Treatment algorithm
Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer
anticonvulsant monotherapy
A trial of anticonvulsant monotherapy is indicated after two spontaneous seizures, or one seizure with one of the following: epileptiform activity on electroencephalogram; structural pathology on brain magnetic resonance imaging or computed tomography; seizure out of sleep; focal onset indicated by semiology (i.e., head turning or gaze deviation).
Anticonvulsant options are listed based on established efficacy and optimal tolerability. However, treatment should always be tailored to the needs of the patient, taking into account age and sex; the underlying etiology of the seizures; the pharmacokinetic properties, mechanism of action, and available formulations of the drugs; and comorbidities and any other medications. Any anticonvulsant, including those not listed here, may be used as first-line monotherapy if it is the most suitable choice for a particular patient.
Lamotrigine, levetiracetam, and oxcarbazepine are suitable first-line anticonvulsants for monotherapy.[74][75][76][77][78][79] Results from a pragmatic randomized controlled trial suggest that the adverse reaction profile of lamotrigine may be superior to that of levetiracetam in patients (>5 years of age) with two or more unprovoked seizures.[80]
Other treatment options include lacosamide, eslicarbazepine, brivaracetam, zonisamide, carbamazepine, valproic acid, topiramate, perampanel, and cenobamate.[77][81][82]
[ 
]
Behavioral adverse events are likely to be less frequent and less severe with brivaracetam than with levetiracetam, except in patients with a history of psychiatric comorbidities.[83][84][85][86] Gabapentin and pregabalin are appropriate options for patients with particular comorbidities.
For patients with psychiatric comorbidities: levetiracetam, brivaracetam, topiramate, zonisamide, and perampanel should only be used with great caution and with close monitoring for recurrence or exacerbation of psychiatric symptoms.
For patients with cognitive problems: topiramate and zonisamide should only be used with great caution.
For patients with renal impairment: levetiracetam should be used with caution and on the advice of a specialist neurologist.
For patients who may have underlying liver disease or other comorbidities requiring multiple drug therapy, including P450 enzyme-inducing medication: levetiracetam, gabapentin, and pregabalin may help minimize effects on the liver and reduce the potential for drug-drug interactions. Valproic acid should not be offered (neither should phenobarbital or phenytoin).
For patients with migraine as well as focal seizures: topiramate and valproic acid are both effective as migraine prophylaxis.
For patients with neuropathic pain: anticonvulsants with efficacy for certain neuropathic pain conditions include gabapentin, pregabalin, oxcarbazepine, and carbamazepine.[70][71][72]
[ ]
Anticonvulsants associated with weight gain include valproic acid, gabapentin, and pregabalin, and these should be used with great caution in patients with obesity. Those associated with weight loss include topiramate and zonisamide. For the most part, other anticonvulsants are considered not to affect body weight.
Anticonvulsant dose adjustment and/or slower titration may be needed (e.g., for people with renal or hepatic impairment).
Avoiding sleep deprivation, alcohol, and excessive stress may be helpful at any stage of treatment, but cannot substitute for anticonvulsant therapy. There is some evidence that adjunctive psychologic and self‐management interventions can improve quality of life and patient outcomes that are important to people with epilepsy.[143][144][145]
[ ]
Primary options
lamotrigine: consult specialist for guidance on dose
OR
levetiracetam: 500 mg orally twice daily initially, increase gradually according to response, maximum 3000 mg/day
OR
oxcarbazepine: 300 mg orally twice daily initially, increase gradually according to response, maximum 2400 mg/day
Secondary options
lacosamide: 100 mg orally twice daily initially, increase gradually according to response, maximum 400 mg/day
OR
eslicarbazepine acetate: 400 mg orally once daily initially, increase gradually according to response, maximum 1600 mg/day
OR
brivaracetam: 50 mg orally twice daily initially, increase gradually according to response, maximum 200 mg/day
Tertiary options
zonisamide: 100 mg orally once daily initially, increase gradually according to response, maximum 400 mg/day
OR
carbamazepine: 200 mg orally (immediate-release) twice daily initially, increase gradually according to response, maximum 1600 mg/day
OR
valproic acid: 10-15 mg/kg/day orally given in 1-3 divided doses initially, increase gradually according to response, maximum 60 mg/kg/day
OR
topiramate: 25 mg orally (immediate-release) twice daily initially, increase gradually according to response, maximum 400 mg/day
OR
perampanel: 2 mg orally once daily at bedtime initially, increase gradually according to response, maximum 12 mg/day
OR
gabapentin: 300 mg orally three times daily initially, increase gradually according to response, maximum 3600 mg/day
OR
pregabalin: 75 mg orally twice daily or 50 mg orally three times daily initially, increase gradually according to response, maximum 600 mg/day
OR
cenobamate: 12.5 mg orally once daily initially, increase gradually according to response, maximum 400 mg/day
anticonvulsant dual therapy
If two separate monotherapy trials at optimal doses do not result in seizure control, a dual therapy trial may be initiated using a combination of two anticonvulsants with different mechanisms of action (with the aim of maximizing efficacy and minimizing toxicity), or a combination of two drugs that have been shown to have anticonvulsant agonistic effects (such as valproic acid plus lamotrigine). These may be a combination of two monotherapy options, or an anticonvulsant that is used primarily as an adjunctive treatment (e.g., clobazam) in combination with one of the monotherapy options.[72][89][90][91][92][93][94][95][96][97][98][99][100][101][102][103]
[ ]
Other adjunctive therapies are available, including rufinamide, vigabatrin, tiagabine, and felbamate.[104][105][106][107][108]
[ ]
[ ]
However, rufinamide, vigabatrin, tiagabine, and felbamate are associated with severe adverse effects, and should only be considered when multiple other medications have been attempted and surgery is deemed not to be an option. An epilepsy specialist should be involved if these agents are being considered. These drugs are not detailed above.
A dose adjustment may be required when using two anticonvulsants together; consult a specialist for guidance on dose.
A list of suitable anticonvulsants for this patient group is detailed here; however, this list is not exhaustive. Two anticonvulsants may be chosen from this list.
Primary options
lamotrigine: consult specialist for guidance on dose
OR
oxcarbazepine: 300 mg orally twice daily initially, increase gradually according to response, maximum 2400 mg/day
OR
levetiracetam: 500 mg orally twice daily initially, increase gradually according to response, maximum 3000 mg/day
OR
brivaracetam: 50 mg orally twice daily initially, increase gradually according to response, maximum 200 mg/day
OR
valproic acid: 10-15 mg/kg/day orally given in 1-3 divided doses initially, increase gradually according to response, maximum 60 mg/kg/day
OR
perampanel: 2 mg orally once daily at bedtime initially, increase gradually according to response, maximum 12 mg/day
OR
clobazam: consult specialist for guidance on dose
OR
gabapentin: 300 mg orally three times daily initially, increase gradually according to response, maximum 3600 mg/day
OR
topiramate: 25 mg orally (immediate-release) twice daily initially, increase gradually according to response, maximum 400 mg/day
OR
zonisamide: 100 mg orally once daily initially, increase gradually according to response, maximum 400 mg/day
OR
pregabalin: 75 mg orally twice daily or 50 mg orally three times daily initially, increase gradually according to response, maximum 600 mg/day
OR
lacosamide: 100 mg orally twice daily initially, increase gradually according to response, maximum 400 mg/day
OR
eslicarbazepine acetate: 400 mg orally once daily initially, increase gradually according to response, maximum 1600 mg/day
OR
carbamazepine: 200 mg orally (immediate-release) twice daily initially, increase gradually according to response, maximum 1600 mg/day
OR
cenobamate: 12.5 mg orally once daily initially, increase gradually according to response, maximum 400 mg/day
OR
phenytoin: 15-20 mg/kg orally as a loading dose given in 3 divided doses every 2-4 hours, followed by 4-7 mg/kg/day (or 300-400 mg/day) given in 2-3 divided doses
OR
phenobarbital: 60 mg orally two to three times daily
OR
primidone: 100-125 mg orally once daily at bedtime for 3 days, increase gradually according to response, maximum 2000 mg/day
resective epilepsy surgery or neurostimulation or ketogenic diet
Failure of at least two anticonvulsant drugs in combination (treatment-resistant or intractable epilepsy) should result in reassessment of the diagnosis. If the diagnosis is not secure, then reinvestigation, possibly with video/electroencephalogram (EEG) monitoring, may be helpful.
If the focal seizure diagnosis is correct, and the patient is truly refractory to anticonvulsants, consider and perform workup for epilepsy surgery or neurostimulation.
Consideration of these advanced options should be pursued at an epilepsy specialty center only.
Candidates for epilepsy surgery include patients with lesions on brain magnetic resonance imaging or in whom the epileptogenic area can be localized to one region by a variety of techniques, including EEG. Minimally invasive alternatives to traditional resective surgery include laser interstitial thermal therapy (LITT), radiofrequency ablation, and stereotactic radiosurgery.[149][150]
If the patient has more than one epileptogenic focus, neurostimulation may be considered an alternative to surgery.[151] Options include vagus nerve stimulation and deep brain stimulation.[152][153][154][155] Responsive neurostimulation (RNS) therapy may be appropriate for some medically refractory patients for whom resective surgery is not a viable option.[157][158][159][160]
The ketogenic diet is high in fat and low in carbohydrates, and has been shown to reduce seizure frequency.[161][162][163]
[ ]
[ ]
The diet must be initiated in the hospital, under close medical supervision, with monitoring for metabolic acidosis and renal calculi.
anticonvulsant monotherapy
The decision to treat focal seizures in older people is often made after the first unprovoked seizure, because the likelihood of recurrence is higher, and the consequences of even a single seizure (falls/hip fracture) may be life changing.
Anticonvulsant options are listed based on established efficacy and optimal tolerability. However, treatment should always be tailored to the needs of the patient, taking into account age and sex; the underlying etiology of the seizures; the pharmacokinetic properties, mechanism of action, and available formulations of drug; and comorbidities and any other medications. Any anticonvulsant, including those not listed here, may be used as first-line monotherapy if it is the most suitable choice for a particular patient.
Older patients are particularly susceptible to adverse effects and often have tolerability issues, especially at higher doses or with polytherapy.
Monotherapy at the lowest possible dose is preferred. Doses should be increased gradually according to patient response, and the patient should be closely monitored for signs of toxicity.
The properties of some anticonvulsants make them less desirable choices for treating focal seizures in older people. These anticonvulsants include drugs that are P450 enzyme inducers or inhibitors; have high protein binding; or are associated with cognitive adverse events.
Anticonvulsants with favorable pharmacokinetics and adverse-effect profiles, such as lamotrigine, gabapentin, and levetiracetam, are usually the most appropriate choice for patients ages 60 years or over. Other options include oxcarbazepine, lacosamide, eslicarbazepine, brivaracetam, pregabalin, carbamazepine, zonisamide, valproic acid, perampanel, and cenobamate.
[ ]
Treatment should always be tailored to the individual patient.[109][110][111]
For patients with psychiatric comorbidities: levetiracetam, brivaracetam, zonisamide, and perampanel (as well as topiramate) should only be used with great caution and with close monitoring for recurrence or exacerbation of psychiatric symptoms.
For patients with cognitive problems: zonisamide (and topiramate) should only be used with great caution.
For patients with renal impairment: levetiracetam should be used with caution and on the advice of a specialist neurologist.
For patients who may have underlying liver disease or other comorbidities requiring multiple drug therapy, including P450 enzyme-inducing medication: levetiracetam, gabapentin, and pregabalin may help minimize effects on the liver and reduce the potential for drug-drug interactions. Valproic acid (and phenobarbital, phenytoin, and felbamate) should not be offered.
For patients with migraine as well as focal seizures: valproic acid is effective as migraine prophylaxis (as is topiramate).
For patients with neuropathic pain: anticonvulsants with efficacy for certain neuropathic pain conditions include gabapentin, pregabalin, oxcarbazepine, and carbamazepine.[70][71][72]
[ ]
Anticonvulsants associated with weight gain include valproic acid, gabapentin, and pregabalin, and these should be used with great caution in patients with obesity. Zonisamide is associated with weight loss (as is topiramate). For the most part, other anticonvulsants are considered not to affect body weight.
Avoiding sleep deprivation, alcohol, and excessive stress may be helpful at any stage of treatment, but cannot substitute for anticonvulsant drug therapy. There is some evidence that adjunctive psychologic and self‐management interventions can improve quality of life and patient outcomes that are important to people with epilepsy.[143][144][145]
[ ]
Primary options
lamotrigine: consult specialist for guidance on dose
OR
gabapentin: 300 mg orally three times daily initially, increase gradually according to response, maximum 3600 mg/day
OR
levetiracetam: 500 mg orally twice daily initially, increase gradually according to response, maximum 3000 mg/day
Secondary options
oxcarbazepine: 300 mg orally twice daily initially, increase gradually according to response, maximum 2400 mg/day
OR
lacosamide: 100 mg orally twice daily initially, increase gradually according to response, maximum 400 mg/day
OR
eslicarbazepine acetate: 400 mg orally once daily initially, increase gradually according to response, maximum 1600 mg/day
OR
brivaracetam: 50 mg orally twice daily initially, increase gradually according to response, maximum 200 mg/day
Tertiary options
pregabalin: 75 mg orally twice daily or 50 mg orally three times daily initially, increase gradually according to response, maximum 600 mg/day
OR
carbamazepine: 200 mg orally (immediate-release) twice daily initially, increase gradually according to response, maximum 1600 mg/day
OR
zonisamide: 100 mg orally once daily initially, increase gradually according to response, maximum 400 mg/day
OR
valproic acid: 10-15 mg/kg/day orally given in 1-3 divided doses initially, increase gradually according to response, maximum 60 mg/kg/day
OR
perampanel: 2 mg orally once daily at bedtime initially, increase gradually according to response, maximum 12 mg/day
OR
cenobamate: 12.5 mg orally once daily initially, increase gradually according to response, maximum 400 mg/day
anticonvulsant dual therapy
If two separate monotherapy trials at optimal doses do not result in adequate seizure control, a dual therapy trial may be initiated after consultation with a specialist neurologist.
Use a combination of two anticonvulsants with different mechanisms of action (with the aim of maximizing efficacy and minimizing toxicity), or a combination of two drugs that have been shown to have anticonvulsant agonistic effects.[72][89][90][91][93][95][96][97][98][99][102][103][105]
[ ]
Anticonvulsants listed for monotherapy above are also the most suitable options for dual therapy in this population; however, any anticonvulsants may be used in combination if that is the most suitable choice for a particular patient.
A dose adjustment may be required when using two anticonvulsants together; consult a specialist for guidance on dose.
anticonvulsant monotherapy
Care should be taken with anticonvulsant treatment for any woman of childbearing potential. Women with epilepsy should receive preconception counseling.[112][113][114]
The choice of anticonvulsant should be based upon the likelihood of pregnancy in the near future. The latest data available on teratogenicity should be consulted.[114] Data on the teratogenic potential of newer anticonvulsants may not be available or may be limited.[118]
Some anticonvulsants are contraindicated in pregnancy due to an increased risk of major congenital malformations and/or child neurodevelopmental disorders (e.g., valproic acid and its derivatives, topiramate, phenobarbital,phenytoin).[115][116][117][118][120][123][124]
Inform women of childbearing potential that they must follow a pregnancy prevention program while on treatment with valproic acid and its derivatives. Some countries may also require that a pregnancy prevention program is in place for other anticonvulsants (e.g., topiramate).
Suitable anticonvulsants for women of childbearing potential include lamotrigine and levetiracetam.[114][118] Other options include oxcarbazepine, lacosamide, and zonisamide.[114] However, treatment should always be tailored to the needs of the patient, also taking into account the underlying etiology of the seizures; the pharmacokinetic properties, mechanism of action, and available formulations of the drugs; and comorbidities and any other medications. Any anticonvulsant, including those not listed here, may be used as first-line monotherapy if it is the most suitable choice for a particular patient.
For women taking birth control pills, avoid anticonvulsants with enzyme-inducing properties (e.g., carbamazepine, phenytoin, phenobarbital, primidone), as these can lower contraceptive efficacy and lead to an increased failure rate.[119]
For patients with psychiatric comorbidities: levetiracetam and zonisamide (as well as brivaracetam and perampanel) should only be used with great caution and with close monitoring for recurrence or exacerbation of psychiatric symptoms.
For patients with cognitive problems: zonisamide should only be used with great caution.
For patients with renal impairment: levetiracetam should be used with caution and on the advice of a specialist neurologist.
For patients who may have underlying liver disease or other comorbidities requiring multiple drug therapy, including P450 enzyme-inducing medication: levetiracetam (as well as gabapentin and pregabalin) may help minimize effects on the liver and reduce the potential for drug-drug interactions.
For patients with neuropathic pain: anticonvulsants with efficacy for certain neuropathic pain conditions include oxcarbazepine and carbamazepine (as well as gabapentin and pregabalin).[70][71][72]
[ ]
Anticonvulsants associated with weight gain include gabapentin and pregabalin, and these should be used with great caution in patients with obesity. Zonisamide is associated with weight loss. For the most part, other anticonvulsants are considered not to affect body weight.
Avoiding sleep deprivation, alcohol, and excessive stress may be helpful at any stage of treatment, but cannot substitute for anticonvulsant therapy. There is some evidence that adjunctive psychologic and self‐management interventions can improve quality of life and patient outcomes that are important to people with epilepsy.[143][144][145]
[ ]
Primary options
lamotrigine: consult specialist for guidance on dose
OR
levetiracetam: 500 mg orally twice daily initially, increase gradually according to response, maximum 3000 mg/day
Secondary options
oxcarbazepine: 300 mg orally twice daily initially, increase gradually according to response, maximum 2400 mg/day
Tertiary options
lacosamide: 100 mg orally twice daily initially, increase gradually according to response, maximum 400 mg/day
OR
zonisamide: 100 mg orally once daily initially, increase gradually according to response, maximum 400 mg/day
anticonvulsant dual therapy
If two separate monotherapy trials at optimal doses do not result in adequate seizure control, a dual therapy trial may be initiated.
Use a combination of two anticonvulsants with different mechanisms of action (with the aim of maximizing efficacy and minimizing toxicity), or a combination of two drugs that have been shown to have anticonvulsant agonistic effects.[89][90][93][97][98][99][128]
[ ]
Anticonvulsants listed for monotherapy above are also the most suitable options for dual therapy in this population; however, any anticonvulsants may be used in combination if that is the most suitable choice for a particular patient.
A dose adjustment may be required when using two anticonvulsants together; consult a specialist for guidance on dose.
resective epilepsy surgery or neurostimulation or ketogenic diet
Failure of at least two anticonvulsants in combination (treatment-resistant or intractable epilepsy) should result in reassessment of the diagnosis. If the diagnosis is not secure, then reinvestigation, possibly with video/electroencephalogram (EEG) monitoring, may be helpful.
If the focal seizure diagnosis is correct, and the patient is truly refractory to anticonvulsants, consider and perform workup for epilepsy surgery or neurostimulation.
Consideration of these advanced options should be pursued at an epilepsy specialty center only.
Candidates for epilepsy surgery include patients with lesions on brain magnetic resonance imaging or in whom the epileptogenic area can be localized to one region by a variety of techniques, including EEG. Minimally invasive alternatives to traditional resective surgery include laser interstitial thermal therapy (LITT), radiofrequency ablation, and stereotactic radiosurgery.[149][150]
If the patient has more than one epileptogenic focus, neurostimulation may be considered an alternative to surgery.[151] Options include vagus nerve stimulation and deep brain stimulation.[152][153][154][155] Responsive neurostimulation (RNS) therapy may be appropriate for some medically refractory patients for whom resective surgery is not a viable option.[157][158][159][160]
The ketogenic diet is high in fat and low in carbohydrates, and has been shown to reduce seizure frequency.[161][162][163]
[ ]
[ ]
The diet must be initiated in the hospital, under close medical supervision, with monitoring for metabolic acidosis and renal calculi.
anticonvulsant monotherapy
Pregnant women with epilepsy should be under the care of a multidisciplinary team that includes a high-risk obstetric specialist, and care should be coordinated through joint obstetric and neurology clinics.[112][113][114] However, risk of cesarean delivery, late pregnancy bleeding, premature contractions, or premature labor and delivery are probably not substantially increased in women taking anticonvulsant drugs who do not smoke.[131]
Particular care should be taken with anticonvulsant treatment for pregnant women. The latest data available on teratogenicity should be consulted.[114]
Suitable anticonvulsants for pregnant women include lamotrigine and levetiracetam.[114][118]
[ ]
Other options include oxcarbazepine, lacosamide, and zonisamide.[114]
Some anticonvulsants are contraindicated in pregnancy due to an increased risk of major congenital malformations and/or child neurodevelopmental disorders (e.g., valproic acid and its derivatives, topiramate, phenobarbital, phenytoin).[115][116][117][118][120][123][124][126]
Monotherapy is preferable to polytherapy, but this is not always achievable. The lowest effective dose should be used.[118]
Serum levels of anticonvulsants may decline during pregnancy, with a potential loss of seizure control.[129] Therefore, close monitoring of serum drug levels and clinical response is advised.[118]
An anatomic ultrasound should be performed between 14 and 18 weeks of pregnancy, and serum alpha-fetoprotein level measured, to check for possible fetal abnormalities. The need for amniocentesis is on a case-by-case basis.
Primary options
lamotrigine: consult specialist for guidance on dose
OR
levetiracetam: 500 mg orally twice daily initially, increase gradually according to response, maximum 3000 mg/day
Secondary options
oxcarbazepine: 300 mg orally twice daily initially, increase gradually according to response, maximum 2400 mg/day
Tertiary options
lacosamide: 100 mg orally twice daily initially, increase gradually according to response, maximum 400 mg/day
OR
zonisamide: 100 mg orally once daily initially, increase gradually according to response, maximum 400 mg/day
anticonvulsant dual therapy
Pregnant women with epilepsy should be under the care of a multidisciplinary team that includes a high-risk obstetric specialist, and care should be coordinated through joint obstetric and neurology clinics.[112][113][114]
If two separate monotherapy trials at optimal doses do not result in adequate seizure control, a dual therapy trial may be initiated after consultation with a specialist neurologist.
Use a combination of two anticonvulsants with different mechanisms of action (with the aim of maximizing efficacy and minimizing toxicity), or a combination of two drugs that have been shown to have anticonvulsant agonistic effects.[89][90][93][97][98][99][128]
[ ]
Anticonvulsants listed for monotherapy above are also the most suitable options for dual therapy in this population; however, any anticonvulsants may be used in combination if that is the most suitable choice for a particular patient (taking into account the latest data on teratogenicity).
A dose adjustment may be required when using two anticonvulsants together; consult a specialist for guidance on dose.
anticonvulsant monotherapy
Treatment should be managed initially by a specialist pediatric neurologist.
Once focal seizures are diagnosed, determination of etiology is important for treatment decisions. For example, certain syndromes, such as the subtype of localization-related/idiopathic epilepsy called benign childhood epilepsy with centrotemporal spikes, often require no anticonvulsant drug treatment.[135]
In some cases (e.g., if seizure episodes are infrequent), it may be appropriate for the parent or caregiver to treat only the prolonged seizure with an acute therapy for aborting the seizure, such as rectal diazepam.
Treatment should always be tailored to the needs of the individual patient, taking into account age and sex; the underlying etiology of the seizures; the pharmacokinetic properties, mechanism of action, and available formulations of drug; and comorbidities and any other medications. Any anticonvulsant, including those not listed here, may be used as first-line monotherapy if it is the most suitable choice for a particular patient.
When selecting an appropriate anticonvulsant for a child, potential effects on cognition, learning, and behavior should be taken into account. For this reason, long-term treatment with anticonvulsants such as phenobarbital and phenytoin should be avoided. Data on the cognitive effects of newer anticonvulsants may not be available or may be limited.
Levetiracetam and oxcarbazepine are suggested as first-line options; they are effective and appear to have favorable profiles with regard to cognitive adverse effects.[136]
Other options for monotherapy in children include lamotrigine, lacosamide, eslicarbazepine, brivaracetam, carbamazepine, zonisamide, topiramate, perampanel, clobazam, and (other than for girls of childbearing potential) valproic acid.[136][137][138]
Care should be taken with anticonvulsant treatment for any girl of childbearing potential. The choice of anticonvulsant should be based upon the likelihood of pregnancy in the near future. The latest data available on teratogenicity should be consulted.[114] Inform girls of childbearing potential that they must follow a pregnancy prevention program while on treatment with valproic acid and its derivatives. Some countries may also require that a pregnancy prevention program is in place for other anticonvulsants (e.g., topiramate).
For patients with psychiatric comorbidities: levetiracetam, brivaracetam, topiramate, zonisamide, and perampanel should only be used with great caution and with close monitoring for recurrence or exacerbation of psychiatric symptoms.
For patients with migraine as well as focal seizures: topiramate is effective as migraine prophylaxis (as is valproic acid).
Anticonvulsants associated with weight gain include valproic acid, gabapentin, and pregabalin, and these should be used with great caution in patients with obesity (they are not generally recommended for children anyway). Those associated with weight loss include topiramate and zonisamide. For the most part, other anticonvulsants are considered not to affect body weight.
Younger children often have more rapid clearance and variability in elimination kinetics of anticonvulsants; this must be factored into dosing regimens. Younger children may require liquid and/or chewable anticonvulsant formulations.
Avoiding sleep deprivation, alcohol, and excessive stress may be helpful at any stage of treatment, but cannot substitute for anticonvulsant therapy. There is some evidence that adjunctive psychologic and self‐management interventions can improve quality of life and patient outcomes that are important to people with epilepsy.[143][144][145]
[ ]
Primary options
levetiracetam: consult specialist for guidance on dose
OR
oxcarbazepine: consult specialist for guidance on dose
Secondary options
lamotrigine: consult specialist for guidance on dose
OR
lacosamide: consult specialist for guidance on dose
OR
eslicarbazepine acetate: consult specialist for guidance on dose
OR
brivaracetam: consult specialist for guidance on dose
Tertiary options
valproic acid: consult specialist for guidance on dose
OR
carbamazepine: consult specialist for guidance on dose
OR
zonisamide: consult specialist for guidance on dose
OR
topiramate: consult specialist for guidance on dose
OR
perampanel: consult specialist for guidance on dose
OR
clobazam: consult specialist for guidance on dose
anticonvulsant dual therapy
If two separate monotherapy trials at optimal doses do not result in adequate seizure control, a dual therapy trial may be initiated after consultation with a specialist pediatric neurologist.
Use a combination of two anticonvulsants with different mechanisms of action (with the aim of maximizing efficacy and minimizing toxicity), or a combination of two drugs that have been shown to have anticonvulsant agonistic effects.[97][98][99][105][139][140]
[ ]
Anticonvulsants listed for monotherapy above are also the most suitable options for dual therapy in this population; however, any anticonvulsants may be used in combination if that is the most suitable choice for a particular patient.
A dose adjustment may be required when using two anticonvulsants together; consult a specialist for guidance on dose.
resective epilepsy surgery or neurostimulation or ketogenic diet
Failure of at least two anticonvulsants in combination (treatment-resistant or intractable epilepsy) should result in a reassessment of the diagnosis. If the diagnosis is not secure, then reinvestigation, possibly with video/electroencephalogram (EEG) monitoring, may be helpful.
If the focal seizure diagnosis is correct, and the patient is truly refractory to anticonvulsants, consider and perform workup for epilepsy surgery or vagus nerve stimulation.
Consideration of these advanced options should be pursued at an epilepsy specialty center only.
Candidates for epilepsy surgery include patients with lesions on brain magnetic resonance imaging or in whom the epileptogenic area can be localized to one region by a variety of techniques, including EEG. Minimally invasive alternatives to traditional resective surgery include laser interstitial thermal therapy (LITT), radiofrequency ablation, and stereotactic radiosurgery.[149][150]
If the patient has more than one epileptogenic focus, vagus nerve stimulation may be considered an alternative to surgery.[151][156]
The ketogenic diet is high in fat and low in carbohydrates, and has been shown to reduce seizure frequency.[161][162][163]
[ ]
[ ]
The diet must be initiated in the hospital, under close medical supervision, with monitoring for metabolic acidosis and renal calculi.
Choose a patient group to see our recommendations
Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer
Use of this content is subject to our disclaimer