What is the management of focal seizures?

From the Guidelines

The management of focal seizures should prioritize pharmacotherapy with antiepileptic drugs (AEDs) as the initial treatment of choice, with consideration of surgery for drug-resistant cases, as supported by the most recent guidelines 1. The goal of treatment is to achieve complete seizure freedom with minimal side effects, as even a single seizure can significantly impact quality of life and increase risk of injury. Some key points to consider in the management of focal seizures include:

• First-line treatment typically includes AEDs such as carbamazepine, lamotrigine, levetiracetam, or oxcarbazepine, with treatment starting with a single AED at a low dose and gradually increasing until seizure control is achieved or side effects become problematic 1.
• If the first medication fails, either switching to an alternative monotherapy or adding a second AED may be considered, with combinations of AEDs with different mechanisms of action often being more effective for drug-resistant focal epilepsy 1.
• Patients should maintain regular sleep patterns, avoid alcohol, take medications consistently, and identify personal seizure triggers to help manage their condition.
• Surgery may be considered for medication-resistant focal seizures, particularly when a well-defined seizure focus can be identified, with approximately 65% of patients becoming seizure-free 1.
• Other options include vagus nerve stimulation, responsive neurostimulation, or deep brain stimulation, and regular follow-up with a neurologist is essential to monitor treatment efficacy and manage potential side effects. Key considerations in the management of focal seizures also include the use of molecular neuroimaging with interictal [18 F]fluorodeoxyglucose ([18 F] FDG) positron emission tomography (PET), ictal perfusion SPECT, or ictal subtraction perfusion SPECT (interictal SPECT fused, normalized, and subtracted from ictal SPECT) to localize the seizure onset for a tailored resection preserving motor, visual, language, or temporal lobe functions 1.

From the FDA Drug Label

Levetiracetam is indicated as adjunctive treatment of partial onset seizures in adults and children 4 years of age and older with epilepsy. Partial Onset Seizures Adults 16 Years And Older In clinical trials, daily doses of 1000 mg, 2000 mg, and 3000 mg, given as twice-daily dosing, were shown to be effective Treatment should be initiated with a daily dose of 1000 mg/day, given as twice-daily dosing (500 mg BID) Additional dosing increments may be given (1000 mg/day additional every 2 weeks) to a maximum recommended daily dose of 3000 mg. Pediatric Patients Ages 4 To <16 Years Treatment should be initiated with a daily dose of 20 mg/kg in 2 divided doses (10 mg/kg BID).

The management of focal seizures (also known as partial onset seizures) involves:

• Initiating treatment with levetiracetam at a daily dose of 1000 mg/day for adults, given as twice-daily dosing (500 mg BID)
• Initiating treatment with levetiracetam at a daily dose of 20 mg/kg for pediatric patients ages 4 to <16 years, given in 2 divided doses (10 mg/kg BID)
• Increasing the dose every 2 weeks by increments of 1000 mg/day for adults or 20 mg/kg for pediatric patients, to a maximum recommended daily dose of 3000 mg for adults or 60 mg/kg for pediatric patients 2

From the Research

Management of Focal Seizures

The management of focal seizures typically involves the use of antiepileptic drugs (AEDs) as the primary treatment option.

• The choice of AED depends on various factors, including the patient's age, medical history, and the presence of any concomitant diseases or medications 3.
• Monotherapy is often the initial treatment strategy, with the goal of achieving seizure control with a single medication 4.
• If monotherapy is ineffective, alternative monotherapy trials or combination therapy with multiple AEDs may be considered 4.

Antiepileptic Drug Options

Several AEDs are available for the treatment of focal seizures, including:

• Older AEDs such as carbamazepine, phenytoin, and valproic acid (sodium valproate) 3
• Newer AEDs such as lamotrigine, gabapentin, topiramate, oxcarbazepine, levetiracetam, zonisamide, and lacosamide 5, 3, 6
• The choice of AED depends on its efficacy, tolerability, and potential interactions with other medications 5, 3

Efficacy and Safety of AEDs

• A network meta-analysis of individual participant data found that lamotrigine and levetiracetam were among the most effective AEDs for treating focal seizures, with a lower risk of treatment failure and adverse events compared to other AEDs 5
• Lacosamide, a newer AED, has been shown to be effective as an adjuvant treatment for focal-onset seizures, with a favorable safety profile and minimal drug interactions 6
• The efficacy and safety of AEDs can vary depending on the individual patient and the specific seizure type, highlighting the need for personalized treatment approaches 5, 4, 3

Treatment Strategies

• Monotherapy is often the initial treatment strategy, with the goal of achieving seizure control with a single medication 4
• If monotherapy is ineffective, alternative monotherapy trials or combination therapy with multiple AEDs may be considered 4
• In patients who fail to respond to multiple AEDs, non-pharmacological treatment options such as epilepsy surgery may be considered 4