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21st June 2023
Treatment for each seizure type
Absence Seizures
NICE advises the following treatment for absence seizures:
| Girls and women of childbearing potential | Medication |
|---|---|
| First line treatment | Ethosuximide |
| Second line treatment | Ethosuximide with lamotrigine as an adjunct |
| Adjunctive treatment | Clobazam, clonazepam, levetiracetam, topiramate or zonisamide.
Also refer to a tertiary epilepsy specialist. *Do not prescribe sodium valproate to women of childbearing potential, as it is teratogenic* |
| Boys, men or women without childbearing potential | Medication |
|---|---|
| First line treatment | Ethosuximide or sodium valproate |
| Second line treatment | Ethosuximide, lamotrigine or sodium valproate |
| Adjunctive treatment | Clobazam, clonazepam, levetiracetam, topiramate or zonisamide.
Also refer to a tertiary epilepsy specialist. |
Focal seizures
NICE advises the following treatment for focal seizures:
| Girls and women of childbearing potential | Medication |
|---|---|
| First line treatment | Lamotrigine |
| Second line treatment | Levetiracetam |
| Adjunctive treatment | Lamotrigine, levetiracetam, carbamazepine, clobazam, gabapentin, oxcarbazepine or topiramate
*Do not prescribe sodium valproate to women of childbearing potential, as it is teratogenic* |
| Boys, men or women without childbearing potential | Medication |
|---|---|
| First line treatment | Lamotrigine or carbamazepine |
| Second line treatment | Levetiracetam, oxcarbazepine or sodium valproate |
| Adjunctive treatment | Carbamazepine, clobazam, gabapentin, lamotrigine, levetiracetam, oxcarbazepine, sodium valproate or topiramate |
Generalised Tonic-Clonic Seizures
NICE advises the following treatment for generalised tonic-clonic seizures:
| Girls and women of childbearing potential | Medication |
|---|---|
| First line treatment | Lamotrigine |
| Adjunctive treatment | Lamotrigine, levetiracetam, clobazam or topiramate (topiramate can impact the effectiveness of contraception).
*Do not prescribe sodium valproate to women of childbearing potential, as it is teratogenic* |
| Boys, men or women without childbearing potential | Medication |
|---|---|
| First line treatment | Sodium valproate |
| Adjunctive treatment | Lamotrigine, levetiracetam, clobazam, sodium valproate or topiramate. |
Myoclonic seizures
NICE advises the following treatment for myoclonic seizures:
| Girls and women of childbearing potential | Medication |
|---|---|
| First line treatment | Levetiracetam or topiramate (*however, topiramate can impact the effectiveness of contraception).
*Do not prescribe sodium valproate to women of childbearing potential, as it is teratogenic* |
| Adjunctive treatment | Levetiracetam or topiramate |
| Boys, men or women without childbearing potential | Medication |
|---|---|
| First line treatment | Sodium valproate |
| Adjunctive treatment | Levetiracetam, sodium valproate or topiramate |
Status Epilepticus
It is essential that status epilepticus is recognised and treated quickly. Initial management in a healthcare setting should include the following:
- A – secure airway
- B – give high-flow oxygen and assess respiratory function
- C – assess cardiac function and secure IV access with a cannula in a large vein.
- D – check blood glucose levels
Pharmacological management in the community:
- Buccal midazolam 10mg
- Rectal diazepam at 10-20mg
Another dose can be given after 15 minutes.
Pharmacological management in hospital:
- First line treatment – IV lorazepam 0.1 mg/kg. Repeat after 10-20 minutes.
- Second line – IV diazepam.
If no IV access – buccal midazolam.
If seizures continue, IV phenytoin can be used, and in refractory cases, intensive care will likely be required for treatment with propofol or thiopental sodium.
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