What are the treatment options for epilepsy?

Treatment Options for Epilepsy

Anti-epileptic drugs (AEDs) are the frontline therapy for epilepsy, with surgical options and vagus nerve stimulation available for refractory cases that don't respond to medication. 1

First-Line Treatment: Anti-Epileptic Drugs (AEDs)

• Monotherapy with a standard anti-epileptic drug should be the initial approach for treating convulsive epilepsy 1
• Approximately 47% of patients achieve complete seizure control with the first AED attempted, and an additional 14% with the second or third AED 1, 2
• Standard first-line AEDs include:
  • Carbamazepine (preferred for partial onset seizures) 1
  • Phenobarbital 1
  • Phenytoin 1
  • Valproic acid 1
• For women with epilepsy, valproic acid should be avoided if possible due to teratogenic risks 1

Treatment Algorithm for New-Onset Epilepsy

1. Start with monotherapy using a single AED appropriate for the seizure type 1, 3
2. Titrate to optimal dose - if seizures continue, increase to maximum tolerated dose before considering alternatives 3
3. If first AED fails, try a second AED monotherapy 2
4. If second AED fails, consider:
   • A third monotherapy trial 2
   • Rational polytherapy (combination of two AEDs) 3, 4
5. If medication-resistant (failure of two or more appropriate AEDs), evaluate for surgical options or neurostimulation 1

Management of Status Epilepticus

• First-line: Intravenous benzodiazepines (lorazepam preferred over diazepam if available) 1
• Second-line (for refractory status epilepticus): Additional antiepileptic medication should be administered (Level A recommendation) 1
  • Intravenous phenytoin, fosphenytoin, or valproate (Level B recommendation) 1
  • Intravenous levetiracetam, propofol, or barbiturates may be considered (Level C recommendation) 1
• While treating status epilepticus, simultaneously search for and address underlying causes (hypoglycemia, hyponatremia, infection, etc.) 1

Treatment of Refractory Epilepsy

• Refractory epilepsy affects 20-40% of newly diagnosed patients and is defined as failure to control seizures despite trying two or more appropriate AEDs 1, 5
• Options for refractory epilepsy include:

1. Surgical Resection

• Highly effective for suitable candidates - approximately 52% remain seizure-free 5 years post-surgery 1
• Not all patients are candidates due to:
  • Location of seizure focus in critical brain regions
  • Multiple seizure foci
  • Medical contraindications to surgery 1

2. Vagus Nerve Stimulation (VNS)

• FDA-approved in 1997 as adjunctive therapy for refractory epilepsy 1
• Involves implanting helical cuff electrodes on the left cervical vagal trunk connected to an implanted pulse generator 1
• Approximately 51% of patients experience ≥50% reduction in seizure frequency with VNS 1
• Both used for seizure prevention and acute seizure termination 1

3. Rational Polytherapy

• Combinations showing synergistic effects include:
  • Lamotrigine + valproate
  • Levetiracetam + valproate
  • Topiramate + carbamazepine 4
• Avoid combinations with known antagonistic effects:
  • Lamotrigine + carbamazepine
  • Lamotrigine + oxcarbazepine 4

Special Considerations

• For pregnant women: Use AED monotherapy at minimum effective dose; avoid valproate; take folic acid supplementation; standard breastfeeding recommendations apply for standard AEDs 1
• For patients with intellectual disability: The same range of investigations and treatments should be available; when possible, consider valproic acid or carbamazepine instead of phenytoin or phenobarbital due to lower risk of behavioral adverse effects 1
• For febrile seizures: Simple febrile seizures generally don't require long-term AED treatment; complex febrile seizures may benefit from prophylactic intermittent diazepam during febrile illness 1

Treatment Discontinuation

• Consider discontinuation of AED treatment after 2 seizure-free years 1
• Decision should involve the patient and family, considering clinical, social, and personal factors 1
• Approximately 70% of patients with epilepsy can achieve seizure freedom with optimum AED therapy 3

Patient Education and Support

• Provide information on avoiding high-risk activities and first aid measures 1
• Consider adjunctive psychological treatments such as:
  • Relaxation therapy
  • Cognitive behavioral therapy
  • Psychoeducational programs
  • Family counseling 1