Epilepsy: treatment

Epilepsy: treatment

Most neurologists now start antiepileptics following a second epileptic seizure. NICE guidelines suggest starting antiepileptics after the first seizure if any of the following are present:

• the patient has a neurological deficit
• brain imaging shows a structural abnormality
• the EEG shows unequivocal epileptic activity
• the patient or their family or carers consider the risk of having a further seizure unacceptable

Safety considerations of specific drugs

The MHRA and NICE have strengthed their advice against sodium valproate use recently:


Topiramate should not be used in women and girls of childbearing potential unless conditions of the Pregnancy Prevention Programme are fulfilled.

Drug treatment according to the type of epilepsy

Generalised tonic-clonic seizures

• lamotrigine or levetiracetam
  Generalised tonic-clonic seizures: lamotrigine or levetiracetam are generally used first-line
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  Importance: 12

Focal seizures

• first line: lamotrigine or levetiracetam
  Focal seizures: lamotrigine or levetiracetam are first-line
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  Importance: 55
• second line
  Focal seizures not responding to first-line drug - try lamotrigine or levetiracetam (i.e. the first-line drug not already tried) and if neither help then carbamazepine
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  Importance: 93
  : carbamazepine, oxcarbazepine or zonisamide

Absence seizures (Petit mal)

• first line: ethosuximide
  Absence seizures: ethosuximide is first-line
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  Importance: 48
• second line: lamotrigine or levetiracetam
• carbamazepine may exacerbate absence seizures
  Carbamazepine is contraindicated in absence seizures
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  Importance: 72

Myoclonic seizures

• first-line: levetiracetam
  Myoclonic seizures: levetiracetam is first-line
  You've never been tested on this concept
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  Importance: 78
• second line: lamotrigine

Tonic or atonic seizures

• first-line: lamotrigine
  Tonic or atonic seizures: lamotrigine is first-line
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  Importance: 37
• second line: clobazam, rufinamide, or topiramate

+PassMedicine Notes

Most neurologists now start antiepileptics following a second epileptic seizure. NICE guidelines suggest starting antiepileptics after the first seizure if any of the following are present:

• the patient has a neurological deficit
• brain imaging shows a structural abnormality
• the EEG shows unequivocal epileptic activity
• the patient or their family or carers consider the risk of having a further seizure unacceptable

Safety considerations of specific drugs

The MHRA and NICE have strengthed their advice against sodium valproate use recently:

Valproate must not be started for the first time in people (male or female) younger than 55 years, unless 2 specialists independently consider and document that there is no other effective or tolerated treatment, or there are compelling reasons that the reproductive risks do not apply.

Topiramate should not be used in women and girls of childbearing potential unless conditions of the Pregnancy Prevention Programme are fulfilled.

Drug treatment according to the type of epilepsy

Generalised tonic-clonic seizures

• lamotrigine or levetiracetam

Focal seizures

• first line: lamotrigine or levetiracetam
• second line: carbamazepine, oxcarbazepine or zonisamide

Absence seizures (Petit mal)

• first line: ethosuximide
• second line: lamotrigine or levetiracetam
• carbamazepine may exacerbate absence seizures

Myoclonic seizures

• first-line: levetiracetam
• second line: lamotrigine

Tonic or atonic seizures

• first-line: lamotrigine
• second line: clobazam, rufinamide, or topiramate

Selecting first- and second-line ASMs by seizure type