Consider nocturnal seizures when evaluating a patient for parasomnias

A 23-year-old woman visited our office complaining that she had had three episodes where she lost complete control of her body for several minutes just as she was about to fall asleep. During one episode, she was stroking her boyfriend’s back as they lay in bed. During that event, she said her head turned toward the side, her right arm started shaking, and then she went limp all over for about one minute.

At first I thought she may be experiencing sleep paralysis, as she also complained of feeling very sleepy on most days. Since all of the events occurred around the time of sleep, my differential included narcolepsy with cataplexy. Then it occurred to be that she may be experiencing some type of seizure, which turned out to be the case.

Nocturnal seizures usually occur during sleep transition or during non-REM (NREM) stage 2 sleep. They can also occur when a patient is transitioning into slow wave sleep.There are various types of seizures that can occur during sleep including tonic-clonic, Rolandic epilepsy (benign focal epilepsy of childhood), petit mal seizures and partial seizures.

Being overly tired can cause seizures, and sometimes sleep studies requiring the patient to be sleep deprived prior to the study are recommended to confirm this diagnosis. Since health-care providers rarely see cases involving nocturnal seizures, it can easily be confused with parasomnias, including confusional arousals, cataplexy and REM sleep behavior disorder.

If your patient relates episodes of losing control of the body before or during sleep, consider that a seizure disorder may be causing the problem. Order a polysomnogram with a full head electroencephalogram (EEG). Since seizures often coexist with other sleep disorders, including obstructive sleep apnea, do not be surprised if a patient has both.

Children are very susceptible to seizures during sleep, especially if they have a history of a seizure disorder. There are some patients who only have nocturnal seizures without experiencing seizures during the day, but most patients will have a history.

Patients can minimize seizures by getting adequate rest. Conversely, too much sleep can also cause seizures. Advise patients who experience nocturnal seizures to establish a regular bedtime schedule, and to get eight hours of sleep per night. Anticonvulsant treatment is also recommended. Preliminary evidence from several small trials suggests that melatonin can be helpful in minimizing seizures.

Keep nocturnal seizure disorder in your differential when assessing for sleep problems. Of course, refer patients to a sleep specialist if you are unsure of the diagnosis or want another opinion.

Sharon M. O’Brien, MPAS, PA-C, works at Presbyterian Sleep Health in Charlotte, N.C. Her main interest is helping patients understand the importance of sleep hygiene and the impact of sleep on health.