Initial Treatment for Seizures
The initial treatment for seizures should be levetiracetam at a starting dose of 500 mg twice daily, which can be titrated up to 1000-3000 mg/day in divided doses based on clinical response. 1
First-Line Management
Immediate Stabilization
- For active seizures:
- Help the person to the ground and place them on their side (recovery position)
- Clear the area around them to prevent injury
- Activate emergency medical services for seizures lasting >5 minutes or if multiple seizures occur without return to baseline 1
Medication Therapy
First-line medication: Levetiracetam
For status epilepticus (prolonged or repeated seizures without recovery):
Addressing Underlying Causes
It's crucial to identify and treat any precipitating factors:
- For provoked seizures: Emergency physicians should identify and treat the underlying medical conditions rather than initiating antiepileptic medication in the ED 3
- Common causes to investigate include:
- Electrolyte imbalances
- Hypoglycemia
- Medication toxicity
- Alcohol withdrawal
- Infection
- Structural brain lesions 4
Special Considerations
Unprovoked First Seizures
- For patients with a first unprovoked seizure without evidence of brain disease or injury, emergency physicians need not initiate antiepileptic medication in the ED 3
- For patients with a first unprovoked seizure with remote history of brain disease or injury, emergency physicians may initiate antiepileptic medication in the ED or defer in coordination with other providers 3
Prophylactic Anticonvulsants
- The American Academy of Neurology recommends that prophylactic anticonvulsants be administered only to patients at risk for seizure 3
- For patients with no history of seizures who are not undergoing surgery, antiepilepsy medication may be omitted 3
Cerebral Edema Management
- For patients with perilesional vasogenic edema (common with brain metastases), oral glucocorticoid steroids are recommended 3
- Starting dosages between 4 and 8 mg/day of dexamethasone are recommended by the European Federation of Neurological Sciences 3
Monitoring and Follow-up
- Regular EEG monitoring is recommended to assess treatment response, with a baseline EEG at diagnosis and follow-up EEG every 3-6 months 1
- Monitor for adverse effects of levetiracetam, which may include irritability, mood changes, and somnolence 1
- For patients with renal impairment, levetiracetam dosing must be individualized according to creatinine clearance 2
Treatment Considerations for Specific Seizure Types
For Partial Onset Seizures
- Levetiracetam is indicated as adjunctive treatment in adults and children 4 years and older 2
- Valproic acid is indicated as monotherapy and adjunctive therapy in complex partial seizures in adults and children 10 years and older 5
For Myoclonic Seizures
- Levetiracetam is indicated as adjunctive therapy in adults and adolescents 12 years and older with juvenile myoclonic epilepsy 2
- Initial dose: 1000 mg/day (500 mg BID), increased by 1000 mg/day every 2 weeks to 3000 mg/day 2
For Primary Generalized Tonic-Clonic Seizures
- Levetiracetam is indicated as adjunctive therapy in adults and children 6 years and older 2
- Valproic acid is effective for simple and complex absence seizures 5
Important Caveats
- Approximately one-third to one-half of patients with a first unprovoked seizure will have a recurrent seizure within 5 years 3
- For patients with a single unprovoked seizure, waiting until a second seizure before initiating long-term antiepileptic medication is considered appropriate 3
- The natural history of untreated cerebral metastases is dismal, with median survival reported as less than 2 months, so aggressive management of seizures in these patients is essential 3
- Non-enzyme-inducing agents (like levetiracetam) should be used whenever possible to avoid impacting metabolism of chemotherapy and steroids in patients with brain tumors 3