A seizure refers to a recurrent, episodic and transient deficit in neurological function that is a hallmark of chronic neurological disorder. It is described as an abnormally coordinated brain activity, which occurs in the event of neuronal firing in either a specific region of the brain or in the entire brain. It is crucial to understand that the cause of seizures is unknown in approximately 50% of cases. Seizures are known to affect approximately 50.4–81.7 per 100,000 people per year [1]. Sleep deprivation is recognized as one of the risk factors in seizure patients. The expression of gamma amino butyric acid (GABA; the main inhibitory neurotransmitter in the central nervous system) receptors is lower in sleep deprived people [2]. The number of patients with neuropsychological issues, who choose complementary and alternative medicine, including acupuncture and yoga is on the rise. In acupuncture, particular body parts and meridian sites are punctured with tiny needles for therapeutic benefits. Discord and dysregulation of organ systems are addressed by stimulating numerous meridian points, which relieves the associated symptoms and restores the natural homeostasis of the body [3]. The mechanisms by which acupuncture prevents seizures include: the release of inhibitory neurotransmitters like serotonin, GABA, and opioid peptides; a reduction in neuronal activity; and inducible nitric oxide synthase transcription in the hippocampus [4]. Yoga is a traditional Indian practice and way of life that is thought to reduce stress and promote relaxation, and possibly impacts cerebral activity and arousal level, which can attenuate the frequency of seizures [5]. In addition, yoga exerts the effect of stimulating the vagus nerve, which might lower the frequency of seizures. This case report aimed to examine the impact of the combination of acupuncture and yogic breathing techniques on seizure control and sleep quality (the trigger factor) in a patient suffering from seizures.

1. Patient information

A 33-year-old female with a history of seizures since 20 years, visited the hospital. Her convulsions were described as durations of five to seven minutes of unconsciousness, accompanied by jerking of the right leg and hand, and frothing of the mouth, after which she would regain consciousness. She mentioned experiencing two days of postictal body ache following a seizure episode. She would sleep only for 3–4 hours in a day, and lack of sleep could be a possible trigger for a seizure attack. After a seizure-free period lasting for more than 14 years, she experienced numerous seizures during her first postpartum period (August 2017). She did not suffer from seizures from 2017 to 2022. She experienced absence seizures (three per week) after the second postpartum phase (April 2022). She was prescribed Epitoin by her neurologist, which she later stopped taking under the supervision of her neurologist. She approached the Government Yoga and Naturopathy Medical College and Hospital in December 2022. Written informed consent was obtained from the participant. Institutional Ethics Committee of Government Yoga and Naturopathy Medical College exempted this study from review as this is a single case report.

2. Clinical findings

An electroencephalogram and magnetic resonance imaging of the brain were performed and were normal.

The timeline has been provided in Fig. 1.

Figure 1. Timeline details of the study from the first day of consultation to final follow-up. UG-OP, undergraduate outpatients.

3. Diagnostic assessment

1) Seizure diary

The patient was instructed to record the information regarding her seizure episodes in a handwritten diary.

2) The Pittsburgh sleep quality index

Pittsburgh sleep quality index is a self-rated questionnaire that is used to assess sleep quality and disturbances in patients. It consists of 19 items under seven components (subjective sleep quality, sleep latency, sleep duration, habitual sleep efficiency, sleep disturbances, use of sleeping medications, and daytime dysfunction). The sum of the scores of these seven components is referred to as the global score, which is used to assess the overall sleep quality of the patient.

4. Therapeutic intervention

Following consultation, a combination of acupuncture and yoga interventions was recommended to her to be performed over the course of 45 days. Treatment was administered by a qualified physician on a regular basis. The patient was advised to practice yoga-based breathing techniques such as yogic breathing (slow and deep inhalation and exhalation through both nostrils) for 10 minutes followed by Bhramari pranayama (humming bee breathing technique) for 15 minutes. After completion of the yoga-based breathing, acupuncture was performed using a stainless filiform needle (0.25 × 13 mm size) with the penetration depth of 5–10 mm perpendicularly, without any stimulation for the duration of 30 minutes. Rest in between the course of acupuncture treatment is traditionally recommended for achieving improvement and adaptation.

In addition, she was instructed to practice yogic breathing at night before sleep for 10 minutes, daily (Table 1).

Table 1 . Details of the intervention provided to the patient.

Name of the practice/point	Procedure/location	Duration (min/d)	Frequency (in 45 days)
Yoga
Bhramari pranayama	Asked the patient to inhale and produce humming bee sounds while exhaling	15	Daily
Deep breathing exercise	Slow and deep inhalation followed by exhalation through both nostrils	10	Daily
Acupuncture
Governing vessel (GV-20 [Baihui])	On the vertex of the skull, 5 cun behind the anterior hairline on the midline	30	1st session: day 1–15
			Rest: day 16–30
			2nd session: day 31–45
Heart (HT-7 [Shenmen]), bilaterally	On the wrist, on the radial side of the tendon of the flexor carpi ulnaris	30
Pericardium (PC-6 [Neiguan]), bilaterally	2 cun proximal to the midpoint of the anterior wrist crease between the tendons of the palmaris longus and flexor carpi radialis	30
Spleen (SP-6 [Sanyinjiao]), bilaterally	3 cun superior to the medial malleolus	30

5. Follow-up and outcomes

The results indicated a reduction in seizure frequency and improvement in the quality of sleep. After completion of the intervention period, the patient was advised to continue the yoga-based breathing techniques at home and a bimonthly phone call was made to ensure adherence to the instructions and also to assess the prognosis or any untoward effects (Table 2).

Table 2 . Baseline and post-test assessments of the patient.

Variable	Baseline	Post-test
Frequency of seizures	3 times in the past week	No episode of seizure after the initiation of intervention
Pittsburgh sleep quality index score	Baseline	Post-intervention
Global score	20	4
Subjective sleep quality	3	1
Sleep latency	6	2
Sleep duration	3	0
Sleep efficiency	3	0
Sleep disturbance	2	1
Use of sleep medications	0	0
Daytime dysfunction	3	0

Slow breathing has been demonstrated to be advantageous in situations of pain, asthma, affective mood disorder, and stress. Slow, deep, and regular breathing aids in reducing the sympathetic component of hyper-arousal (i.e., sleeplessness), produces greater cardiorespiratory synchronization, and improves the parasympathetic tone. Stronger sympathoinhibition has been linked to deeper breathing, while rapid and erratic breathing has been demonstrated to cause sympathetic excitement. Practicing deep breathing exercises before sleeping has been observed to reduce sleep onset latency, improve the quality of sleep, and it also improves the consistency of sleep pattern. Regular practice of calm breathing exercises can provide long-term relief from sympathetic over-arousal. In addition, slow, deep breathing has been demonstrated to result in the generation of melatonin, a vital hormone that induces sleep by encouraging parasympathetic tone and inhibiting the sympathetic tone, as well as through relaxation [6,7]. Reduced sympathetic tone and increased parasympathetic output resulting from breathing exercises like Bhramari pranayama help to lessen unpleasant feelings like stress, depression, and worry by balancing the autonomic nervous system [8]. Therefore, stimulation of the vagal nerve due to Bhramari pranayama and deep breathing exercises could be attributed to reduced seizure frequency [9]. Few previously conducted studies have indicated that nitric oxide, beta-endorphin, and melatonin levels, which are linked to better sleep, are elevated by acupuncture [10,11]. Acupuncture causes an increased release of GABA (the inhibitory neurotransmitter), which could counterbalance the overexcitation of neurons, thereby implicating a role in seizure prevention [12]. The acupuncture points GV20, HT7, PC6, and SP6 together possess a combined ability to regulate the nervous system and emotional balance, which are crucial in managing seizures, and were therefore selected in this patient. GV20 (Baihui) is known to regulate the central nervous system and calm the excessive yang, thereby reducing the triggers leading to seizures. HT7 (Shen men) calms the mind and reduces anxiety, stress, and insomnia, which are common seizure precursors, and promotes emotional stability. PC6 (Neiguan) assists in regulating the autonomic nervous system, thereby alleviating stress and palpitations that often accompany seizure episodes. SP6 (Sanyinjiao) supports the harmonization of the spleen, liver, and kidneys, and promotes overall body balance and reduction of tension that could exacerbate seizures. Together, through both neurological and emotional stabilization, these points provide a holistic approach to managing seizures [13]. Therefore, the reduced frequency of seizure attacks and improved sleep quality could be attributed to the combined effect of both acupuncture and yoga-based breathing techniques.

1. Strength and limitation

The intervention of acupuncture and yoga-based breathing techniques was feasible, was accepted by the patient, was easy to follow-up, and no adverse effects were reported by the patient throughout the study period. However, objective measures were lacking for a better understanding of the disease activity. However, this was a single case study, and further randomized controlled trials (RCTs) are required to validate the results of this study.

2. Conclusion

In conclusion, the combination of acupuncture and yoga-based breathing techniques might help to reduce the seizure frequency and improve the quality of sleep in patients suffering from seizures. However, RCTs with a large sample size are required to confirm the effectiveness of this treatment modality.

Conceptualization: ED, AM. Methodology: ED. Supervision: NM, AM. Validation: AM. Writing – review & editing: LN, AM.

The authors have no conflicts of interest to declare.

None.

Written informed consent was obtained from the participant. Institutional Ethics Committee of Government Yoga and Naturopathy Medical College exempted this study from review as this is a single case report.