Complementary and Alternative Medical Therapies

Steven C. Schachter

Carlos Acevedo

Keryma A. Acevedo

Chi-Wan Lai

Amadou G. Diop

Introduction

Despite the introduction of new antiepileptic drugs (AEDs), increasing use of brain surgery, and aggressive worldwide campaigns to improve the diagnosis, treatment, and access to care of patients with epilepsy, nearly one in three patients continues to have seizures despite therapy and others endure side effects from treatment,⁹ while the large majority of people with epilepsy around the world have no access to modern treatments.

Whereas AEDs and epilepsy surgery are relatively new in the history of epilepsy treatment (e.g., bromides were introduced in 1857, phenobarbital in 1912, and epilepsy surgery in the 1940s), people with epilepsy have used a variety of therapies for thousands of years. Some of these therapies persist today, especially in regions of the world where access to medical care is poor, and are generally called complementary and alternative medical (CAM) therapies.

The National Center of Complementary and Alternative Medicine (http://nccam.nih.gov.easyaccess1.lib.cuhk.edu.hk/), a National Institutes of Health (NIH) Center, defines CAM therapies as those health care and medical practices that are not currently an integral part of conventional medicine. In this context, “conventional medicine” is generally understood to represent the “Western” system of medical knowledge and practices, as taught in Western medical schools.

CAM therapies emphasize a focused and individualized approach to patients, with respect for the connection between mind and body, the responsibility of patients for their health, the spiritual nature of people, and the need to stimulate the strength and vital energy necessary for the recovery and sustenance of health.⁶⁶

Patients with chronic illnesses, including epilepsy, use CAM therapies for several reasons. They may prefer “natural” treatments to “artificial” or “synthetic” drugs, assuming that “natural” treatments are better and safer. They may believe that alternative health care providers give them more control over their health care decisions. Lastly, they may have ready access to CAM therapies but not Western-style treatments due to geographic, economic, cultural, social, or religious conditions and factors, which is particularly the case in developing countries.

CAM therapies include traditional Chinese medicine, Ayurveda, homeopathy, naturism and acupuncture; mind–body therapies, such as yoga, hypnosis, music therapy, prayer, and therapeutic touch; botanicals and other “natural” substances, including herbs, herbal medicines, and herbal formulas, which in the United States are classified as dietary supplements; special diets; movement and massage therapies, including reflexology, massage, osteopathy, Reiki, and Qigong; and electromagnetic forces.

This chapter reviews several of the more commonly used CAM therapies for epilepsy, regulatory aspects of herbal medicines, safety issues, and opportunities for further research. A discussion of other CAM therapies for patients with epilepsy, such as acupuncture,⁹⁴^,¹⁵⁵ dietary approaches,⁹²^,¹¹⁵ and neurofeedback,⁶⁹^,⁹⁰^,¹³²^,¹⁴⁶ is beyond the scope of this chapter. Interested readers are also referred to a book on CAM therapies and epilepsy²⁹ in which these topics are discussed at length, as well as several other excellent reviews on herbal medicines and epilepsy.³⁵^,¹⁰¹^,¹³⁰^,¹⁴²

Scope of Use

Developed Countries

In developed countries, CAM therapies are often used for general health maintenance or by patients with chronic conditions that respond poorly or incompletely to conventional treatments, such as back pain, anxiety, depression, headaches, and fibromyalgia.³²^,¹¹⁶^,¹⁴⁵ Despite a lack of evidence for efficacy and safety, surveys suggest that up to one third of patients with epilepsy in the United States and the United Kingdom take herbal medicines and/or dietary supplements, and that the majority of these patients do not discuss this intake with their physicians.³¹^,¹⁰⁷^,¹²⁸ One survey of patients attending an American epilepsy clinic found that ginseng, St. John’s wort, melatonin, gingko biloba, garlic, and black cohosh were the most frequently taken herbal medicines and dietary supplements¹⁰⁷; another found that garlic, gingko, soy, melatonin, and kava were most often taken.¹²⁸

Some of these herbal medicines may be taken for non-seizure-related symptoms (e.g., valerian for difficulty sleeping, St. John’s wort for depression, and ginkgo biloba for memory disturbance). Therefore, the herbal medicines and dietary supplements taken by patients with epilepsy may be clues to possible side effects from AEDs or symptoms of possible comorbid disorders.

Developing Countries

Throughout history, CAM practices and therapies have reflected cultural beliefs about epilepsy.³⁴ In developing countries, people turn to CAM practitioners, often under the influence of their families, either before seeing a Western-style doctor or after the perceived failure of Western medicine.³^,³³^,³⁶^,¹³⁹ According to a survey conducted in China in 1988, nearly 40% of the respondents would suggest that a friend with epilepsy ask for an herbal medicine doctor or seek acupuncture.⁷¹ It should be understood that traditional local treatments are alternative, or “CAM,” from the Western perspective, not from the local perspective.

Lack of education may favor magical beliefs in the power of CAM therapies.¹³^,²³ For example, in sections of the world
where epilepsy is still believed to have supernatural causes, spiritual healing and CAM therapies are used under the direction of traditional healers and include forehead scarifications, shaving of the entire body using glass, herbal concoctions, roots, baths, infusions, or banishment.⁷^,¹²^,⁴⁵^,⁸⁶^,⁹¹^,¹²⁰

The situation in Africa is particularly illustrative. Epilepsy is known in African societies by a variety of names, including ngbitie (Ivory Coast; meaning the brutal, sudden, or surprising disease); ibi-foukougni (Burundi; the snoring disease); adigbe (Benin; the falling disease); tibu sugo (Mali; the “falling like a rock” disease); say (Senegal; convulsion or trance or rabies); and haoua (Nigeria; the [strong] black bull). In much of Africa, epilepsy is conceived as a manifestation of supernatural forces, caused by ancestral spirits or attributed to possession by evil spirits, demonic possession, or divine punishment for the commission of sins. It is also thought to be due to witchcraft and “poisoning,” and is often taken to be contagious, especially via breath, blood, sperm, and genital secretions. Consequently, affected persons may seek out traditional healers in addition to practitioners of modern (“Western”) medicine, particularly when it is clear the disorder is chronic.

African traditional healers utilize a variety of techniques for diagnosis, including “complementary exploration” via search with cowries, sand, stones, animal sacrifices, interpretation of dreams, and contact and dialogue with supernatural personages and forces. Recommended treatments usually utilize different elements derived from animals, vegetables, minerals, and liquids, according to the potential benefits as assessed by the practitioner, and may be recommended as amulets or to be inhaled, eaten, drunk, or bathed in. Supernatural forces will be “invited” during special mystical celebrations to either visit the patient if they are protective or to be withdrawn from the patient’s body and soul if they are negative. These rituals are often witnessed by the public and accompanied by religious songs and dances. The themes of these evocations generally focus on the patient’s family and ancestors. Blood from sacrificed animals may be used to satisfy evil forces or to calm devils.

In many other developing countries around the world, CAM therapies are administered in conjunction with AEDs,²⁵^,⁷⁴ and authors have stressed the relevance of CAM therapies in the management of epilepsy in those settings.²⁵^,²⁸

Complementary and Alternative Medicine Therapies Used for Epilepsy

Herbal Medicines and Other Dietary Supplements

Herbal medicines have been used to treat seizures for centuries. Arguably the earliest use of herbal medicines for epilepsy dates back to 6000 BC in India. According to old Chinese medical texts, herbal epilepsy treatments started in China about 3000 BC. In Peru, iconographies on stones dating back to about 3000 BC describe the medicinal use of Saint Peter herb (Trichocereus peruvianis). Persian medieval medical texts document the clinical manifestations and herbal treatments of epilepsy.⁴⁴ Numerous substances were used to treat seizures over the past 500 years in Europe and in pre-Columbian America.³⁴ In 1763, Pedro de Horta in Mexico wrote an extensive monograph on epilepsy, including the use of herbal medicines, earning his title as the first American epileptologist.³⁹ Today, many herbal medicines around the world are anecdotally believed to have anticonvulsant properties in humans, generally with inadequate scientific support.²¹^,⁸⁰

Traditional Chinese Medicine

The use of herbal medicines in China has a long and sophisticated tradition based on a well-developed system of medical principles.¹⁴⁷ Lai and Lai noted that the first known document on epilepsy in China is in The Yellow Emperor’s Classic of Internal Medicine, Huang Di Nei Ching, dating from about 770 to 221 BC.⁷² Today, traditional Chinese herbal medicine is widely practiced. Similarly, in Japan, over 100 herbal (Kampo) medicines are reimbursed by the national health system and widely prescribed; for example, over 70% of the members of the Kyoto Medical Association who responded to a survey questionnaire on CAM practices routinely prescribe Kampo medicines.¹⁴⁹^,¹⁵⁰

Herbal medicines traditionally used to treat convulsive diseases in Asia include Chai-Hu-Long-Ku-Mu-Li-Tan, a mixture of extracts from 13 herbal medicines¹⁵³; Gastrodia elata⁶⁴; Uncaria rhynchophylla⁷³; Menispermum dauricum⁷⁹; Shitei-To, a mixture of extracts from three medicinal herbs, Shitei (Kaki Calyx; calyx of Diospyros kaki L. f.), Shokyo (Zingiberis Rhizoma; rhizome of Zingiber officinale Roscoe), and Choji (Caryophylli flos; flowerbud of Syzygium aromaticum [L.])⁸⁷; a mixture of radish and pepper (which contains the alkaloid piperine)³⁰; Qingyangshen⁴⁶; Kanbaku-taiso-to, a mixture of three herbal drugs, Glycyrrhizae Radix, Tritici Semen, and Zizyphi Fructus¹⁴¹; Paeoniae Radix¹⁸; and Zheng Tai Instant Powder (a complex prescription of traditional Chinese medicine used for tonic–clonic seizures).⁵⁴

Published reports suggest that several of these herbs have neuroprotective properties,⁵¹^,⁵³^,⁶⁴^,⁶⁵^,⁷³ efficacy in animal models of epilepsy¹⁹^,³⁰^,⁵¹^,⁵²^,⁵³^,⁵⁴^,⁶⁵^,⁸⁷^,⁸⁸^,¹⁴¹ and hippocampal slice models,⁵ and effects on gene expression.¹³⁵^,¹³⁶ Interpretation of these studies is limited, however, by inconsistent descriptions of herbal production and extraction methods as well as the lack of characterization of active ingredients.

Based on the traditional Chinese medicine (TCM) principles of holism and differentiation,⁷⁵^,⁸¹ practitioners recommend individualized prescriptions (formulas/combinations) of herbal medicines and acupuncture to their patients with epilepsy¹⁴⁷ (Fig. 1). Differentiation is the process in TCM whereby different treatable syndromes are diagnosed according to various theories and principles based on symptoms, physical signs, disease history, and other information gathered from other diagnostic methods. As a result, herbal formulas with varying components and acupuncture using different points are commonly recommended to different patients who may have the same seizure type, leading to methodologic issues in conducting clinical research. Accordingly, a comprehensive literature search carried out in March 2005 of published studies using herbal medicines for the treatment of epilepsy in the Far East identified only three randomized controlled trials and five nonrandomized controlled trials, whereas there were six case control studies and 57 observational studies including case reports.¹⁰⁵ Over 135 individual herbal medicines were used singly or in various combinations (formulas) in these investigations (Park, personal communication; Table 1). Rarely was the same herbal formula used in more than one study. Consequently, evidence from controlled trials to support the use of specific Asian herbal medicines either alone or in combination for patients with epilepsy is lacking, and further research is needed.

FIGURE 1. An example of an herbal formula, called Tianma Gouteng Yin. Concha Haliotidis (1), Ramulus Uncariae cum uncis (2), Herba Taxilli (3), Caulis Polygoni multiflori (4), Radix Scutellariae (5), Radix Achyranthis bidentatae (6), Fructus Gardeniae (7), Rhizoma Gastrodiae (8), Poria cum ligno hospite (9), Cortex Eucommiae (10), and Herba Leonuri (11). (Reprinted from Sucher NJ. Insights from molecular investigations of traditional Chinese herbal stroke medicines: implications for neuroprotective epilepsy therapy. Epilepsy Behav. 2006;8:350–362, with permission.) (See the color insert.)

Table 1 Most Frequently Used Herbs in the Far East for Clinical Studies of Epilepsy

Number of studies	Botanical name	Chinese name
21	Pinella ternate	Ban Xia
20	Arisaemi japonicum	Tian Nan Xing
17	Acorus calamus	Shi Chang Pu
14	Gastrodia elata	Tian Ma
13	Buthus martensii	Quan Xie
12	Poria cocos	Fu Ling
12	Bombyx bartryticatus	Jiang Chan
11	Citrus reticulate	Chen Pi
11	Uncaria rhynchophylla	Gou Teng
10	Glycyrrhiza glaba	Gan Cao
10	Salivae miltiorrhizae	Dan Shen
7	Scolopendra subspinipes	Wu Gong
7	Bupleurum falcatum	Chai hu
7	Succinum	Hu Po
7	Paeonia albiflora	Bai Shao
6	Panax ginseng	Ren Shen
6	Perichaeta communissma	Di Long
6	Curcuma longa	Yu Jin
From Park, personal communication.

Ayurveda

“Ayurveda” means the knowledge of life and is derived from two Sanskrit words: Ayu, which means life, and Veda, which means to know. Ayurveda is both a medical system and a science of life that is believed to have originated in India 6000 years BC.⁵⁹ Ayurveda guides the selection of food and lifestyle so that healthy people stay healthy and those who are sick
improve their health. Specific recommendations are individualized based on ancient texts and are validated by observation, inquiry, and direct examination. Encyclopedic texts written about 1000 BC by Caraka and Susruta are considered the most authentic representatives of the original Ayurveda.⁵⁹

The Ayurvedic literature contains references about several aspects of epilepsylike symptoms, etiology, diagnosis, and treatment. Epilepsy is called “Apasmara.” Apa means loss or negation and smara means memory, cognition, recollection, or consciousness.⁸² Epilepsy is classified into four types, all of which are caused by disturbances of the three humors (doshas) that are believed to govern the body’s physiologic properties: vayu or vata (air), pitta (bile), and kapha (phlegm).⁵⁹^,⁸² The causes of seizures are thought to be directly related to practices involving diet, lifestyle, emotions, and ingestion of toxins. If toxins in the body are believed to be abundant, they must be eliminated by drastic emesis, enemas, and purgatives.⁵⁹

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