From the Guidelines
The best treatment approach for patients with focal seizures typically begins with antiepileptic drug (AED) monotherapy, with first-line medications including levetiracetam, lamotrigine, carbamazepine, or oxcarbazepine, as supported by recent guidelines 1.
Treatment Approach
The initial treatment should start with a low dose and gradually increase to minimize side effects while achieving seizure control.
- First-line medications include:
- Levetiracetam (500-1500 mg twice daily)
- Lamotrigine (25-200 mg twice daily)
- Carbamazepine (200-400 mg twice or three times daily)
- Oxcarbazepine (300-600 mg twice daily) If the first medication fails due to ineffectiveness or intolerable side effects, switching to an alternative monotherapy is recommended before considering combination therapy.
Drug-Resistant Focal Epilepsy
For drug-resistant focal epilepsy (defined as failure of two appropriate AEDs), options include:
- Adding a second or third medication
- Considering surgical evaluation
- Exploring neuromodulation therapies such as vagus nerve stimulation or responsive neurostimulation Medication selection should be individualized based on seizure type, potential side effects, comorbidities, drug interactions, and patient factors like age, gender, and pregnancy potential, as emphasized in the European Association of Nuclear Medicine (EANM) guidelines 1.
Lifestyle Modifications and Follow-Up
Regular follow-up is essential to monitor seizure frequency, medication adherence, side effects, and drug levels when applicable.
- Patients should maintain a seizure diary
- Be counseled on lifestyle modifications including:
- Adequate sleep
- Stress management
- Alcohol limitation These factors can trigger seizures in susceptible individuals, highlighting the importance of a comprehensive treatment approach that considers both pharmacological and non-pharmacological interventions, as discussed in the context of epilepsy management 1.
From the FDA Drug Label
The effectiveness of topiramate as an adjunctive treatment for adults with partial onset seizures was established in six multicenter, randomized, double-blind, placebo-controlled trials, two comparing several dosages of topiramate and placebo and four comparing a single dosage with placebo, in patients with a history of partial onset seizures, with or without secondarily generalized seizures. The effectiveness of lacosamide as adjunctive therapy in partial-onset seizures was established in three 12-week, randomized, double-blind, placebo-controlled, multicenter trials in adult patients.
Treatment Approach for Focal Seizures:
- Topiramate: can be used as an adjunctive treatment for adults with partial onset seizures, with a recommended dosage of 400 mg/day 2.
- Lacosamide: can be used as adjunctive therapy for partial-onset seizures, with statistically significant effects observed at doses of 200 mg/day, 400 mg/day, and 600 mg/day 3. Key Considerations:
- Patients should be stabilized on optimum dosages of their concomitant antiepileptic drugs (AEDs) during the baseline phase.
- The dosage of topiramate or lacosamide should be titrated according to the patient's response and tolerance.
- Patients should be monitored for adverse reactions and seizure frequency during the maintenance phase.
From the Research
Treatment Approaches for Focal Seizures
The treatment of focal seizures typically involves the use of antiepileptic drugs (AEDs). Several studies have compared the efficacy and tolerability of different AEDs in patients with focal epilepsy.
- First-line treatments: Carbamazepine, phenytoin, and valproic acid (sodium valproate) are often considered first-line treatments for focal seizures 4. However, newer AEDs such as lamotrigine, gabapentin, topiramate, and oxcarbazepine have also been shown to be effective and may have better tolerability profiles 4, 5.
- Newer AEDs: Levetiracetam, lacosamide, and zonisamide are newer AEDs that have been studied as potential treatments for focal seizures. A study found that lacosamide was non-inferior to levetiracetam in terms of efficacy and tolerability 6.
- Comparative efficacy: A network meta-analysis found that lamotrigine, levetiracetam, and carbamazepine were among the most effective AEDs for treating focal seizures, with high-certainty evidence supporting their use as first-line treatments 7.
- Tolerability: Lamotrigine has been shown to have a favorable tolerability profile, with a low risk of adverse reactions and a high probability of being the best AED for tolerability outcomes 5.
Key Findings
- Levetiracetam did not meet the criteria for non-inferiority compared to lamotrigine in a study of patients with focal epilepsy 8.
- Lacosamide was found to be non-inferior to levetiracetam in a study of patients with new-onset focal epilepsy 6.
- A network meta-analysis found that lamotrigine, levetiracetam, and carbamazepine were among the most effective AEDs for treating focal seizures 7.
- Lamotrigine has a favorable tolerability profile and may be the best option for the treatment of focal epilepsy in children and adults 5.