 60 mg/kg, valproate 40 mg/kg, or phenytoin 20 mg/kg. Refractory status requires anaesthesia with EEG monitoring. Non-convulsive status needs EEG for diagnosis.
Antiseizure medication
Focal seizures: carbamazepine, oxcarbazepine, lamotrigine, levetiracetam. Generalised: valproate is effective but teratogenic (neural tube defects, neurodevelopmental harm) and is avoided in women of childbearing potential; lamotrigine and levetiracetam are preferred in pregnancy. Absence seizures: ethosuximide. Watch for hyponatraemia (oxcarbazepine), rash (lamotrigine, carbamazepine; HLA-B*15:02), and enzyme induction.
Prognosis and safety
SUDEP counselling, driving restrictions (in the Czech Republic generally 12 months seizure-free), folic acid 5 mg in pregnancy planning, and bone health on enzyme inducers.
Sleep
Scoring uses 30-second epochs. Obstructive sleep apnoea is defined by an apnoea–hypopnoea index ≥5 with symptoms or ≥15 regardless. Narcolepsy type 1: cataplexy plus low orexin; the MSLT shows mean sleep latency ≤8 minutes with ≥2 sleep-onset REM periods. REM sleep behaviour disorder is confirmed by REM without atonia on polysomnography and often heralds synucleinopathy. Restless legs syndrome is a clinical diagnosis (urge to move, worse at rest and in the evening, relieved by movement). Cognitive behavioural therapy is first-line for chronic insomnia.
Worked example
A 19-year-old has brief morning arm jerks, one generalised seizure after sleep deprivation, and a photoparoxysmal response. This is juvenile myoclonic epilepsy - generalised, so carbamazepine may worsen it; valproate or levetiracetam is appropriate, with counselling about sleep and driving.
Traps
Diagnosing epilepsy after a single provoked seizure; treating syncope with antiseizure medication; assuming a normal EEG excludes epilepsy; missing non-convulsive status in a confused patient.