Many seizures are the direct result of an underlying brain or bodily disorder. In such a case, treatment of the underlying condition will often be sufficient to prevent seizures from recurring, and the seizures themselves will need no specific management. In general, seizures that have only occurred once are not treated unless they recur. Once seizures are recurrent, specific anti-epileptic medication will generally be needed. Some epileptics will only have seizures in certain settings, or find that their seizures are reliably provoked by specific triggers. Alcohol use and sleep deprivation are frequently responsible.
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There has recently been an explosion of new drugs for treating epilepsy. These new-generation medications may be better tolerated and are all considerably more expensive than the older medications, which remain the mainstay of treatment. Examples of widely-used established medications are Carbamazepine, Phenytoin, Phenobarbital, Valproic acid and Ethosuximide. Examples of newer medications are Levetiracetam, Lamotrigine, Topiratmate and Gabapentin. All anti-epileptic drugs have side effects, and currently, no particular drug is clearly more effective than another. Choosing the best agent is a complex task best done by a neurologist with a special interest in epilepsy. The choice will rest on the type of seizure, as well as the efficacy of the medication and how well it is tolerated by the individual patient. Most patients are rendered seizure-free with the use of a single medication, or, if necessary, medications in various combinations.
Follow-up should occur at least annually. Monitoring drug levels in the blood is important for continued control of seizures and reduction of side-effects, but is often unnecessary with newer agents. Illness, pregnancy, sleep deprivation, skipping medication doses and using drugs, alcohol or certain medications may cause seizures in someone with previously well-controlled epilepsy. People with epilepsy should wear Medic-Alert bracelets, and family members should be instructed in how to assist during a seizure.
The last decade has seen the development of effective surgery for seizures of certain kinds. In general, surgery is reserved for patients with a seizure focus that can be precisely identified, and who have failed drug therapy. Workup for surgery is complex, but when successful, surgery may render patients seizure-free without having to use medications. Other modalities of treatment, such as the vagal nerve stimulator, are also used in specific cases, although results with vagal nerve stimulators are disappointing.
Reviewed by Dr Andrew Rose-Innes, MD, Department of Neurology, Yale University School of Medicine, New Haven.
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