The first decision and sometimes the most difficult decision to make in the epilepsy patient is whom to treat. Only a minority of patients with a first seizure will go on to develop multiple seizures and therefore it is not necessary for every patient with a single seizure to be treated. Neurologists use several factors to determine who should be treated, including results of the EEG (brain wave test) and MRI of the brain, and circumstances surrounding the first seizure or two. In addition, the feelings and concerns of the patient need to be taken into account, as any treatment plan the patient is not in complete agreement with is doomed to failure.

Once it is decided that the benefits outweigh the risks of treatment, it is important to choose an appropriate treatment with the least side effects as many patients will have to take the medications for several years. The principal benefit of the newer anti-epileptic drugs (AEDs) for the treatment of seizures has to do with the reduction of side effects and not with the increase in single agent epilepsy control or efficacy. In fact, in all head-to-head studies that this author is aware of, no single epileptic agent has been shown to be superior to any other agent if chosen for the proper type of seizure (provided it could be tolerated by the patient). Therefore, the principal differences in the choice of medications is the medication side effects, frequency of administration, method of administration, and cost.

Some of the medications (Neurontin, Depakote) cause weight gain and should therefore be avoided in patients who are overweight. A few cause weight loss (Topamax, Zonegran, Felbatol) and are therefore more likely to be used in those who are overweight. AEDs such as Lamictal, Keppra, and Neurontin do not interfere with birth control pills. Individualized treatment is key and therefore it important for the patient to choose a physician who is comfortable with all of the newer medications.

Of the newer AEDs, Guidelines of the American Academy of Neurology support initial treatment of partial onset seizures with Neurontin, Lamictal, Topamax, and Trileptal. For newly diagnosed absence seizures, only Lamictal is supported among the new AEDs for initial use.

In a recent study by Kwan and Brodie published in the New England Journal of Medicine during 2000, almost 50% of patients were made seizure-free by the very first seizure agent they were able to tolerate. Only 13% became seizure free after switching to the second agent that they could tolerate. After a second agent, all subsequent medication trials (some in combination) resulted in seizure freedom in only an additional 4% of the time. Therefore, it should be possible to completely control seizures medically in about 2/3rds of all patients. Conversely, once a patient has failed to have their seizures controlled by 3 agents they were able to tolerate, non-medical therapies like epilepsy surgery needs to be considered. A detailed discussion of epilepsy surgery is beyond the scope of this web site but patients with temporal lobe epilepsy associated with mesial temporal sclerosis who are medically intractable do best with surgery.

Because there is no "best" medication, the neurologist and patient must work together as a team in choosing, discontinuing, and switching the patient's medication.

Two of the older anti-epileptics, phenobarbital and primidone, should not, in my opinion, be used for controlling seizures in adults. These medications are very sedating and I have made a large number of patients very happy by discontinuing or changing these medications. Over the years, these medications are metabolized by the body more slowly and therefore the levels slowly rise in the patient. Many of these patients have not even realized the degree they were being negatively impacted by the medication until it was discontinued. I have articles on the other antiepileptic medications on this web site.

The use of the vagal nerve stimulator (VNS) has been a breakthrough in the treatment of epilepsy. Just like medication, the VNS has side effects, but the side effects are very different from the other medications and therefore it is an excellent agent to use in combination with other AEDs. In addition, compliance, which is so difficult in a chronic disease like epilepsy, is guaranteed (at least until the battery runs out).

Once on anti-epileptic therapy, deciding when to stop therapy can be an even more difficult decision. In general, most neurologists wait two or three years (I use three) for a patient to remain seizure-free and aura-free before considering this decision. Again, the neurologist will look to the MRI, EEG, and most importantly, the patient's history and feelings on the subject before making a decision.