From the Guidelines
Alcoholic seizures do not typically require long-term antiepileptic medication, and benzodiazepines are the preferred treatment for acute alcohol withdrawal seizures. For acute alcohol withdrawal seizures, benzodiazepines like diazepam (5-10mg IV) or lorazepam (2-4mg IV) are the first-line treatment rather than traditional antiepileptic drugs, as they enhance GABA activity in the brain, helping to control the hyperexcitability caused by alcohol withdrawal 1. Short-term benzodiazepine treatment following a tapering schedule over 3-7 days is usually sufficient to prevent further seizures during the withdrawal period.
Key Considerations
- The most recent and highest quality study, published in 2018, supports the use of benzodiazepines as the primary treatment for alcohol withdrawal syndrome, including seizures 1.
- Anticonvulsants should not be used following an alcohol withdrawal seizure for the prevention of further alcohol withdrawal seizures, according to the 2011 WHO guidelines 1.
- If seizures persist beyond the acute withdrawal phase (typically 48-72 hours after the last drink), or if there is evidence of underlying epilepsy unrelated to alcohol use, then traditional antiepileptic drugs like levetiracetam or valproate may be considered.
- Adequate hydration, electrolyte replacement, and thiamine supplementation (100mg IV or IM followed by oral doses) are essential components of management to prevent complications like Wernicke's encephalopathy.
- The most effective long-term treatment for preventing alcohol withdrawal seizures is alcohol abstinence, supported by appropriate addiction treatment programs.
Treatment Approach
- Benzodiazepines are considered the 'gold standard' treatment for alcohol withdrawal syndrome, given their efficacy for reducing both withdrawal symptoms and the risk of seizures and/or delirium tremens 1.
- Long-acting benzodiazepines (e.g. diazepam, chlordiazepoxide) provide more protection against seizures and delirium, but short and intermediate-acting benzodiazepines (e.g. lorazepam, oxazepam) are safer in elderly patients and those with hepatic dysfunction.
From the Research
Alcoholic Seizures and Antiepileptic Medications
- Alcoholic seizures are a common medical emergency that can occur after cessation of alcohol use 2
- The primary goal of treatment is to terminate and prevent further seizures, with benzodiazepines being the first-line treatment for alcohol-withdrawal seizures 2
Role of Benzodiazepines
- Benzodiazepines, such as lorazepam and diazepam, are commonly used to treat alcohol-withdrawal seizures due to their ability to act on the GABAA receptor and promote a state of central nervous system depression 3
- Benzodiazepines are also used as anticonvulsants in the treatment of epilepsy, with clobazam and clonazepam being good options for seizure prophylaxis in patients with epilepsy refractory to multiple antiepileptic drugs 3
Antiepileptic Medications for Alcoholic Seizures
- There is no evidence to support the routine use of antiepileptic medications, such as phenytoin, for seizure prophylaxis in alcohol withdrawal 4
- However, antiepileptic medications may be valuable in patients at high risk for seizures, such as those with a history of skid-row alcoholism 4
- The selection of antiepileptic medications should be individualized and based on the type of seizures, epilepsy syndrome, and adverse effects associated with the drug 5
Treatment Considerations
- The treatment of alcoholic seizures should focus on terminating and preventing further seizures, rather than solely on the use of antiepileptic medications 2
- Benzodiazepines, such as lorazepam and diazepam, are effective in treating alcohol-withdrawal seizures and should be considered as first-line treatment 2, 3