After making the correct diagnosis of a patient but before writing the prescription for a specific antiepileptic drug (see previous section), the physician must consider a number of additional issues. The full understanding of these issues is reviewed in this section and should permit the best outcome for the patient, regardless of the drug or other therapy that is chosen.

However, before entering into the complexities of treatment strategies, we need to provide a brief reminder about the accuracy of the patient’s diagnosis. The correct diagnosis is, after all, the fundament on which all therapy is based. Inadequate or wrong diagnosis is likely to lead to inadequate and potentially harmful treatment. This a difficult area given that epilepsy is not a single disease but a heterogeneous array of syndromes with innumerable causes and a wide range of clinical expressions, the final one of which is the seizure itself. So how are we to make a correct diagnosis of the patient with the disorder? We can only do this by recognizing that multiple levels of diagnosis are present, and these must be identified in each patient.

The meaningful levels of diagnosis in patients with epilepsy can conveniently be divided into three basic categories: (a) the etiologic diagnosis, (b) the seizure diagnosis, and, where possible, (c) the epilepsy syndrome diagnosis. The etiologic diagnosis requires identification of the cause of the epileptic seizures. The causes range from obvious structural abnormality of the brain to usually still obscure genetic abnormality. Every patient deserves a search for the etiologic diagnosis—and appropriate specific therapy for this etiology, when possible—even though, in a substantial proportion of patients, the effort will be unsuccessful. In most patients, the correct classification of seizure type(s) and, possibly, epilepsy syndrome permits the correct choice of therapy and, even more specifically, the correct choice of antiepileptic drug. Our ability to establish an accurate diagnosis has been greatly aided not only by a better overall understanding of the disorder, but also by technical advances such as brain imaging (for improved etiologic diagnosis) and intensive electroencephalographic (EEG)/video monitoring (for more precise seizure diagnosis). Although the seizure diagnosis alone can help with the choice of medication, the epilepsy syndrome diagnosis is more important for predicting the prognosis and, potentially, the duration of therapy. Recent improvements have been made in both the seizure classification and the classification of the epilepsies but, as noted in other chapters, considerable refinements are needed for better diagnosis at both of these levels.

Once the patient’s diagnosis is secure, what are the treatment issues that must be considered to optimize the outcome for the individual? These treatment variables, discussed at length in the following three dozen chapters, have been divided into the following sections: (a) general aspects (indications for treatment, goals of treatment, need for a comprehensive treatment approach, assessment tools, and age considerations), (b) principles of drug treatment, (c) strategies for pharmacotherapy, (d) special therapeutic considerations, and (e) alternative and experimental approaches, although inevitably these areas will have considerable overlap and interaction.