Epilepsy: Treatment Options

 

Am Fam Physician. 2017 Jul 15;96(2):87-96.

  Patient information: See related handout on seizures and epilepsy.

Author disclosure: No relevant financial affiliations.

The occurrence of a single seizure does not always require initiation of antiepileptic drugs. Risk of recurrent seizures should guide their use. In adults, key risk factors for recurrence are two unprovoked seizures occurring more than 24 hours apart, epileptiform abnormalities on electroencephalography, abnormal brain imaging, nocturnal seizures, or an epileptic syndrome associated with seizures. In children, key risk factors are abnormal electroencephalography results, an epileptic syndrome associated with seizures, severe head trauma, and cerebral palsy. The risk of adverse effects from antiepileptic drugs is considerable and includes potential cognitive and behavioral effects. In the absence of risk factors, and because many patients do not experience recurrence of a seizure, physicians should consider delaying use of antiepileptic drugs until a second seizure occurs. Delaying therapy until a second seizure does not affect one- to two-year remission rates. Treatment should begin with monotherapy. The appropriate choice of medication varies depending on seizure type. Routine monitoring of drug levels is not correlated with reduction in adverse effects or improvement in effectiveness and is not recommended. When patients have been seizure free for two to five years, discontinuation of antiepileptic drugs may be considered. For patients with seizures that are not controlled with these agents, alternative treatments include surgical resection of the seizure focus, ketogenic diets, vagus nerve stimulators, and implantable brain neurostimulators. Patients who have had a recent seizure within the past three months or whose seizures are poorly controlled should refrain from driving and certain high-risk physical activities. Patients planning for pregnancy should know that antiepileptic drugs are possibly teratogenic.

The lifetime risk of developing epilepsy is 3.9%, with males having a slightly higher risk.1 However, because many persons (particularly children) become seizure free, at any given time epilepsy affects less than 1% of the U.S. population, with a disproportionate impact on infants and older adults.2 Total annual health care costs associated with epilepsy are an estimated $15.5 billion.3 Illness-related absences from work or school occur more commonly in patients with epilepsy, further increasing the economic burden.4

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Electroencephalography should be used to confirm, but not to exclude, a diagnosis of epilepsy.

B

12, 13

Children should not routinely be started on an AED to prevent recurrent seizures after a first unprovoked seizure. The use of AEDs should be considered only when the benefits of reducing the risk of a second seizure outweigh the risks of an adverse drug effect.

B

19

Monotherapy with all indicated AEDs should be attempted before initiating combination therapy.

B

8, 10, 24

Routine monitoring of AED levels is not recommended unless clinically indicated.

B

13, 26, 27

Women of childbearing age should be counseled about the potential decreased effectiveness of AEDs when used with estrogen-based contraception, teratogenicity of AEDs, adverse neurodevelopmental outcomes, and increase in risk of complications during pregnancy and labor; and they should be offered genetic counseling.

C

8, 4750

Screening for cognitive difficulties and mental health issues is recommended at diagnosis because of the high prevalence of cognitive impairment and mood disorders among persons with epilepsy.

C

54


AED = antiepileptic drug.

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Electroencephalography should be used to confirm, but not to exclude, a diagnosis of epilepsy.

B

12, 13

Children should not routinely be started on an AED to prevent recurrent seizures after a first unprovoked seizure. The use of AEDs should be considered only when the benefits of reducing the risk of a second seizure outweigh the risks of an adverse drug effect.

B

19

Monotherapy with all indicated AEDs should be attempted before initiating combination therapy.

B

8, 10, 24

Routine monitoring of AED levels is not recommended unless clinically indicated.

B

13, 26, 27

Women of childbearing age should be counseled about the potential decreased effectiveness of AEDs when used with estrogen-based contraception, teratogenicity of AEDs, adverse neurodevelopmental outcomes, and increase in risk of complications during pregnancy and labor; and they should be offered genetic counseling.

C

8, 4750

Screening for cognitive difficulties and mental health issues

The Authors

show all author info

GERALD LIU, MD, is a family physician at Atrius Health, Weymouth, Mass....

NICOLE SLATER, PharmD, is a pharmacist at Auburn (Ala.) University Harrison School of Pharmacy.

ALLEN PERKINS, MD, MPH, is a professor in the Department of Family Medicine at the University of South Alabama, Mobile.

Address correspondence to Gerald Liu, MD, Atrius Health, 90 Libbey Industrial Pkwy., Wymouth, MA 02189 (e-mail: Gerald_Liu@atriushealth.org). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

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