Is there a role for using Keppra (levetiracetam) in treating psychogenic non-epileptic seizures (PNES)?

From the Guidelines

Levetiracetam (Keppra) is not recommended for treating psychogenic non-epileptic seizures (PNES). PNES are not caused by abnormal electrical activity in the brain like epileptic seizures, but rather have psychological origins, making anti-seizure medications ineffective for this condition 1. The primary treatments for PNES include psychotherapy, particularly cognitive behavioral therapy (CBT), and other psychological interventions that address underlying psychological factors such as trauma, anxiety, or emotional distress.

Some key points to consider when treating PNES include:

• The importance of accurate diagnosis, which can be challenging due to the potential coexistence of true seizure disorders and PNES in some patients 1
• The need for psychological interventions to address the underlying causes of PNES, rather than relying solely on medication
• The potential risks of using anti-seizure medications like Keppra for PNES, including exposure to unnecessary side effects and reinforcement of the patient's belief that they have a neurological rather than psychological condition

Using Keppra for PNES may expose patients to unnecessary medication side effects (including irritability, mood changes, fatigue, and dizziness) without providing therapeutic benefit. Additionally, prescribing anti-seizure medications for PNES may delay appropriate treatment, as seen in studies where accurate diagnosis and psychiatric treatment led to resolution of PNES in 72% of patients on follow-up 1. The diagnostic distinction between epilepsy and PNES is crucial, typically requiring video-EEG monitoring to confirm the absence of epileptiform activity during events. Once PNES is diagnosed, treatment should focus on psychological approaches rather than anti-seizure medications like Keppra.

From the Research

Role of Keppra in Treating Psychogenic Non-Epileptic Seizures (PNES)

• There is limited research on the use of Keppra (levetiracetam) in treating PNES, as most studies focus on its efficacy in epilepsy.
• A study published in 2018 2 found that levetiracetam can induce PNES in susceptible populations, and that withdrawal of the medication can lead to subsidence of PNES.
• This suggests that Keppra may not be an effective treatment for PNES, and may even exacerbate the condition in some cases.
• Another study published in 2021 3 found that cognitive behavioral therapy (CBT) is a effective treatment for PNES, and that medication such as Keppra is not typically used to treat this condition.
• The use of Keppra in PNES is not supported by the available evidence, and more research is needed to fully understand its potential role in treating this condition.

Comparison with Other Treatments

• A study published in 2021 4 compared the efficacy of levetiracetam with other antiepileptic medications, such as lamotrigine and valproate, in treating epilepsy.
• The study found that levetiracetam was not as effective as these other medications in controlling seizures, and was associated with a higher risk of treatment failure.
• This suggests that Keppra may not be the best choice for treating epilepsy, and that other medications may be more effective.
• However, it is worth noting that the study did not specifically look at the use of Keppra in PNES, and more research is needed to fully understand its potential role in treating this condition.

Mechanism of Action

• Keppra has a unique mechanism of action that involves binding to synaptic vesicle protein 2A, which is thought to be involved in modulating synaptic neurotransmitter release 5, 6.
• This mechanism of action is different from that of other antiepileptic medications, and may contribute to its potential efficacy in treating certain types of seizures.
• However, the exact mechanism by which Keppra may induce PNES is not fully understood, and more research is needed to clarify this.