Pharmacotherapy of focal-onset epilepsy

Most adult-onset epilepsies are symptomatic or probably symptomatic epilepsies. While the definition of the seizure symptom type is based on the onset's cerebral region, diagnosis is based on clinical findings that match the focal onset, EEG and imaging results.

Oxcarbazepine (A) or long-acting carbamazepine (A) are recommended as drug treatment for focal-onset epilepsy. Alternative drugs include lamotrigine (B), levetiracetam (B), topiramate (A), valproate (A) and gabapentin (B).

Gabapentin (A), clobazam, lamotrigine (A), levetiracetam (A), pregabalin (A), tiagabine (A), topiramate (A) or zonisamide (A) can be used as supplemental drugs. The selection of the proper medication is always preceded by careful analysis of individual factors and evaluating the risk-benefit ratio of the suggested treatment, as well as its possible adverse effects.

Pharmacotherapy of idiopathic generalised epilepsies

Idiopathic generalised epilepsies form a syndrome continuum, including childhood/juvenile absence epilepsy, generalised tonic-clonic seizures upon waking, juvenile myoclonic epilepsy and photosensitive epilepsy.

The primary drug for idiopathic epileptic syndromes and the related generalised seizures is valproate (C). Alternative drugs include lamotrigine and topiramate (C). Levetiracetam (B) and clobazam can be used as supplemental drugs.

In juvenile absence epilepsy, valproate and ethosuximide are equally efficient in treating absence seizures (C), whereas ethosuximide only affects absence seizures. If a young patient has suffered seizures with convulsions and loss of consciousness, medication should be commenced with valproate (C). Alternatively, treatment of absence seizures can be initiated with ethosuximide in the same way as in childhood absence epilepsy (C). Lamotrigine (C), (D) can be used as alternative medication or a supplemental drug, and topiramate, levetiracetam or clobazam as supplemental drugs.

In juvenile myoclonic epilepsy, the primary seizure type includes myoclonal jerks soon after waking (sudden, brief, mono- or bilateral muscle jerks, primarily in the upper limbs). Valproate (C) is recommended as primary medication with topiramate (C) as an alternative, and levetiracetam (B) or lamotrigine as supplemental drugs.

Discontinuing medication

Discontinuing drug therapy can be considered after the patient has had 3 to 5 years without seizures. For adults, the risk of seizure recurrence is between 30% and 60%, representing more than double the risk incurred by those who continue on medication. For some syndrome types, such as juvenile myoclonic epilepsy, the risk of recurrence is significantly higher. Hence, it is not recommended that medication be discontinued, even after long seizure-free periods, but patient and guardian should discuss the risk of recurrence and its contributory factors, alongside the impact of possible seizures on working ability and driving. Antiepileptic medication should be discontinued gradually, leaving out one drug at a time over a period of several months.

Epilepsy surgery

Epilepsy surgery refers to the surgical removal or isolation of an epileptogenic region in the treatment of difficult-to-control epilepsies. Surgery should be considered for patients of such epilepsies.

The surgical treatment of temporal lobe epilepsy which continues to be symptomatic despite medication terminates seizures in 2 out of every 3 adults, proving more effective than pharmacotherapy (B). However, in most cases medication should be continued following surgery. Surgical treatment of focal-onset epilepsy outside the temporal lobe ends seizures in one third of patients (C). For excisions of single lesions and the related epileptogenic regions, the prognosis of surgical treatment may be better, even in cases relating to areas beyond the temporal lobe (C). Corpus callosotomy results in a complete lack of seizures in 35% of patients experiencing the severest seizures (atonic seizures) (D).