Nocturnal Frontal Lobe Epilepsy vs Parasomnias

The diagnosis and treatment of nocturnal events can present significant challenges to the clinician. Correct diagnosis is the first step towards appropriate treatment, but may not be straightforward. In particular, non-rapid eye movement (NREM) arousal parasomnias, such as sleepwalking, sleep terrors, and confusional arousal can present in a similar fashion to nocturnal frontal lobe epilepsy (NFLE); dramatic and often bizarre behaviors from sleep are features of both conditions, and may result in diagnostic confusion. A careful clinical history, however, often enables accurate diagnosis, and the frontal lobe epilepsy and parasomnia (FLEP) scale, a validated questionnaire for the diagnosis of nocturnal events, can add diagnostic confidence. Recording of events on video-EEG-polysomnography is required if diagnostic doubt remains although is not always achievable, particularly if events are occurring infrequently. Treatments for NFLE and parasomnias are different, but lifestyle modification and treatment of coexisting sleep disorders (such as obstructive sleep apnoea) may have a role in both. In NFLE, medical treatment with antiepileptic drugs, particularly carbamazepine and topiramate, forms the mainstay of treatment; a small proportion of individuals with treatment-resistant seizures may benefit from epilepsy surgery. For parasomnias, reassurance and the removal of priming and precipitating factors is often sufficient. A minority of individuals will, however, need medical treatment, usually with benzodiazepines or tricyclic antidepressants. Unfortunately, there are few data on which to base treatment decisions in this area, with the evidence comprising predominantly case reports and case series. Well-designed studies, including randomised control trials, are needed and may require a multicentre approach.