Epilepsy
NICE guideline [NG217] Epilepsies in children, young people and adults. Last updated: Jan 2025.
Guidelines
Referral Criteria
Refer urgently (appointment within 2 weeks) if:
- After first seizure
- Seizure recurrence after a period of remission
In the UK, urgent appointments in the context of new-onset seizures are scheduled in first seizure clinics (FSCs).
Investigation and Diagnosis
Standard Workup
A standard workup for suspected epilepsy includes:
| Test | Notes |
|---|---|
| 12-lead ECG | |
| Neuroimaging |
|
| Electroencephalogram (EEG) |
|
Additional Testing
| Test | Indications |
|---|---|
| Genetic testing (whole genome sequencing) |
|
| Antibody testing (e.g. anti-NMDA, anti-GABA) |
|
Management
When to Start Anti-Epileptic Drugs
Consider starting treatment after a first unprovoked seizure if any of the following:
- Neurological deficit on examination
- Abnormal EEG (unequivocal epileptic activity)
- Structural abnormality on neuroimaging
- Patient / family / carers consider risk of further seizures unacceptable
Management Principles
Use monotherapy whenever possible
If 1st line monotherapy is unsuccessful → attempt monotherapy with a different medication
- Increase the dose of the second medicine slowly while maintaining the dose of the first medicine
- If the second medicine is successful, slowly taper off the dose of the first medicine
- If still unsuccessful → consider add-on therapy
Choice of Anti-Epileptic Drugs
Note that MHRA advises that sodium valproate should NOT be started for the first time in males or females who are younger than 55 y/o (this is because valproate is highly teratogenic).
It would be incorrect to say that sodium valproate is no longer 1st line for epilepsy, as it is still a 1st line option but just limited largely by the MHRA safety measures and precautionary advice for sodium valproate.
However, it might be beneficial to think that the other listed medications are generally 1st line, instead of sodium valproate (for exam purposes only), as the onset of epilepsy is unlikely to be >55 y/o, so most cases sodium valproate is contraindicated anyway, and the other options are generally safe in both males and females.
1st line anti-epileptic drugs for various types of seizures:
| Seizure Type | 1st line medication |
|---|---|
| Generalised tonic-clonic seizure | Monotherapy of:
|
| Focal seizure | Monotherapy of:
|
| Absence seizure | Monotherapy of ethosuximide |
| Myoclonic seizure | Monotherapy of:
|
| Tonic or atonic seizure | Monotherapy of:
|
| Idiopathic generalised epilepsies | Monotherapy of:
|
Be aware that certain anti-epileptic drugs may exacerbate seizures in people with absence seizures:
- Phenytoin
- Carbamazepine, oxcarbazepine
- Pregabalin, gabapentin
- Phenobarbital
- Tiagabine
- Vigabatrin
Discontinuing Anti-Epileptic Drugs
Only consider discontinuing anti-epileptic drugs after 2 years of seizure-free
- An individualised assessment by a specialist should be done to determine risk of seizure recurrence if medications are discontinued
Anti-epileptic drugs should be stopped gradually:
- For most medicines: over at least 3 months
- For benzodiazepines and barbiturates, this would typically be over a longer period to reduce the risk of drug-related withdrawal symptoms
- For those who take multiple medications: discontinue one at a time