What is the best course of action for a 63-year-old male with a history of tonic-clonic seizures, hypertension, vitamin D deficiency, and prediabetes, who stopped taking Keppra (levetiracetam) 4 months ago and is now experiencing intermittent episodes of anxiety and numbness on the left side of his face?

Immediate Management: Restart Levetiracetam and Urgent Neurological Evaluation

This patient requires immediate reinitiation of levetiracetam and urgent neurological assessment, as his recurrent facial numbness episodes are highly concerning for focal seizures that have emerged after premature discontinuation of antiepileptic therapy.

Critical Clinical Context

This patient stopped levetiracetam only 4 months into a recommended 1-year seizure-free period and is now experiencing stereotyped episodes of facial numbness with anxiety occurring 3 times weekly—a pattern highly suggestive of focal seizures with preserved awareness (previously called simple partial seizures). The motor vehicle collision further raises concern for structural brain injury that could lower seizure threshold.

Immediate Actions Required

Restart Antiepileptic Therapy Now

• Reinitiate levetiracetam immediately at his prior effective dose (typically 500-1500 mg twice daily for maintenance therapy) 1, 2
• Levetiracetam should not be abruptly discontinued, as withdrawal increases seizure risk—this patient has already demonstrated breakthrough seizure activity after premature cessation 1
• The recurrent facial numbness episodes represent likely focal seizures that require immediate treatment to prevent progression to generalized tonic-clonic seizures 3, 4

Neurological Evaluation Priority

Head CT is the highest priority imaging study given:

• Recent motor vehicle collision with no prior evaluation
• New-onset focal neurological symptoms (unilateral facial numbness)
• History of tonic-clonic seizures now with suspected focal seizure activity
• Need to rule out structural lesions (subdural hematoma, contusion, mass) that could explain seizure recurrence 3, 4

If financial constraints prevent immediate CT:

• Contact neurology for urgent consultation—many hospitals have charity care programs or can expedite imaging for seizure patients
• Document that imaging was recommended but delayed due to financial barriers
• Emphasize to patient/family that untreated seizures carry significant morbidity risk (injury from falls, progression to status epilepticus, sudden unexpected death in epilepsy)

What You've Already Done Correctly

• Orthostatic vitals appropriately ruled out syncope/orthostatic hypotension as cause of dizziness
• Blood pressure readings during episodes (120-130/70s) exclude hypertensive emergency
• Comprehensive metabolic workup (CBC, CMP, TSH, vitamin D) will identify metabolic seizure triggers

Additional Immediate Assessments

Seizure-Specific History Details

Document precisely:

• Duration of each facial numbness episode (seconds to minutes suggests focal seizure)
• Awareness during episodes (can he respond to questions, or is there impaired consciousness?)
• Progression pattern (does facial numbness ever spread to arm/leg, suggesting Jacksonian march?)
• Post-episode confusion or fatigue (suggests seizure rather than anxiety)
• Tongue biting, incontinence, or witnessed convulsive movements during any episode 3

Differentiate Seizure from Other Causes

The clinical picture strongly favors focal seizures over:

• Anxiety attacks: Stereotyped unilateral facial symptoms are atypical for panic disorder; anxiety typically causes bilateral paresthesias
• TIA/stroke: Episodes lasting minutes with complete resolution and high frequency (3x/week) are inconsistent with vascular events
• Cardiac arrhythmia: Normal vital signs during episodes and lack of syncope make this unlikely

Medication Management Strategy

Levetiracetam Reinitiation Protocol

• Start at prior maintenance dose if known, or begin 500 mg twice daily and titrate to 1000-1500 mg twice daily based on response 1, 2
• No loading dose is needed for outpatient reinitiation in a patient not actively seizing—loading doses (30 mg/kg IV) are reserved for status epilepticus 3, 4, 5
• Levetiracetam has minimal drug interactions, making it safe with his current medications 2
• Monitor for behavioral side effects (irritability, depression, mood changes), which occur in 11-13% of patients but are usually mild 1

Duration of Treatment

• Continue levetiracetam for minimum 2 seizure-free years before considering discontinuation 3
• Discontinuation should only occur after neurological consultation, normal EEG if available, and shared decision-making with patient 3
• Emphasize that premature discontinuation led to seizure recurrence and increases risk of status epilepticus 1

Back Pain Management Consideration

The lumbar spine x-ray is reasonable given the MVA history and 8/10 pain severity, but this is secondary priority to neurological evaluation. The fact that cyclobenzaprine provided complete pain relief (0/10 currently) suggests musculoskeletal rather than neurological cause.

Critical Pitfalls to Avoid

• Do not attribute facial numbness to anxiety alone without ruling out focal seizures—this is a dangerous missed diagnosis that could lead to status epilepticus 3, 4
• Do not delay restarting antiepileptic therapy while awaiting imaging—seizure control takes precedence 3, 4
• Do not use benzodiazepines chronically for "anxiety" in this patient, as this may mask ongoing seizure activity 3
• Avoid medications that lower seizure threshold including bupropion, tramadol, and high-dose stimulants 3

Financial Barrier Solutions

• Many hospitals offer financial assistance programs for uninsured/underinsured patients
• Outpatient neurology clinics often have sliding-scale fees
• Generic levetiracetam is inexpensive ($10-30/month at most pharmacies)
• CT head without contrast costs $300-500 at many imaging centers—significantly less than hospitalization for status epilepticus

Follow-Up Plan

• Neurology referral within 1-2 weeks for EEG and ongoing seizure management 3
• Recheck levetiracetam levels if seizures continue (therapeutic range 10-37 mcg/mL) 6
• Counsel on seizure precautions: no driving until seizure-free per state law (typically 3-12 months), avoid heights/water activities, shower rather than bathe 3
• Document discussion about risks of medication non-adherence including sudden unexpected death in epilepsy (SUDEP)