Epilepsy: Treatment

Key points

• Most neurologists start antiseizure medication after a SECOND seizure; NICE: consider after a first seizure if there is a neurological deficit, a structural abnormality on imaging, unequivocal epileptiform EEG activity, or the patient considers the risk unacceptable.
• Focal seizures (NG217): lamotrigine or levetiracetam first-line (carbamazepine is now an add-on option, not first-line).
• Generalised tonic-clonic: lamotrigine, levetiracetam or sodium valproate first-line — but do NOT use valproate in women/girls able to have children (offer lamotrigine or levetiracetam); valproate first-line is appropriate for boys/men and women unable to have children.
• Absence: ethosuximide first-line; sodium valproate second-line (not in women/girls of childbearing potential). Myoclonic: sodium valproate (levetiracetam for women/girls of childbearing potential). Carbamazepine may EXACERBATE absence and myoclonic seizures.
• MHRA valproate restrictions: valproate is highly teratogenic (neural tube defects, neurodevelopmental disorder) — only under a Pregnancy Prevention Programme in women/girls of childbearing potential, and must NOT be started in any new patient (male or female) under 55 unless two specialists document no other effective/tolerated option.
• DRIVING (DVLA, Group 1 — car/motorcycle): after a FIRST UNPROVOKED seizure, stop driving for 6 MONTHS from the date of the seizure — or 12 MONTHS if clinical factors or investigations suggest an underlying cause raising the risk of recurrence.
• With ESTABLISHED EPILEPSY (two or more unprovoked seizures), the driver must be seizure-free for 12 MONTHS from the most recent seizure · more than one seizure within 24 hours counts as a single event · the patient must notify the DVLA themselves.
• If a seizure occurs after a doctor-directed reduction or change of antiseizure medication, driving stops for 12 months, though earlier relicensing may be considered once the previously effective medication has been reinstated for 6 months · Group 2 (lorry/bus) standards are far stricter.

Decision points in this pathway

• Seizure type?

The full step-by-step algorithm, including what to do at each branch, opens in the app for approved members.