What is the treatment for seizures?

Treatment for Seizures

For seizures refractory to benzodiazepines, fosphenytoin, levetiracetam, or valproate should be administered promptly as second-line agents with similar efficacy. 1

Initial Seizure Management

Acute Seizure Treatment

1. First-line treatment: Benzodiazepines (e.g., lorazepam IV) for active seizures that are not self-limiting 2
2. Second-line options (if seizures continue despite optimal benzodiazepine dosing):
   • Levetiracetam: 30-50 mg/kg IV (44-73% success rate, minimal adverse effects) 1
   • Valproate: 20-30 mg/kg IV (88% success rate) 1
   • Fosphenytoin: 18-20 mg/kg IV (56% success rate) 1

Management Based on Seizure Type

Provoked Seizures

• Do not initiate antiepileptic medication in the ED for patients with provoked seizures 2
• Identify and treat the precipitating medical conditions (e.g., metabolic abnormalities, infections, toxins) 2, 3
• Common causes include organ failure, electrolyte imbalance, medication toxicity, and withdrawal 3

First Unprovoked Seizure

• Do not initiate antiepileptic medication in the ED for patients with a first unprovoked seizure without evidence of brain disease or injury 2
• For patients with a first unprovoked seizure with remote history of brain disease/injury:
  • Emergency physicians may initiate antiepileptic medication or defer in coordination with other providers 2
  • Consider risk factors for recurrence: brain insult history, epileptiform EEG abnormalities, structural lesions on imaging 4

Recurrent Unprovoked Seizures (Epilepsy)

• Initiate antiepileptic medication for patients with established epilepsy (≥2 unprovoked seizures) 4
• Medication selection based on:
  1. Seizure type
  2. Patient comorbidities
  3. Side effect profile
  4. Dosing schedule
  5. Cost

Medication Selection by Seizure Type

Partial Onset Seizures

• First-line options:
  • Levetiracetam: Starting dose 1000 mg/day (500 mg BID), can increase by 1000 mg/day every 2 weeks to maximum 3000 mg/day 5
  • Valproate: Effective for partial seizures as monotherapy or adjunctive therapy 6
  • Topiramate: Effective as adjunctive therapy, typically titrated from 25-50 mg/day to target dose 7

Generalized Seizures

• First-line options:
  • Valproate: Particularly effective for absence seizures and multiple seizure types 6, 4
  • Lamotrigine and topiramate: Also effective for generalized seizures 4

Pediatric Considerations

• Levetiracetam for children ≥4 years: Start at 20 mg/kg/day in 2 divided doses, increase by 20 mg/kg every 2 weeks to recommended dose of 60 mg/kg/day 5
• Topiramate for children ≥2 years: Dosing based on weight, typically titrated to approximately 6 mg/kg/day 7

Monitoring and Follow-up

Immediate Monitoring

• Monitor vital signs, airway patency, and neurological status during and after seizure treatment 1
• Watch for tardive seizures (late seizures occurring after the initial event) for at least 24 hours 2
• Obtain neurology consultation if recurrent or prolonged seizures occur 2

Long-term Management

• Schedule follow-up within 1-2 weeks after a breakthrough seizure 1
• Have patients maintain a seizure diary to track frequency, duration, and medication adherence 1
• Consider MRI with 3D volumetric sequencing for neuroimaging in patients with seizures 1

Important Considerations and Pitfalls

Medication Safety

• Avoid prophylactic use of anticonvulsants in patients with ischemic stroke - may have negative effects on neurological recovery 2
• Valproic acid is contraindicated in females who may become pregnant 1
• Monitor for adverse effects:
  • Valproate: GI disturbances, somnolence, tremor, rare hepatotoxicity 1
  • Phenytoin/Fosphenytoin: Hypotension, cardiac dysrhythmias, purple glove syndrome 1
  • Levetiracetam: Minimal adverse effects, making it favorable in many situations 1

Common Pitfalls

1. Medication non-compliance: Up to 58.5% of patients with known seizure disorders are immediately non-compliant with medications 8
2. Misdiagnosis: Many conditions mimic seizures (pseudoseizures, syncope, migraine, movement disorders) 4
3. Inadequate follow-up: Failure to refer patients with refractory epilepsy (failed ≥2 appropriate medications) to epilepsy centers for additional treatment options 4
4. Inappropriate long-term treatment: Treating provoked seizures with long-term antiepileptic medications when not indicated 3

Special Populations

• Pregnant women: Avoid valproate; levetiracetam may be preferred 1
• Elderly: Start at lower doses and titrate more slowly due to altered pharmacokinetics
• Hepatic/renal impairment: No dosage adjustments needed for acute administration, but caution with frequent dosing 1

Remember that approximately 10% of the population will experience a seizure during their lifetime, but only 2-3% develop epilepsy requiring long-term treatment 4, 9. Proper diagnosis and treatment selection are essential to avoid unnecessary medication exposure while ensuring adequate seizure control.