Management of Epilepsy

exp date isn't null, but text field is

Epilepsy is a common neurological disorder characterised by recurring seizures.  About two-thirds of  people  with  active  epilepsy  have  their  epilepsy  controlled  satisfactorily  with  anti-epileptic  drugs  (AEDs).  Other treatment approaches may include surgery and neuromodulation. Optimal management is required to improve patient’s health outcomes and minimise detrimental impacts on  social, educational, and occupational activities.  

Clinical presentation  Recurrent seizures 

Investigations 

  • Serum electrolytes
  • Serum antiepileptic drug levels
  • Electroencephalogram (EEG)
  • Brain CT scan
  • Brain MRI with epilepsy protocol

Classification of epileptic syndromes 

Classify  epileptic  seizures  and  epilepsy  syndromes  in  all  patients  using  a  multi-axial  diagnostic  scheme (refer to ILAE classification) as failure to classify the epilepsy syndrome correctly can lead  to inappropriate treatment and persistence of seizures.  

Pharmacological management 

  • Utilize a single AED (monotherapy) and increase dose until seizures are controlled or side effects cannot be tolerated.
  • If the initial treatment is unsuccessful, initiate alternative monotherapy with different drugs before resorting to drug combinations.
  • Combination  therapy  (adjunctive  or  'add-on'  therapy)  should  only  be  considered  when attempts at monotherapy with AEDs have not resulted in seizure freedom.
  • If trials of combination therapy do not bring about worthwhile benefits, revert treatment to the  initial  monotherapy  regimen  that  has  proved  most  acceptable  to  the  patient  and consider referral for expert evaluation.

For management of status epilepticus—refer to emergency and critical care chapter 

Focal seizures

First Line:

A: carbamazepine (PO) 10-20mg/kg 12hourly for 4weeks 

OR  

S: lamotrigine (PO) 1-5mg/kg 12hourly for 4weeks 

Second line: 

S: levetiracetam (PO) 10mg/kg 12hourly for 4weeks 

Add-on treatment: gabapentin or sodium valproate as adjunctive treatment if first-line treatments are  ineffective or not tolerated.  

Generalised tonic–clonic (GTC) seizures

C: sodium valproate (PO) 10-15mg/kg 12hourly for 4weeks

OR 

S: lamotrigine (PO) 1-5mg/kg 12hourly for 4weeks 

Add on treatment: offer levetiracetam as adjunctive treatment if first-line treatments are ineffective or not tolerated.

Absence seizures

First Line: 

C: sodium valproate (PO) 10-15mg/kg 12hourly for 4weeks 

Second line: consider levetiracetam 

Note: DO NOT offer carbamazepine, phenytoin or pregabalin for absence seizures. 

Myoclonic seizures

First Line:

C: sodium valproate (PO) 10-15mg/kg 12hourly for 4weeks 

Second line: 

S: levetiracetam (PO) 10mg/kg 12hourly for 4weeks 

Lenox Gastaut syndrome (LGS)

First Line:

C: sodium valproate(PO) 10-15mg/kg 12hourly for 4weeks 

Second line: 

S: lamotrigine (PO) 1-5mg/kg 12hourly as adjunctive treatment 

Note: DO NOT offer carbamazepine or pregabalin. 

Idiopathic generalised epilepsy (IGE)

First Line:

C: sodium valproate (PO) 10-15mg/kg 12hourly for 4weeks 

Second line: 

S: lamotrigine (PO) 1-5mg/kg 12hourly for 4weeks 

Juvenile Myoclonic epilepsy (JME)

First line: 

C: sodium valproate (PO) 10-15mg/kg 12hourly for 4weeks 
Second line: 

S: lamotrigine (PO) 1-5mg/kg 12hourly for 4weeks 

OR  

S: levetiracetam (PO) 10mg/kg 12hourly for 4weeks 

Childhood absence epilepsy

First Line: 

C: sodium valproate (PO) 10-15mg/kg 12hourly for 4weeks 
Second line:  

S: lamotrigine (PO) 1-5mg/kg 12hourly for 4weeks 

Add-on treatment: consider clonazepam, levetiracetam if first-line treatments are ineffective or not tolerated. 

Management of epilepsy in pregnancy 

The use of antiepileptic drugs (AEDs) is associated with increased baseline risk of fetal  malformations during pregnancy. Prescribe Folic acid to all women of childbearing age and girls on  AEDs preconception.  Attempt to decrease pharmacological treatment to monotherapy and utilize the lowest possible effective dose of drugs that have shown minimal risk of maternal and fetal neural  tube defects 

S: lamotrigine (PO) 1-5mg/kg 12hourly for 4weeks 

OR  

S: levetiracetam (PO) 10mg/kg 12hourly for 4weeks 

AND 

A: folic acid (PO) 5mg 24hourly for 3-6months 

In women who have not had a seizure for at least 2years, attempt complete withdrawal of AEDs. 

Non-pharmacological Treatment 

  • Consider ketogenic diet—based on specialist assessment and expert opinion
  • Refer all medically refractory seizures for expert neurosurgical evaluation for epilepsy surgeries
  • Consider evaluation for Vagus Nerve Stimulation (VNS) as an adjunctive treatment in reducing the frequency of seizures in adults who are refractory to AEDs but who are not suitable for resective surgery