Epilepsy: treatment

Most neurologists now start antiepileptics following a second epileptic seizure. NICE guidelines suggest starting antiepileptics after the first seizure if any of the following are present: - The patient has a neurological deficit - brain imaging shows a structural abnormality - the EEG shows unequivocal epileptic activity - the patient or their family or carers consider the risk of having a further seizure unacceptable

It should be remembered that the following are only general guidelines. For example, maternal use of sodium valproate is associated with a significant risk of neurodevelopmental delay in children. Guidance is now clear that sodium valproate should not be used during pregnancy and in women of childbearing age unless clearly necessary.

Drug treatment according to the type of epilepsy

Generalised tonic-clonic seizures males: sodium valproate females: lamotrigine or levetiracetam girls aged under 10 years and who are unlikely to need treatment when they are old enough to have children or women who are unable to have children may be offered sodium valproate first-line

Focal seizures first line: lamotrigine or levetiracetam second line: carbamazepine, oxcarbazepine or zonisamide

Absence seizures (Petit mal) first line: ethosuximide second line: male: sodium valproate female: lamotrigine or levetiracetam carbamazepine may exacerbate absence seizures

Myoclonic seizures males: sodium valproate females: levetiracetam

Tonic or atonic seizures males: sodium valproate females: lamotrigine