From the Guidelines
Seizures should be managed by first ensuring the patient's safety, and if the seizure lasts longer than 5 minutes, emergency services should be called immediately. When evaluating adult patients presenting to the emergency department with seizures, it is crucial to follow a diagnostic process to determine the cause of the seizure, as various clinical conditions can lead to events that resemble convulsive seizures but are not actually seizures 1. According to the clinical policy for the evaluation and management of adult patients presenting to the emergency department with seizures, the terminology for seizures and epilepsy is not straightforward and continues to evolve 1.
Key Considerations
- The correct categorization of a clinical event as a seizure may be difficult even after thorough evaluation in the emergency department 1.
- Seizures can be classified as acute symptomatic or provoked seizures, which occur at the time of or within 7 days of an acute neurologic, systemic, metabolic, or toxic insult 1.
- An unprovoked seizure occurs in the absence of acute precipitating factors and includes remote symptomatic seizures, as well as seizures that are not established to have a cause 1.
- Epilepsy is defined as recurrent unprovoked seizures 1.
Treatment
- Antiepileptic medication may be prescribed for seizure prevention, and the choice of medication depends on the type and frequency of seizures 1.
- Benzodiazepines, such as midazolam or lorazepam, may be administered to decrease the occurrence of alcohol withdrawal seizures or to treat status epilepticus 1.
- Lifestyle modifications, such as adequate sleep, stress reduction, and avoiding alcohol, can help reduce seizure frequency.
From the Research
Seizure Treatment Options
- Various antiepileptic drugs are available for the treatment of seizures, including valproate, lamotrigine, phenytoin, carbamazepine, topiramate, levetiracetam, and phenobarbital 2
- The efficacy of these drugs varies, with lamotrigine showing the highest probability of presenting the outcome "Seizure free" (61%) in the treatment of generalized tonic-clonic, tonic, and clonic seizures 2
- Levetiracetam has been proposed as a potential substitute for phenytoin in the treatment of established status epilepticus, with some studies suggesting it may be more effective and associated with a lower incidence of serious adverse events 3
Comparison of Antiepileptic Drugs
- A systematic review and network meta-analyses compared the relative efficacy of antiepileptic drugs in the monotherapy treatment of generalized epileptic seizures, finding that lamotrigine, levetiracetam, and topiramate are as effective as valproate for treating generalized tonic-clonic, tonic, and clonic seizures 2
- Another study compared the efficacy of phenytoin, valproate, and levetiracetam as second-line treatment of status epilepticus, finding that levetiracetam failed more often than valproate to control seizures 4
- A review of levetiracetam as a first-line treatment in status epilepticus in adult patients found that existing data lay a substantial foundation for further investigation of levetiracetam as a primary therapy in acute status epilepticus 5
Status Epilepticus Treatment
- Status epilepticus is a critical neurological illness that requires prompt treatment, with benzodiazepines being the first-line treatment and phenytoin or levetiracetam being used as second-line treatment 4, 3
- A systematic review and meta-analysis compared the efficacy and safety of levetiracetam and phenytoin in the treatment of established status epilepticus, finding that levetiracetam may be more effective and associated with a lower incidence of serious adverse events 3
Epilepsy Treatment
- A systematic review of epilepsy treatment found that about 70% of people with epilepsy eventually go into remission, and that antiepileptic drugs can be effective in controlling seizures 6
- The review also found that the risk of relapse in people in remission when withdrawing antiepileptic drugs is a concern, and that surgery may be an effective treatment option for people with drug-resistant temporal lobe epilepsy 6