Overview of treatment guidelines for epilepsy

Opinion statement

The selection of an antiepileptic drug (AED) for the newly diagnosed patient is a critical decision because patients who are successfully treated usually respond to the first medication tried and changing the medication when treatment has been successful usually is avoided. However, the evidence needed to choose an AED wisely is incomplete, which is demonstrated by multiple practice guidelines that have been produced using systematic reviews of the medical literature. No individual AED or group of AEDs has been found to have superior efficacy for seizure control, nor can any AED or group of AEDs be considered first-line therapy. Nevertheless, the AEDs differ in their efficacy for different seizure types. Therefore, initial treatment should be based in part on the seizure type diagnosis or, at least, on whether the epilepsy syndrome is focal or generalized. The AEDs also differ in their safety, tolerability, and potential for pharmacologic interactions. These issues and the patient’s comorbid conditions are additional bases for AED selection. The failure of AEDs to produce complete seizure control should lead to consideration of epilepsy surgery, especially for patients with mesial temporal lobe epilepsy. However, consensus does not exist regarding how many AEDs should be tried before determining the condition to be pharmacoresistant. Vagus nerve stimulation is an alternative treatment for patients who have pharmacoresistant epilepsy and choose not to have epilepsy surgery or have undergone unsuccessful epilepsy surgery. Infantile spasms are a seizure type requiring their own specific treatment. At present, the best evidence supports treatment with adrenocorticotropic hormone or vigabatrin.