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What is Epilepsy – when do we start treatment and with what?

Abstract

Roy G Beran

Introduction: Epilepsy comprises ≥ 2 unprovoked seizures (>24 h apart), 1 unprovoked seizure with probability of recurrence (≥ 60%) or an epilepsy syndrome. What follows is consideration of treatment.

Background: Newer ASMs offer adjunctive treatment but none has better efficacy than carbamazepine (CBZ) although possibly less adverse effects. Valproate (VPA) is preferred for generalised epilepsy (except child-bearing age women) with increased preference for the levetiracetam and lamotrigine (LTG). Despite decline for older ASMs, Beran supported CBZ.

First unprovoked seizure has 30-50% chance of recurrence, rising to 70-80% with a second seizure. Percentages increase with abnormal neurologic examination, focal spikes on electroencephalography (EEG) and focal seizures.

Most common epilepsy presentation to the emergency department is non-compliance causing breakthrough seizures, having: shorter duration seizure control; worse adherence to ASM; more frequent polytherapy; more abnormal EEGs; and cerebral imaging abnormalities.

Discussion: Epilepsy presentations comprise 2 categories; first ever or recurrent seizures. Factors, such as infections or alcohol withdrawal, demand intervention and on-going seizures must be aborted. Recurrent seizures require blood levels before administering the current ASM(s).

Treating first ever focal seizure favoured newer, and tendency to ignore older, ASMs, despite support for CBZ. VPA is favoured in non-childbearing age women for generalised epilepsy. Trials advocated LTG.

Conclusion: Epilepsy represents a tendency to seizure recurrence, including a single seizure, assuming ≥ 60% risk of recurrence. Treatment of first focal seizures favours the newer ASMs (the author advocating CBZ); VPA was preferred in non-childbearing aged women with generalised seizures. For non-compliance, restarting the previous ASM(s), after sampling for ASM levels, seems optimal.