Management of epilepsy requires an individualized, longitudinal approach that incorporates seizure type, recurrence risk, comorbidities, lifestyle, reproductive planning, and safety implications of recurrent seizures. Family physicians play a central role in early counseling, initial medication discussions, monitoring for adverse effects, and recognizing when referral for advanced therapies is warranted. Evidence shows that early initiation of maintenance antiseizure medication after a first unprovoked seizure lowers short-term recurrence but does not change long-term remission or mortality, underscoring the need for shared decision-making grounded in patient preferences and psychosocial or occupational needs. Because epilepsy is increasingly viewed as a heterogeneous group of disorders rather than a single entity, treatment must integrate mechanism-based medication selection, titration principles, therapeutic monitoring, and nonpharmacologic options such as dietary therapy, neuromodulation, and surgery. This section provides a primary care–focused overview of medication strategy, emphasizing when to start medication, how to choose and adjust therapy, and how to manage breakthrough seizures, drug resistance, and pregnancy-related issues.
Mullur K, Bertelli G. Seizure Disorders in Adults: Principles of Treatment of Epilepsy. FP Essent. 2026;568:18-25.
Case 3. TT is a 27-year-old paralegal who received a diagnosis of generalized tonic-clonic epilepsy 1 year ago. At that time, his brain magnetic resonance imaging study was normal and electroencephalography (EEG) showed generalized epileptiform discharges. He was started on levetiracetam, which was gradually titrated to an adequate therapeutic dose. He reports excellent medication adherence and denies missed doses, sleep deprivation, alcohol excess, or illicit drug use. Nonetheless, TT has experienced several breakthrough generalized tonic-clonic seizures over the past year, occurring every few months. He also reports increasing irritability and emotional lability since starting levetiracetam, which he finds distressing and disruptive to his work. He asks whether he needs a different medication, whether adding a second antiseizure medication would improve seizure control, and what options exist if medications continue to fail.
Goals and Principles of Epilepsy Treatment
The treatment of epilepsy is fundamentally aimed at achieving sustained seizure control while minimizing adverse effects and preserving quality of life. Although complete seizure freedom is the ideal outcome, this goal must be balanced against medication tolerability, cognitive and psychiatric adverse effects, long-term safety, and the patient’s personal and occupational priorities. Most adults with epilepsy (60% to 70%) will achieve remission with the first or second appropriately chosen antiseizure medication, underscoring the importance of correct early decisions in medication selection and dosing.1,2
A core principle of epilepsy treatment is shared decision-making. Evidence consistently demonstrates that although early antiseizure medication initiation can reduce short-term recurrence risk, it does not alter long-term remission rates or mortality rates.1,3 Therefore, treatment decisions should incorporate not only clinical risk factors but also patient values, tolerance for uncertainty, and the potential psychosocial consequences of recurrent seizures, such as driving restrictions, employment limitations, and injury risk.1,3
Epilepsy management is inherently longitudinal. Seizure patterns, comorbid conditions, reproductive plans, and social circumstances evolve over time, requiring periodic reassessment of the treatment strategy. Family physicians play a central role in this continuum of care, particularly in counseling patients at diagnosis, monitoring stable disease, identifying treatment failure or adverse effects, and coordinating care with neurology when escalation is needed.4 In this context, epilepsy should be approached not as a static diagnosis but as a chronic condition requiring dynamic management. Follow-up frequency is individualized, occurring at least every 3 to 6 months during titration and at least annually once seizures are controlled.
Read the full edition
Get immediate access, anytime, anywhere.
Choose a single edition, 1-year or 2-year full-access subscription.
Earn 4 CME credits for this edition.