Current Treatment Options in Neurology

, Volume 1, Issue 4, pp 323–337 | Cite as

Complex partial seizures in adults

  • Michael D. Privitera
  • Jerzy P. Szaflarski
Article

Opinion statement

  • Many disorders can mimic complex partial seizure (CPS), and clinicians must be careful to make an accurate diagnosis. Complex partial seizures must be distinguished from generalized-onset seizures (such as absence seizures), which require a different treatment regimen.

  • Treatment of CPS should begin with monotherapy with a standard antiepileptic drug (AED), such as phenytoin or carbamazepine.

  • Increasing evidence indicates that the newer AEDs, such as lamotrigine, topiramate, and possibly gabapentin, are effective as monotherapy. These AEDs may prove to be as effective as the standard AEDs but with fewer adverse effects.

  • All the newer AEDs have significant efficacy when used as add-on treatments, and they may have fewer adverse effects than standard AEDs used in combination.

  • Surgery for epilepsy should be considered in any patient in whom adequate Current Science Inc. trials of AEDs have failed.

  • The vagus nerve stimulator, a new nonpharmacologic treatment, is a reasonable option in patients in whom AED treatment has failed.

  • Randomized clinical trials comparing older and newer AEDs in the treatment of CPS are needed.

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References and Recommended Reading

  1. 1.
    Hauser WA, Hesdorffer DC: Epilepsy: Frequency, Causes and Consequences. New York: Demos; 1990. This entire textbook is an excellent source of information about the epidemiologic aspects of epilepsy.Google Scholar
  2. 2.
    Commission on Classification and Terminology of the International League Against Epilepsy: Proposal for revised clinical and electroencephalographic classification of epileptic seizures. Epilepsia 1981, 22:489–501.Google Scholar
  3. 3.
    Hauser WA, Annegers JF: Epidemiology of acute symptomatic seizures. In Epilepsy: A Comprehensive Textbook. Edited by Engel J, Pedley TA. Philadelphia: Lippincott-Raven; 1997:87–91.Google Scholar
  4. 4.
    First Seizure Trial Group: Randomized clinical trial on the efficacy of antiepileptic drugs in reducing the risk of relapse after a first unprovoked tonic-clonic seizure. Neurology 1993, 43:478–483. This randomized clinical trial compares the efficacy and adverse effects of antiepileptic drug treatment with those of no treatment for new-onset seizures.Google Scholar
  5. 5.
    Sander JWAS, Sillanpää M: Natural history and prognosis. In Epilepsy: A Comprehensive Textbook. Edited by Engel J, Pedley TA. Philadelphia: Lippincott-Raven; 1997:69–86.Google Scholar
  6. 6.
    Wilmore LJ, Shu V, Wallin B, et al.: Efficacy and safety of add-on divalproex sodium in the treatment of complex partial seizures. Neurology 1996, 46:49–53.Google Scholar
  7. 7.
    Mattson RH, Cramer JA, Collins JF, et al.: Comparison of carbamazepine, phenobarbital, phenytoin, and primidone in partial and secondary generalized tonic-clonic seizures. N Engl J Med 1985, 313:145–151. This superb randomized study compared the four antiepileptic drugs most commonly used at the time. The design set a standard for future comparison studies.PubMedCrossRefGoogle Scholar
  8. 8.
    Troupin A, Ojemann LM, Halpern L, et al.: Carbamazepine —a double-blind comparison with phenytoin. Neurology 1977, 27:511–519.PubMedGoogle Scholar
  9. 9.
    Kosteljanetz M, Christiansen J, Mouritzen A, et al.: Carbamazepine vs. phenytoin. A controlled clinical trial in focal motor and generalized epilepsy. Arch Neurol 1979, 36:22–24.PubMedGoogle Scholar
  10. 10.
    Ramsay RE, Wilder BJ, Berger JR, et al.: A double-blind study comparing carbamazepine with phenytoin as initial seizure therapy in adults. Neurology 1983, 33:904–910.PubMedGoogle Scholar
  11. 11.
    Mattson RH, Cramer JA, Collins JF, et al.: A comparison of valproate with carbamazepine for the treatment of complex partial seizures and secondarily generalized tonic-clinic seizures in adults. N Engl J Med 1992, 327:765–771. This was a follow-up to the study published in 1985 [7].PubMedCrossRefGoogle Scholar
  12. 12.
    Brodie MJ, Richens A, Yuen AWC: Double-blind comparison of lamotrigine and carbamazepine in newly diagnosed epilepsy. Lancet 1995, 345:476–479. This important study was the first to compare a drug from the new generation of antiepileptic drugs with carbamazepine, one of the standard antiepileptic drugs. Lamotrigine was as effective as carbamazepine and had fewer adverse effects.PubMedCrossRefGoogle Scholar
  13. 13.
    Bergey GK, Morris HH, Rosenfeld W, et al.: Gabapentin monotherapy: I. An 8 day, double-blind, dosecontrolled, multicenter study in hospitalized patients with refractory complex partial or secondary generalized seizures. Neurology 1997, 49:739–745.PubMedGoogle Scholar
  14. 14.
    Wilensky AJ, Ojemann LM, Temkin NR, et al.: Clorazepate and phenobarbital as antiepileptic drugs: a double-blind study. Neurology 1981, 31:1271–1276.PubMedGoogle Scholar
  15. 15.
    Beydoun A, Sackellares JC, Shu V, et al.: Safety and efficacy of divalproex sodium monotherapy in partial seizures. A double-blind, concentration-response design clinical trial. Neurology 1997, 48:182–188.PubMedGoogle Scholar
  16. 16.
    Beydoun A, Fischer J, Labar DR, et al.: Gabapentin monotherapy: II. A 26-week, double-blind, dose controlled, multicenter study of conversion from polytherapy in outpatients with refractory complex partial or secondary generalized seizures. Neurology 1997, 49:746–752.PubMedGoogle Scholar
  17. 17.
    Gilliam F, Vazquez B, Sackellares JC, et al.: An activecontrol trial of lamotrigine monotherapy for partial seizures. Neurology 1998, 51:1018–1025.PubMedGoogle Scholar
  18. 18.
    Sachdeo RC, Reife RA, Lim P, et al.: Topiramate monotherapy for partial onset seizures. Epilepsia 1997, 38:294–300.PubMedCrossRefGoogle Scholar
  19. 19.
    Sachdeo R, Kramer LD, Rosenberg A, et al.: Felbamate monotherapy: controlled trial in patients with partial onset seizures. Ann Neurol 1992, 32:386–392.PubMedCrossRefGoogle Scholar
  20. 20.
    Devinsky O, Faught RE, Wilder BJ, et al.: Efficacy of felbamate monotherapy in patients undergoing presurgical evaluation of partial seizures. Epilepsy Res 1995, 20:241–246.PubMedCrossRefGoogle Scholar
  21. 21.
    Faught E, Sachdeo RC, Remler MP, et al.: Felbamate monotherapy for partial-onset seizures: an activecontrol trial. Neurology 1993, 42:688–692.Google Scholar
  22. 22.
    Ng SKC, Hauser WA, Brust JCM, et al.: Alcohol consumption and withdrawal in new-onset seizures. N Engl J Med 1988, 319:666–673.PubMedCrossRefGoogle Scholar
  23. 23.
    Wolf P, Goosses R: Relation of photosensitivity to epileptic syndromes. J Neurol Neurosurg Psychiatry 1986, 49:1386–1391.PubMedGoogle Scholar
  24. 24.
    Privitera MD: Clinical rules for phenytoin dosing. Ann Pharmacother 1993, 27:1169–1172.PubMedGoogle Scholar
  25. 25.
    Anderson GD: A mechanistic approach to antiepileptic drug interactions. Ann Pharmacother 1998, 32:554–563. This review provides a useful guide to the P450 subenzyme systems and a practical method for predicting drug interactions.PubMedCrossRefGoogle Scholar
  26. 26.
    Levine M, McCollom RM, Chang T, et al.: Evaluation of serum phenytoin monitoring in an acute care setting. Ther Drug Monit 1988, 10:50–57.PubMedGoogle Scholar
  27. 27.
    Heller AJ, Chesterman P, Elwes RDC, et al.: Phenobarbitone, phenytoin, carbamazepine, and sodium valproate for newly diagnosed adult epilepsy: a randomised comparative monotherapy trial. J Neurol Neurosurg Psychiatry 1995, 58:44–50.PubMedGoogle Scholar
  28. 28.
    Richens A, Davidson DL, Cartlidge NE, et al.: A multicentre comparative trial of sodium valproate and carbamazepine in adult onset epilepsy. J Neurol Neurosurg Psychiatry 1994, 57:682–687.PubMedGoogle Scholar
  29. 29.
    Wilder BJ, Ramsay RE, Murphy JV, et al.: Comparison of valproic acid and phenytoin in newly diagnosed tonic-clonic seizures. Neurology 1983, 33:1474–1476.PubMedGoogle Scholar
  30. 30.
    Isojärvi JIT, Laatikainen TJ, Pakarinen AJ, et al.: Polycystic ovaries and hyperandrogenism in women taking valproate for epilepsy. N Engl J Med 1993, 329:1383–1388.PubMedCrossRefGoogle Scholar
  31. 31.
    Faught E, Wilder BJ, Ramsay RE, et al.: Topiramate placebo-controlled dose-ranging trial in refractory partial epilepsy using 200-, 400-, and 600-mg daily doses. Neurology 1996, 46:1684–1690.PubMedGoogle Scholar
  32. 32.
    The US Gabapentin Study Group No. 5: Gabapentin as add-on therapy in refractory partial epilepsy: a double-blind, placebo controlled, parallel-group study. Neurology 1993, 43:2292–2298.Google Scholar
  33. 33.
    Beydoun A, Fakhoury T, Nasreddine W, et al.: Conversion to high dose gabapentin monotherapy in patients with medically refractory partial epilepsy. Epilepsia 1998, 39:188–193.PubMedCrossRefGoogle Scholar
  34. 34.
    Wilensky AJ, Temkin NR, Ojemann LM, et al.: Gabapentin and carbamazepine as monotherapy and combined: a pilot study. Epilepsia 1992, 33(suppl 3):77.Google Scholar
  35. 35.
    Schachter S, Biton V, Boellner V, et al.: Safety and efficacy of tiagabine HCl monotherapy in the treatment of partial seizures: high dose versus low dose. Epilepsia 1995, 36(suppl 3):148.Google Scholar
  36. 36.
    Milligan NM, Dhillon S, Griffiths A, et al.: A clinical trial of single dose rectal and oral administration of diazepam for prevention of serial seizures in adult epileptic patients. J Neurol Neurosurg Psychiatry 1984, 47:235–240.PubMedCrossRefGoogle Scholar
  37. 37.
    Dreifuss FE, Rosman NP, Cloyd JC, et al.: A comparison of rectal diazepam gel and placebo for acute repetitive seizures. N Engl J Med 1998, 338:1869–1875.PubMedCrossRefGoogle Scholar
  38. 38.
    Akinbi MS, Welty TE: Benzodiazepines in the home treatment of acute seizures. Ann Pharmacother 1999, 33:99–102.PubMedCrossRefGoogle Scholar
  39. 39.
    Leppik IE, Dreifiss FE, Pledger GW, et al.: Felbamate for partial seizures: results of a controlled clinical trial. Neurology 1991, 41:1785–1789.PubMedGoogle Scholar
  40. 40.
    Theodore WH, Raubertas RF, Porter RJ, et al.: Felbamate: a clinical trial for complex partial seizures. Epilepsia 1991, 32:392–397.PubMedGoogle Scholar
  41. 41.
    Handforth A, DeGiorgio CM, Schachter SC, et al.: Vagus nerve stimulation therapy for partial-onset seizures: a randomized active-control trial. Neurology 1998, 51:48–55.PubMedCrossRefGoogle Scholar
  42. 42.
    Lüders HO, Engel J, Munari C: General principles. In Surgical Treatment of the Epilepsies, edn 2. Edited by Engel J. New York: Raven Press; 1993:137–153. This chapter, in a comprehensive textbook of epilepsy surgery, reviews the overall principles for choosing appropriate candidates for surgery.Google Scholar
  43. 43.
    Arruda F, Cendes F, Andermann F, et al.: Mesial atrophy and outcome after amygdalohippocampectomy or temporal lobe removal. Ann Neurol 1996, 40:446–450.PubMedCrossRefGoogle Scholar
  44. 44.
    Engel J, Ojemann GA: The next step. In Surgical Treatment of the Epilepsies, edn 2. Edited by Engel J. New York: Raven Press; 1993:319–329.Google Scholar
  45. 45.
    King JT, Sperling MR, Justice AC, et al.: A costeffectiveness analysis of anterior temporal lobectomy for intractable temporal lobe epilepsy. J Neurosurg 1997, 87:20–22.PubMedCrossRefGoogle Scholar

Copyright information

© Current Science Inc 1999

Authors and Affiliations

  • Michael D. Privitera
    • 1
  • Jerzy P. Szaflarski
    • 1
  1. 1.Department of NeurologyUniversity of Cincinnati Medical CenterCincinnatiUSA

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