Seizure clusters: diagnostic and therapeutic advances

Epilepsy affects 45.9 million people globally. For individuals with epilepsy who continue to have seizures, up to half experience seizure clusters. These seizure clusters have a significant impact, worsening the quality of life for those with epilepsy and their caregivers, and leading to increased healthcare utilization including emergency-department visits and admissions. The risk of premature death including sudden unexpected death in epilepsy (SUDEP) is also increased with seizure clusters. Newly emerging technologies that provide long-term ambulatory electroencephalographic recordings are creating full and accurate seizure histories, resulting in a greater appreciation of the prevalence of seizure clusters and the potential for prediction or identification of seizure clusters. It is hoped that the abundance of data will lead to not only improved clinical care of seizure clusters, but also improved understanding of the pathophysiological mechanisms underlying seizure clusters. Approved treatments, currently in the form of benzodiazepines delivered via rectal, intranasal, or buccal routes, are available. While all current rescue therapies demonstrate clinical efficacy, real-world effectiveness is determined based on the pharmacology of the active drug as well as on the ease and acceptability of drug delivery. Therefore, recently developed alternatives to rectal administration represent significant advances in our treatment armamentarium. With these new options, the utility of identifying seizure clusters and developing a seizure action plan increases, improving the care of individuals with epilepsy and seizure clusters.