by Ishpreet Singh, M.B.B.S. and Sat Bir Singh Khalsa, Ph.D.
Epilepsy is a disorder in which recurrent seizures are caused by abnormal electrical discharges in the brain. A person is diagnosed with epilepsy if they have two unprovoked seizures (or one unprovoked seizure with the likelihood of more) that were not caused by some known and reversible medical condition. There are different types of seizures. Generalized onset seizures affect both sides of the brain or groups of cells on both sides of the brain at the same time. On the other hand, focal onset seizures can start in one area or group of cells in one side of the brain. Epileptic seizures are the result of excessive and abnormal neuronal activity in the cortex of the brain and often brought on by factors such as stress, alcohol abuse, flickering light, or a lack of sleep, among others. An electroencephalogram (EEG) to look for abnormal patterns of brain waves and neuroimaging (CT scan or MRI) to look at the structure of the brain are also usually part of the diagnostic evaluation. In the United States, epilepsy affects an estimated 2.2 to 2.3 million people. The key driver of direct costs in epilepsy is medical service expenditures, which are substantial. However, the overwhelming majority of total costs are attributable to indirect costs such as job absenteeism. For general epilepsy populations, total annual direct healthcare costs per person ranged from $10,192 to $47,862 and epilepsy‐specific costs ranged from $1,022 to $19,749. These costs are a healthcare burden that needs to be addressed.
Epilepsy cannot usually be cured outright, but pharmaceutical medications can control seizures effectively in about 70 percent of the cases. The mainstay treatment of epilepsy is anticonvulsant medications, possibly for the person’s entire lifespan. Trials of single medications are recommended initially. However, if this is not effective, two medications simultaneously may be prescribed. Medications available include older antiepileptic drugs such as phenytoin, carbamazepine, and valproate and newer ones which include lamotrigine, levetiracetam, zonisamide, etc. Adverse effects from medications are reported in 10 to 90 percent of people. Most adverse effects are dose-related and mild and can include mood changes, sleepiness, or unsteadiness in gait. Certain medications have side effects that are not related to dose such as rashes, liver toxicity, or suppression of the bone marrow. Importantly, up to a quarter of people stop treatment due to adverse effects and some medications are not appropriate during pregnancy. Therefore, there is a need for alternative, nonpharmacological interventions.
There is credible and mounting evidence that yoga and meditation practices can improve stress, psychophysiological hyperarousal, and psychological well-being, and may be helpful in treating clinical problems such as depression, anxiety, and chronic pain. The relationship between stress and epilepsy is well known. Stress leads to release of glucocorticoids, neuropeptides, and corticotrophin-releasing hormone (CRH), which can excite immature hippocampal neurons and cause seizures, resulting in a vicious cycle. A majority of adult patients with medically refractory epilepsies have mesial temporal lobe epilepsy. Yoga and meditation interventions may modulate the disturbed limbic system activity in such patients and may help to maintain normal homeostatic conditions. Stress reduction and subjective feelings of well-being may be important factors contributing to seizure reduction and EEG changes ascribed to some forms of meditation. Yoga is thought to achieve seizure control through experience-related plasticity or through a shift in autonomic output toward relative parasympathetic dominance. Other proposed mechanisms of yoga benefit include EEG desynchronization and activation of inhibitory circuits through vagal nerve stimulation. One study has suggested that yoga training stimulates the vagus nerve, which may be relevant because electrical stimulation of the vagus nerve has been shown to decrease seizure frequency by 28 to 38 percent. There is therefore a positive rationale for the therapeutic role of yoga and meditation practices.
However, there has been controversy about the link between meditation practice and the neurological disorder of epilepsy. Some have suggested the concern that brain states induced by meditation could be conducive to triggering seizures in epileptics or could trigger epilepsy with patients with no known history or risk factors for epilepsy. The proposed epileptogenic influence of meditation is based on observed meditation-induced alterations in neurophysiology (hypersynchrony and increased coherence of brain activity) and neurochemistry (release of glutamate and serotonin). A study in 1993 found a significantly large incidence of complex partial epilepsy-like signs and experiences in meditators compared to controls. The study presented data of 221 meditators who displayed these signs compared to 860 non-meditators. However, several studies on patients with epilepsy practicing meditation have actually demonstrated improvement in seizure frequency and duration and EEG profile. A study published in 1995 has shown that experiences of unbounded awareness (transcendental consciousness) during meditation are correlated with specific physiological changes, e.g., global increase in EEG coherence, slowing of respiration and heart rate, and increased basal skin resistance. These changes are not epileptic-like and are not pathological but are positively correlated with intelligence, creativity, and mental health.
A number of studies have further attested to the safety and efficacy of yoga practices in epilepsy. Two unblinded randomized controlled trials (RCTs) in 1996 and 2008, recruited a total of 50 adults with refractory epilepsy and compared any type of classical Indian yoga to control conditions with no intervention or interventions such as yoga-mimicking exercises or Acceptance and Commitment Therapy. Results of the overall efficacy analysis showed that yoga treatment was better when compared with no intervention or interventions other than yoga. These data also suggested that yoga may have a role as an adjuvant therapy in the management of autonomic dysfunction in patients with refractory epilepsy.
A recent review paper on mindfulness-based interventions for epilepsy published in 2017 described three RCTs with a total of 231 participants in the USA (n = 171) and Hong Kong (n = 60). Significant improvements were reported in depression symptoms, quality of life, anxiety, and depression. Despite positive findings, the authors noted significant design limitations including unclear or high risk of bias, low statistical power, lack of measurement of longer-term effects, limited accounting for confounding factors, no measures of home practice, and poor reporting of randomization procedures, adverse events, and reasons for subject drop-outs. This systematic review concluded that there is limited evidence for the effectiveness of mindfulness-based interventions in epilepsy, however preliminary evidence suggests it may lead to some improvement in anxiety, depression, and quality of life.
In summary, yoga interventions may contribute positively to the treatment of epilepsy by enhancing quality of life and by decreasing seizure activity. Yoga interventions can be integrated into an outpatient clinic with good results, are noninvasive and low cost, and can be conducted even in the presence of language barriers and cultural differences. However, much more rigorous research needs to be conducted in this field and yoga can only be justified as an adjunctive treatment to antiepileptic drugs at the present time and should not generally be used as the sole treatment method.
Ishpreet Singh is a medical doctor and researcher from the Dayanand Medical College in India. He has worked extensively in India and USA with individuals with mental health and neurological disorders and is inclined towards integrating eastern yogic and meditation methods into mainstream medicine. He is an avid practitioner of Kundalini Yoga and meditation and brings this as a tool to help people heal, addressing deeper causes of illness and disease.
Sat Bir Singh Khalsa, Ph.D. is the KRI Director of Research, Research Director for the Kripalu Center for Yoga & Health, and Assistant Professor of Medicine at Harvard Medical School. He has practiced a Kundalini Yoga lifestyle since 1973 and is a KRI certified Kundalini Yoga instructor. He has conducted research on yoga for insomnia, stress, anxiety disorders, and yoga in public schools. He is editor in chief of the International Journal of Yoga Therapy and The Principles and Practice of Yoga in Health Care and author of the Harvard Medical School ebook Your Brain on Yoga.