From the Guidelines
The first-line treatment for seizure management is administering a benzodiazepine, specifically lorazepam, diazepam, or midazolam, as soon as possible once a seizure has lasted more than 5 minutes or if multiple seizures occur without recovery between them. This recommendation is based on the most recent and highest quality study available, which emphasizes the importance of prompt treatment with benzodiazepines to prevent prolonged seizures and potential neuronal damage 1. The study highlights that benzodiazepines should be administered as first-line treatment, with second-line agents such as phenytoin, levetiracetam, and valproic acid considered if the seizure continues after initial treatment.
Key Considerations in Seizure Management
- Administering benzodiazepines as soon as possible to prevent prolonged seizures and potential neuronal damage
- Maintaining the patient's airway, providing oxygen if needed, and positioning them on their side to prevent aspiration
- Monitoring vital signs and being prepared to administer second-line agents if the seizure continues
- Considering the potential impact of prescribed and illicit substance use on seizure threshold and management
Second-Line Treatment Options
- Phenytoin (20 mg PE/kg IV)
- Levetiracetam (60 mg/kg IV up to 4500 mg)
- Valproic acid (40 mg/kg IV) These options should be considered if the seizure continues after initial treatment with benzodiazepines, as emphasized in the study 1. The study also notes that noncompliance with antiseizure drug therapy and substance use can complicate seizure management, highlighting the need for careful consideration of these factors in treatment decisions.
From the Research
Seizure Management
The first-line treatment for seizure management depends on the type of epilepsy.
- For focal epilepsy, oxcarbazepine and lamotrigine are considered first-line therapy, while levetiracetam can also be considered if there is no history of psychiatric disorder 2.
- For generalized epilepsy, the selection of the antiseizure drug (ASD) is based on the type of epilepsy syndrome and the patient's sex, age, and psychiatric history 2. Some studies suggest that levetiracetam may be a suitable alternative to carbamazepine and lamotrigine for individuals with partial onset seizures, and sodium valproate may be the first-line treatment for individuals with generalized tonic-clonic seizures 3.
Antiseizure Medications
There are 26 US Food and Drug Administration-approved medications for epilepsy, of which 24 have similar antiseizure efficacy for focal epilepsy and 9 have similar efficacy for generalized epilepsy 2.
- The decision to initiate an ASD should be individualized, but should be strongly considered after 2 unprovoked seizures or after 1 unprovoked seizure that occurred during sleep and/or in the presence of epileptiform activity on an electroencephalogram and/or in the presence of a structural lesion on the brain magnetic resonance imaging 2.
- ASDs with cytochrome P450 enzyme-inducing properties (e.g., carbamazepine, phenytoin) may worsen comorbid coronary and cerebrovascular disease by causing hyperlipidemia and accelerating the metabolism of concomitant drugs used for their treatment 2.
Treatment Outcomes
Seizure freedom is achieved in approximately 60% to 70% of all patients 2.
- A total of 25% to 50% of patients also experience neurologic, psychiatric, cognitive, or medical disorders, such as mood, anxiety, and attention deficit disorders and migraines 2.
- The most commonly reported adverse events across all drugs were drowsiness/fatigue, headache or migraine, gastrointestinal disturbances, dizziness/faintness, and rash or skin disorders 3.