Case Presentation: A 44-year-old female with history of a seizure disorder presented with status epilepticus. She had four witnessed seizures with generalized convulsions at home and two more en route to the hospital with EMS, for which she received two doses of 5mg of midazolam. Upon arriving to the ED, she had two to three more seizures and was given lorazepam (1mg IV x 2), intubated, and started on Propofol and Fentanyl, and given a loading dose of 2g of levetiracetam. She was reportedly adherent to her home regimen of valproic acid (VPA) 750mg BID and her VPA levels at time of admission were at the lower end of therapeutic range at 61.3ug/mL. She was restarted on VPA 750mg BID. A CT head without contrast showed no acute intracranial abnormalities. Her twenty-four-hour continuous video EEG was abnormal and demonstrated diffuse mixed theta, alpha, and delta frequency slowing without focal features with reactivity present, but no evidence of epileptiform discharges or seizures.Her seizures began at the age of 38 and typically involved generalized convulsions with tongue biting and occasional incontinence. They usually lasted less than five minutes and involved a post-ictal period of one hour. The seizures were perimenstrual, typically occurring a few days before to a few days after her menstrual cycle. She was discharged on VPA 750 mg and instructed to take an additional 500 mg per day starting one day prior to her menstrual cycle until one day after the end of her menstrual cycle. Initiating a hormonal based birth control was also discussed and she was dosed with Depo-Provera before discharge. At follow-up two weeks later, she was seizure-free and had just begun her next menstrual cycle. Unfortunately, she missed her next Depo-Provera dose and presented to the ED 3 months later with seizures where she was administered her second dose of Depo-Provera. She remains under follow-up care at this time.
Discussion: Seizures tend to cluster and exhibit periodicity. When they cluster perimenstrually, it is termed catamenial epilepsy. Catamenial epilepsy is thought to occur in up to a third of women with epilepsy. Why exactly seizures may cluster around the menstrual cycle in females is unclear but is thought to be due to the cyclic variation in endogenous steroid hormones around this time. As such, control of these seizures involves traditional anti-epileptic drugs as well as hormonal therapies. In patients with epilepsy, it is important to consider the patient holistically and recognize factors such as hormones, medication compliance, and substance use among others, that may be exacerbating their disease.
Conclusions: Our case underscores the importance of considering catamenial epilepsy in the differential diagnosis in female patients who have recurrent seizures despite adherence to AED therapy. It also demonstrates the potential utility of hormonal therapies in addition to traditional AEDs in controlling these perimenstrually exacerbated seizure episodes.