Can epilepsy cause palpitations?

Can Epilepsy Cause Palpitations?

Yes, epilepsy can cause palpitations through several mechanisms, particularly in temporal lobe epilepsy where autonomic symptoms including heart rate changes commonly occur before, during, or after seizures. 1, 2

Mechanisms of Epilepsy-Related Palpitations

Seizure-Related Cardiac Effects

• Autonomic activation: Epileptic discharges, especially from the temporal lobe, can activate autonomic pathways leading to:
  • Tachycardia (most common cardiac manifestation)
  • Bradycardia
  • Asystole (in severe cases)
  • Atrial fibrillation 3

Timing of Cardiac Changes

• Pre-ictal: Heart rate changes can occur before visible seizure onset
  • Median of 7 seconds before clinical seizure onset in medial temporal lobe epilepsy 4
• Ictal: During the seizure itself
• Post-ictal: Following the seizure

Anatomical Considerations

• Medial temporal lobe epilepsy has significantly higher likelihood of heart rate changes before seizure onset compared to:
  • Lateral temporal lobe epilepsy
  • Extratemporal lobe epilepsy 4

Clinical Presentation

Characteristic Features

• Episodic palpitations that may be accompanied by:
  • Rising abdominal sensation (epigastric aura)
  • Breathlessness
  • Excessive sweating
  • Dizziness
  • Possible progression to loss of consciousness 2, 5

Diagnostic Clues

According to the European Society of Cardiology guidelines, palpitations can be a trigger or symptom associated with both cardiac arrhythmias and seizures 1. Key distinguishing features include:

• Pattern: Episodic, stereotyped events
• Associated symptoms: Presence of other seizure-related symptoms
• Response to treatment: Improvement with antiepileptic medications 2

Differential Diagnosis

When evaluating palpitations, consider:

1. Primary cardiac arrhythmias

   • More likely to occur without other neurological symptoms
   • May require cardiac monitoring during episodes

2. Postural Orthostatic Tachycardia Syndrome (POTS)

   • Can coexist with epilepsy
   • Characterized by orthostatic tachycardia upon standing 6

3. Psychogenic causes

   • Anxiety-related palpitations
   • Panic attacks

Evaluation Approach

For patients presenting with palpitations who might have epilepsy:

1. Detailed seizure history:

   • Timing and circumstances of palpitations
   • Associated symptoms (auras, altered awareness)
   • Duration and recovery pattern

2. Diagnostic testing:

   • EEG (preferably with video monitoring)
   • Cardiac evaluation during interictal period (ECG, Holter monitoring)
   • Brain imaging if structural cause suspected 1

Management Considerations

1. For confirmed epilepsy-related palpitations:

   • Antiepileptic medications to control seizures
   • Regular cardiac monitoring in patients with known seizure-related cardiac changes

2. For severe cases with ictal bradycardia/asystole:

   • Consider cardiac pacemaker implantation 1
   • The American College of Cardiology/American Heart Association guidelines state: "In patients with epilepsy associated with severe symptomatic bradycardia (ictal bradycardia) where antiepileptic medications are ineffective, permanent pacing is reasonable for reducing the severity of symptoms" 1

Important Caveats

• Palpitations alone are rarely the sole manifestation of epilepsy
• Cardiac evaluation should not be overlooked, as primary cardiac conditions can coexist with epilepsy
• Sudden unexpected death in epilepsy (SUDEP) has been associated with cardiac arrhythmias, making recognition of cardiac symptoms in epilepsy patients particularly important 1, 3

Remember that while palpitations can be a symptom of epilepsy, they are more commonly caused by primary cardiac conditions, anxiety, or other medical disorders. A thorough evaluation is necessary to determine the true cause.