Epilepsy
- Treatment

Treatment of active seizure

• While seizure is actually happening, protect the patient from injury (and there is little else to do).
• Gentle but firm restraint to prevent falls.
• If possible, turn patient to one side to reduce risk of aspiration
• Once attack subsides, ensure a clear airway
• No indication for IV anticonvulsant during an uncomplicated seizure

General principles

Starting treatment

Treatment after the first seizure (without any previous history) is controversial.

Treatment is recommended after 2nd seizure or after the 1st juvenile myoclonic seizure (due to increased risk of recurrence).

Maintenance therapy

Once the seizure is fully controlled by therapy that does not cause unacceptable adverse effects, continue with that therapy until the patient has been seizure-free for at least 3 years.

Occasional measurement of drug concentration will help preventing non-compliance.

Others

Pt must not operate heavy machinery, swim, drive, climb ladder, or engage in activities where momentary lapse of consciousness would be detrimental.

Delayed adverse effects

• Gum hypertrophy
• Hirsutism
• Lymphadenopathy
• Osteomalacia (phenytoin)
• Hyponatremia (carbamazepine)
• Deteriorating school performance (phenobarbitone)
• Liver failure (sodium valproate)

Other drug interaction/implication

• Carbamazepine, phenytoin, barbiturates, and topiramate induce liver enzymes and increase the metabolism of oestrogen and progesterone, making OCP unreliable (and causing hirsutism).
• Sodium valproate, carbamazepine, and lamotrigine may be teratogenic in pregnancies
     -> Consider folic acid supplement

Treatment of generalised seizures

Tonic-clonic

Sometimes may be difficult to determine if the seizure is a generalised seizure or a partial seizure with secondary generalisation.

 

• First line: Sodium valproate
• Otherwise carbamazepine (but may exacerbate absence and myoclonic seizures)
• Second line include: lamotrigine, phenytoin, gabapentin, topiramate, tiagabine, or phenobarbitone.

 

Absence seizure

If infrequent and no other seizure occur, drug therapy may not be necessary.

If needed, ethosuximide OR sodium valproate are equally effective.

• Ethosuximide is preferred if no other type of seizure.
• Sodium valproate is used if there is co-existing tonic-clonic seizures

Treatment is continued until the EEG ceases to show 3 per second spike wave activity and no seizure has occurred for 2 years.

 

Myoclonic seizures

• Sodium valproate

 

Partial (focal) seizures

• Carbamazepine (preferred) (but may exacerabe absence and myoclonic seizures)
            OR
• Sodium valproate
            OR
• Phenytoin

Surgical treatment for temporal lobe epilepsy secondary to hippocampal sclerosis

   -> Partial temporal lobectomy

 

Special seizure syndromes

Febrile seizures

Rectal diazepam may be used for seizures lasting more than 5 minutes

Otherwise drug treatment is rarely necessary.

Neonatal seizures

Identify and treat other causes (e.g. meningitis)

If a cause cannot be found, use:

• Pyridoxine (preferred)
            OR
• Phenobarbitone
            OR
• Phenytoin
            OR
• Clonazepam