Management

First and most important question….. treat or don’t treat? →confirmed epilepsy? →trigger or provoking factors ? →bothersome? →Patients view on treatment?

Treatment Anti-Epilepsy Drug Therapy Surgery Alternative Therapies Up to % chance of seizure freedom Available for refractory patients only: resective or stimulation Most commonly used (esp paeds) ketogenic diet

Commonly used AED’s Carbamazepine Sodium Valproate Leveitracetam Lamotrigine Phenytoin Topiramate Zonisamide

Common Rescue Medications Midazolam / Diazepam / Clobazam

Major drug related issues Type of epilepsy Age Sex Co-morbid problems Compliance Understanding of treatment Guidance (NICE, SIGN) Drug interactions

Aims of treatment →Long term →Single drug →Lowest effective dose →Established treatments first →Minimise adverse effects

Vigabatrin and visual field loss

Foetal Valproate Syndrome Women of childbearing age should not be started on sodium valproate without specialist neurological advice

Epilepsy surgery ResectiveStimulation

Resective Young age Partial onset / 2nd generalised seizures Resistance to AED Identifiable site of origin Minimal risk to memory and speech Concordance of all factors

Stimulation

Ketogenic diet →high-fat, low-carbohydrate “long-chain triglyceride diet” →3 / 4 g of fat for every 1 g of carbohydrate and protein →mechanisms unknown but Ketones are thought to be the more likely mechanism with higher ketone levels often leading to improved seizure control →Research in adults limited →In paeds 50% have up to 50% seizure reduction

Ultimate Treatment Aim For patients to be seizure free on appropriate medication, with little or no side-effects form their AED →70% of patients will become seizure free optimal therapy →80% controlled on single drug →10 – 15% controlled on polytherapy