What are the management guidelines for epilepsy?

Management Guidelines for Epilepsy

The management of epilepsy should follow a structured approach beginning with monotherapy using standard antiepileptic drugs (AEDs) selected based on seizure type, with the primary goal of achieving complete seizure freedom while minimizing adverse effects. 1

Initial Diagnosis and Assessment

• Classify the specific type of seizures and epilepsy syndrome through:

  • Detailed seizure description
  • EEG findings
  • Neuroimaging (MRI of brain is standard for structural causes) 2
  • Consider MR spectroscopy and PET when available for additional diagnostic information 2

• For first-time seizures:

  • Antiepileptic drugs should not be routinely prescribed after a first unprovoked seizure 1
  • Consider treatment after 2 unprovoked seizures or after 1 unprovoked seizure with risk factors (seizure during sleep, epileptiform activity on EEG, or structural brain lesion) 3

Medication Selection and Management

First-line Treatment Approach

• Begin with monotherapy at the lowest effective dose and titrate gradually 1
• Drug selection should be based on:
  • Seizure type and epilepsy syndrome
  • Patient characteristics (age, sex, comorbidities)
  • Potential adverse effects
  • Drug interaction profile 3

Recommended First-line Medications by Seizure Type

• Focal epilepsy:

  • Oxcarbazepine or lamotrigine as first-line options
  • Levetiracetam (if no psychiatric history) 3
  • Carbamazepine (starting at 200 mg twice daily for adults, 100 mg twice daily for children 6-12 years) 4

• Generalized epilepsy:

  • Valproate (up to 30 mg/kg IV at maximum rate of 10 mg/kg/min) 2, 1
  • Important: Valproate should be avoided in women of childbearing potential due to significant teratogenic risk 1, 5

Medication Titration and Monitoring

• Titrate medication gradually to minimize side effects 1

• Monitor blood levels to increase efficacy and safety 4

• For carbamazepine:

  • Adults: Initial 200 mg twice daily, increase weekly by 200 mg/day
  • Children 6-12 years: Initial 100 mg twice daily, increase weekly by 100 mg/day
  • Maximum doses: 1000 mg/day (children 12-15 years), 1200 mg/day (>15 years) 4

• Perform liver function tests prior to therapy and at frequent intervals, especially during first six months for valproate 5

Management of Refractory Epilepsy

• If the first drug fails due to inefficacy, switch to an alternative monotherapy from a different drug class 1

• Consider a patient refractory to treatment when two appropriately chosen, well-tolerated first-line AEDs have failed 6

• For refractory status epilepticus (failed benzodiazepine treatment):

  • Administer IV phenytoin, fosphenytoin, or valproate 2
  • Alternative options include IV levetiracetam, propofol, or barbiturates 2

• Consider "rational polytherapy" with carefully selected drug combinations for patients not responding to monotherapy 6

• Up to 70% of people with epilepsy can achieve seizure freedom with optimum AED therapy 7

Surgical Considerations

• For epilepsy associated with dysembryoplastic neuroepithelial tumors (DNETs):
  • Early surgical removal is recommended to achieve seizure freedom and prevent tumor progression 2
  • Extended lesionectomy (excision of the lesion and abnormal dysplastic cortex) is preferred 2
  • Consider surgical options early when multiple appropriate AEDs have not established control 2

Seizure Management in Special Situations

Status Epilepticus

• Status epilepticus is defined as unremitting convulsive seizure activity lasting 20 minutes or more, or intermittent seizures without regaining consciousness 2
• Emergency physicians should administer additional antiepileptic medication in patients with refractory status epilepticus who have failed treatment with benzodiazepines 2

Intracerebral Hemorrhage with Seizures

• Clinical seizures occur in up to 16% of patients within 1 week after intracerebral hemorrhage, with cortical involvement being the most important risk factor 2
• Prophylactic antiseizure drugs have not been demonstrated to be beneficial and may be associated with increased death and disability 2
• Treat clinical seizures or electrographic seizures in patients with altered mental status 2

Long-term Management and Follow-up

• Regular follow-up appointments to assess:

  • Seizure frequency and characteristics
  • Medication efficacy and side effects
  • Quality of life impact
  • Need for medication adjustments 1

• Consider discontinuation of antiepileptic drugs after 2 seizure-free years, taking into account clinical, social, and personal factors 1

• Avoid abrupt discontinuation which can precipitate withdrawal seizures or status epilepticus 1

Patient Education and Support

• Provide comprehensive education on:

  • Seizure management techniques
  • Medication adherence importance
  • Safety precautions for daily activities 1
  • Avoiding high-risk activities (swimming only with supervision, showering rather than bathing, cooking safety precautions) 1

• Emergency services should be called for:

  • Seizures lasting >5 minutes
  • Multiple seizures without return to baseline
  • Breathing difficulties after seizure
  • Injury during seizure
  • First-time seizure
  • Seizure occurring in water 1

Common Pitfalls to Avoid

• Failing to recognize status epilepticus (seizures lasting >5 minutes or multiple seizures without return to baseline) 1
• Restraining a person during a seizure or putting objects in their mouth 1
• Using valproate in women of childbearing potential without thorough discussion of risks 5
• Discontinuing antiepileptic drugs abruptly in patients with major seizures 5
• Failing to monitor liver function tests with certain AEDs, particularly valproate 5