Sleep-Related Seizures
Epileptic seizures that occur predominantly or exclusively during sleep, which can disrupt sleep quality and be difficult to distinguish from other sleep disorders.
What is Sleep-Related Seizures?
Sleep-related seizures are epileptic seizures that occur predominantly or exclusively during sleep. Several epilepsy syndromes are characterized by sleep-related seizures, including nocturnal frontal lobe epilepsy, benign epilepsy with centrotemporal spikes (BECTS), and others. Sleep and epilepsy have a complex bidirectional relationship: sleep can trigger seizures, and seizures/epilepsy can disrupt sleep. Nocturnal seizures can be difficult to distinguish from parasomnias, and accurate diagnosis is important for appropriate treatment.
Prevalence
Approximately 10-20% of people with epilepsy have seizures that occur exclusively during sleep, and about 30-40% have seizures that occur both during sleep and wakefulness. Certain epilepsy syndromes are highly associated with sleep-related seizures. BECTS, a common childhood epilepsy, occurs almost exclusively during sleep. Nocturnal frontal lobe epilepsy is another well-recognized sleep-related epilepsy syndrome.
Causes
Sleep-related seizures occur because sleep alters brain activity in ways that can promote seizure activity. NREM sleep, in particular, is associated with increased synchronization of brain activity that can facilitate seizure propagation. Specific epilepsy syndromes have genetic causes or result from structural brain abnormalities. Sleep deprivation is a well-known seizure trigger. Other factors that can provoke nocturnal seizures include stress, alcohol withdrawal, and missed medications.
Types
Nocturnal Frontal Lobe Epilepsy (NFLE)
Features brief, stereotyped motor seizures arising from the frontal lobes during sleep. Can appear similar to parasomnias.
Benign Epilepsy with Centrotemporal Spikes (BECTS)
A common childhood epilepsy with seizures occurring almost exclusively during sleep, typically outgrown by adolescence.
Electrical Status Epilepticus during Sleep (ESES)
Continuous spike-wave activity during NREM sleep, associated with cognitive and language problems.
Generalized Tonic-Clonic Seizures during Sleep
Various epilepsy syndromes can cause generalized convulsive seizures during sleep.
Symptoms
Nocturnal motor events
Jerking, stiffening, twitching, or complex movements during sleep. May be brief (seconds) or more prolonged.
Tongue biting or incontinence
Signs that may indicate a convulsive seizure rather than a parasomnia.
Stereotyped events
Seizures are typically very similar from one episode to the next, unlike more variable parasomnia behaviors.
Post-ictal confusion
Confusion, fatigue, or headache following the event may indicate a seizure.
Disrupted sleep
Seizures fragment sleep, leading to daytime sleepiness and fatigue.
Waking with unexplained injuries
Tongue bites, bruises, or muscle soreness upon waking without memory of the event.
Bedwetting in older children/adults
New-onset nocturnal incontinence can indicate seizures.
Diagnosis
Self-Assessment Questions
If you answer yes to any of these questions, consider consulting a sleep specialist:
- 1Have you had episodes of jerking, stiffening, or unusual movements during sleep?
- 2Do you wake up with unexplained tongue bites, bruises, or muscle soreness?
- 3Has a bed partner witnessed convulsive movements or rhythmic shaking during your sleep?
- 4Are the events very similar (stereotyped) from one night to the next?
- 5Do you wake up confused, with a headache, or excessively tired?
- 6Have you ever been diagnosed with epilepsy or had daytime seizures?
Diagnosis requires capturing events on video-EEG monitoring to document that events are epileptic seizures. Routine EEG (especially with sleep deprivation), brain MRI, and careful history help distinguish seizures from parasomnias.
Video-EEG Monitoring
Extended EEG monitoring with video recording to capture events is the gold standard for diagnosis, showing ictal EEG changes during events.
Routine EEG
Standard EEG, especially with sleep deprivation and recording during sleep, may show interictal epileptiform discharges.
Sleep-Deprived EEG
Sleep deprivation increases the likelihood of capturing sleep and epileptiform activity on EEG.
Brain MRI
MRI may identify structural causes of epilepsy such as malformations, tumors, or scarring.
Home Video Recording
Videos recorded by family members can help clinicians characterize events before formal monitoring.
Treatment
Treatment involves antiseizure medications appropriate for the specific epilepsy syndrome. Maintaining good sleep hygiene is important as sleep deprivation can trigger seizures. Some patients may be candidates for surgery.
Antiseizure Medications
Carbamazepine, oxcarbazepine, lacosamide, and other medications are used depending on the seizure type and syndrome. Medication choice is tailored to the individual.
Avoid Seizure Triggers
Getting adequate sleep, avoiding alcohol, and taking medications consistently help prevent seizures.
BECTS Management
For benign epilepsy with centrotemporal spikes, treatment may not be necessary as seizures are infrequent and the condition is outgrown.
Epilepsy Surgery
For refractory cases with an identifiable seizure focus, surgery may be an option.
Treat Comorbid Sleep Disorders
Treating sleep apnea or other sleep disorders that fragment sleep may improve seizure control.
Lifestyle Adjustments
- •Get adequate, regular sleep (sleep deprivation triggers seizures)
- •Take antiseizure medications consistently as prescribed
- •Avoid alcohol and recreational drugs
- •Maintain a regular sleep schedule
- •Treat any underlying sleep disorders
- •Consider safety modifications for the sleep environment
- •Ensure bed partners know seizure first aid
- •Wear medical identification if you have epilepsy
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