What is the treatment for a focal seizure affecting only the face?

Treatment of Focal Seizures Affecting Only the Face

For focal seizures affecting only the face, first aid management should focus on safety measures and EMS activation for specific high-risk scenarios, while definitive antiseizure medication treatment decisions depend on whether this is a first-time seizure versus recurrent epilepsy. 1

Immediate First Aid Management

Safety Measures

• Help the person safely to the ground if they are at risk of falling, place them on their side in the recovery position, and clear the surrounding area to prevent injury 1, 2, 3
• Stay with the person throughout the seizure and the postictal period 1, 2
• Do not restrain the person or place anything in their mouth 1
• Do not give food, liquids, or oral medications during the seizure or if the person has decreased responsiveness afterward 1

When to Activate EMS

Activate emergency medical services for: 1, 2, 3

• First-time seizure occurrence
• Seizures lasting >5 minutes
• Multiple seizures occurring without the person returning to baseline mental status between episodes
• Seizures occurring in water
• Seizures with traumatic injuries, difficulty breathing, or choking
• Seizure in an infant <6 months of age
• Seizure in pregnant individuals
• Failure to return to baseline within 5-10 minutes after seizure activity stops

Diagnostic Evaluation

Essential Workup

For adults presenting with a first-time focal seizure: 4

• Serum glucose and electrolyte determination are required
• Pregnancy test for women of reproductive age
• Patients with comorbidities, focal neurologic examination findings, or who have not returned to normal baseline mental status require noncontrast head CT scan in the emergency department

Advanced Diagnostic Testing

• EEG is crucial for accurate seizure classification to guide medical management 1, 3
• Brain MRI should be obtained for cases with rapid head growth increase, changes in neurologic examination, or regression of skills 1
• EEG evidence of epileptiform abnormalities increases seizure recurrence risk and should inform treatment decisions 5

Common pitfall: Focal status epilepticus affecting the face may be missed or diagnosis delayed, as it can present without obvious generalized motor activity and patients may only have abnormal mental status 6. The diagnosis should be considered when patients do not stabilize or improve as expected after initial seizure activity 6.

Antiseizure Medication Treatment Decisions

First-Time Seizure

Immediate antiseizure drug (ASD) therapy after a first unprovoked seizure reduces recurrence risk within the first 2 years but does not improve long-term prognosis for sustained seizure remission beyond 3 years. 5

Risk Factors for Recurrence (21%-45% overall risk):

• Prior brain insult 5
• EEG with epileptiform abnormalities 5
• Significant brain-imaging abnormality 5
• Nocturnal seizure 5

Treatment Initiation Considerations:

• Patients with normal neurologic examination, normal laboratory results, and no signs of structural brain disease do not require immediate hospitalization or antiepileptic medications 4
• AED adverse events may range from 7% to 31%, though these are likely predominantly mild and reversible 5
• The decision to initiate immediate AED treatment should weigh the individual's recurrence risk factors against potential adverse effects 5

Established Focal Epilepsy

First-Line Medication Options

For focal-onset seizures, carbamazepine, phenytoin, or valproic acid are often rated as first-line drugs, though newer AEDs (lamotrigine, gabapentin, topiramate, oxcarbazepine) have better tolerability profiles 7

Levetiracetam dosing for focal seizures: 8

• Adults ≥16 years: Start 1000 mg/day (500 mg twice daily), increase by 1000 mg/day every 2 weeks to maximum 3000 mg/day
• Pediatric patients 4 to <16 years: Start 20 mg/kg/day in 2 divided doses, increase every 2 weeks by 20 mg/kg increments to recommended 60 mg/kg/day (30 mg/kg twice daily)

Topiramate dosing for focal seizures: 9

• Adults: Begin at 100 mg/day, increase by 100-200 mg/day increments weekly or every other week until assigned dose reached
• Target doses in clinical trials ranged from 200-1000 mg/day, with doses of 200-400 mg/day showing efficacy

Treatment Response Expectations

• Most people with newly diagnosed focal epilepsy (59.6%) achieve seizure freedom, though this takes more than a year and typically requires more than one ASM 10
• Among treatment-sensitive patients, 89.3% respond to monotherapy, and 49.4% become seizure free on their first ASM 10
• Median time to first seizure freedom is 12.1 months 10
• Patients with infrequent pretreatment seizures are less likely to be treatment resistant than those with very frequent seizures 10
• Self-reported comorbid psychological disorders increase the likelihood of treatment resistance by 1.78-fold 10

Important caveat: In the first year of treatment, 63% of patients have ongoing or worsening seizures, so early lack of response does not necessarily predict treatment resistance 10.

Focal Status Epilepticus Considerations

Focal status epilepticus affecting the face may present without obvious continuous motor activity and can be diagnosed by abnormal mental status alone. 6

• EEG evidence may show either discrete recurrent focal electrographic seizures or rapid continuous focal epileptiform discharges—both patterns should be treated equally 6
• The diagnosis is often delayed or missed and should be considered when patients do not stabilize or improve as expected after initial seizure activity 6
• With antiepileptic drugs, almost all patients achieve control of clinical seizures and most improve in mental status 6