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An Overview of Epilepsy Treatment
An Overview of Epilepsy Treatment
Introduction
The treatment of epilepsy can be complex, particularly in cases of medically intractable epilepsy. For the purposes of this book, the authors will provide a short and concise synopsis of available treatments for the different broad categories of epilepsy. The medical management of epilepsy starts with a selection of appropriate antiepileptic drugs (AEDs) and if three or more AEDs fail after adequate trials, the epilepsy is termed intractable. At this stage, appropriate surgical options should be considered. A careful review of the treatment history is important to determine if the AED trials were indeed optimal prior to pursuing a surgical option. An AED trial is adequate if control of seizures is achieved with a tolerable dose. An AED trial attempts to address two main issues: seizure control and tolerability of the medication. This can be achieved by designing titration schedules and determining target doses that should be individualized to each patient.
Table 8.1 lists the most common side effects of regularly used AEDs. Patients most often complain of sedation, double-vision, ataxia and dizziness. Measurement of AED concentrations in plasma can help in guiding medical therapy especially at times of initiation, dose adjustment, appearance of side effects, therapeutic failure, therapeutic success, or with multiple AED usage. However, the clinical effects of some AEDs do not correlate well with their concentrations in the plasma. Recommended concentrations are therefore only to be used as general guidelines for therapy. The clinically relevant AED regimen is then guided by a clinical assessment of efficacy and toxicity.
Generalized epilepsies
Valproic acid is often effective in patients with juvenile myoclonic epilepsy. It is effective in the treatment of myoclonus and generalized tonic-clonic seizures, as well as absence seizures (ILEA classification). Newer AEDs such as levetiracetam, topiramate or lamotrigine may also be useful. There is some evidence to suggest that myoclonus could be worsened with the use of lamotrigine. Ethosuximide is noted to be effective in controlling absence seizures but does not suppress generalized tonic-clonic seizures. Clonazepam may be helpful in controlling myoclonus but is less effective in controlling generalized tonic-clonic seizures. Carbamazepine, phenytoin, vigabatrin and tiagabine may worsen some seizure types in generalized epilepsy (Table 8.3).
