How is it treated and managed?
Medication
Epilepsy is eminently treatable with medication and the aim of treatment is to totally suppress seizures with the lowest possible dose of a single Anti-Epileptic Drug (AED). It is worth being aware that control of seizures is affected by failure to comply with prescribed treatment and a surprisingly large number of individuals do not accurately follow prescribed treatment.
In general, the outlook is better than many people realise, with 80% being well controlled with no or few seizures. Complete suppression of seizures can be achieved in about 70% of those developing epilepsy.
The type of AED prescribed will depend upon the following factors -:
- Type of epilepsy,
- Age,
- Drugs taken for other conditions,
- Possible AED side-effects,
Monitoring of blood levels may be appropriate with the use of some AED’s, and in some situations, such as the suspected toxic effects of the medication or suspected non-compliance.
The following table lists the current recommended anti-epileptic drugs (AEDs) for different seizure types.
The individual should always be started on a single drug and if the epilepsy is more difficult to control, more drugs will be added.
| Seizure Type | First-line Drugs | Second-line Drugs | Other Drugs that may be considered | Drugs to be avoided (may worsen seizures) |
|---|---|---|---|---|
| Generalised tonic-clonic | Carbamazepine
Lamotrigine Sodium Valproate Topirmate |
Clobazam
Levetiracetam Oxcarbazepine |
Acetazolamide
Clonazepam Phenobarbital Phenytoin Primidone |
Tiagabine
Vigabatrin |
| Absence | Ethosuximide
Lamotrigine Sodium Valproate |
Clobazam
Clonazepam Topiramate |
Carbamazepine
Gabapentin Oxcarbazepine Tiagabine Vigabatrin | |
| Myoclonic | Sodium Valproate
(Topiramate) |
Clobazam
Clonazepam Lamotrigine Levetiracetam Piracetam Topiramate |
Carbamazepine
Gabapentin Oxcarbazepine Tiagabine Vigabatrin | |
| Tonic | Lamotrigine
Sodium Valproate |
Clobazam
Clonazepam Levetiracetam Topiramate |
Acetazolamide
Phenobarbital Phenytoin Primidone |
Carbamazepine
Oxcarbazepine |
| Atonic | Lamotrigine
Sodium Valproate |
Clobazam
Clonazepam Levetiracetam Topiramate |
Acetazolamide
Phenobarbital Primidone |
Carbamazepine
Oxcarbazepine Phenytoin |
| Focal with/without secondary generalisation | Carbamazepine
Lamotrigine Oxcarbazepine Sodium Valproate Topirmate |
Clobazam
Gabapentin Levetiracetam Phenytoin Tiagabine |
Acetazolamide
Clonazepam Phenobarbital Primidone |
Diazepam Use
Rectal diazepam may be used in the home management of prolonged or repetitive seizures. The clinical effect from rectal diazepam occurs rapidly, within a few minutes. It should be used with caution as it can cause, although rarely, respiratory depression (slower breathing or even brief cessation of breathing) especially in children. It is usually not necessary for children with mild or well-controlled forms of epilepsy. More recently however, buccal midazolam (the medication is placed against the sides of the gums and cheek) is being used instead of rectal diazepam. Buccal midazolam is easier to administer, with similar effectiveness and a better safety margin.
Withdrawing medication
The reduction and withdrawal of medication is a complex decision usually negotiated over a period of time, between the epilepsy specialist and patient. The risks include increased risk of seizures. This has implications for driving, and the use of machinery.
If an individual has been seizure free for 2 years, then consideration may be given to the withdrawal of medication in certain types of epilepsy.
Generally, medication is continued until at least a 2 to 3 year period free of seizures is established. Any drug withdrawal should be gradual, (i.e. over a period of 3 to 6 months).
Factors to take into account include -:
- Fear and risks of long term unwanted effects of Anti-Epileptic Drug (AED) treatment.
AED withdrawal is associated with an increased risk of seizure recurrence.
Other therapies
Surgery
This is an option in a very small number of cases. It may be considered where a specific structural abnormality of the brain can be identified, such as an area of scar tissue, and this is in an area suitable for surgery, and where medication has proven unsuccessful. The need for surgery suggests likely poor control of the condition and therefore increased risk and the need for supervision or attention to avoid or reduce that risk.
Devices
A battery-powered device to stimulate the vagus nerve can be fitted under the skin like a pacemaker to send electrical signals to the brain via the vagus nerve in the lower back. This can help reduce seizure frequency. It is of most use where seizures are not well controlled by Anti-Epileptic Drugs (AEDs).
Diet
A “Ketogenic diet” which is rich in fats and low in carbohydrate can reduce seizure frequency in some children where AEDs have been ineffective. This therapy is mainly for children and young people. The need for a specialised diet suggests likely poor control of the condition and therefore increased risk and the need for supervision or attention to avoid or reduce that risk.
Lifestyle Issues
Getting adequate sleep, eating regularly, and the avoidance of stress and alcohol (in older children) are sensible lifestyle modifications. Compliance with treatment is also a very important factor.
