Treatment of epilepsy involves medications as well as surgical methods. There should be a complete care plan of treatment for epileptics that addresses lifestyle issues as well as medical issues.
The anti-epileptic drug (AED) treatment is individualized based on:-
- seizure type
- epilepsy syndrome
- use of other medications or presence of other disorders that may render the AED less potent or effective.
- preferences of the person and their carers
When to begin treatment?
Before starting on a medication the diagnosis should be critically evaluated especially if seizures continue despite an optimal dose of a first-line AED. Treatment with AED therapy is generally recommended after a second epileptic seizure.
In some cases AED may be started after the first seizure. These special cases include presence of neurological deficit, the EEG shows unequivocal epilepsy or brain imaging shows a structural abnormality. AED may also be started if the patient finds the risk of another seizure unacceptable.
First-line and second-line drugs
First-line drugs are older and have treated epilepsy for decades. Second-line drugs are much newer. The first line AEDs include:
- sodium valproate
Newer second-line AEDs include:
Availability of the AED
Another vitally important issue is availability of the AED in constant supply. Treatment should be with a single AED wherever possible. If this is unsuccessful then another drug may be tried alone.
To institute a new drug the second drug should be started and dose increased to an adequate and then the first drug should be tapered off slowly and withdrawn. If both drugs have failed singly, a combination therapy is considered.
Where possible, controlled release preparations should be used for single drugs. These preparations have longer duration of action and maintain levels of the drug within the body over a longer period of time and thus a once-daily dose suffices. During continuation of AEDs a check on effectiveness, seizure-free duration and side effects of the AEDs should be monitored. Certain specific clinical conditions, e.g. status epilepticus, organ failure and pregnancy should be anticipated and handled carefully.
Epilepsy is resistant to drug treatment in one third of all patients. These patients may be tried with newer AEDs like levetiracetam, topiramate, and zonisamide that have a varied mechanism of action and can help control seizures.
Withdrawal of medication
Sometimes after long term seizure-freedom AEDs may be stopped or withdrawn. The decision to continue or withdraw medication should be based on the risks and benefits. Withdrawal of AED treatment should be carried out slowly (at least 2-3 months) and one drug should be withdrawn at a time. There should be an agreed plan that if seizures recur the last reduced dose is reinstated along with consultation with the attending physician.
Side effects of AEDs
Side effects of AEDs include:
- balance problems
- allergic rashes
- bleeding disorders
- gum problems and gum swellings
- weight gain
- polycystic ovarian syndrome etc.
A significant population of epileptic patients have resistance or refractoriness to AEDs in use. Surgery is increasingly used as treatment for refractory focal epilepsy. There are techniques by which the location of epileptic discharge is found and neurosurgical techniques are applied to achieve a possible cure. Surgical operations for epilepsy include:
- anteromedial temporal resection (the most common procedure for medial temporal lobe epilepsy)
- corpus callosotomy (used for generalised epilepsy syndromes)
- multiple subpial transaction
- surgery to place a vagus nerve stimulator (VNS) - this is like a pacemaker used in heart - it can help reduce the number of seizures.
- deep brain stimulation (DBS) therapy is also a surgical treatment for epilepsy. DBS involves implanting electrodes into specific areas of the brain to control seizures. These electrodes are controlled by an external device called a neurostimulator.
Reviewed by April Cashin-Garbutt, BA Hons (Cantab)