Choosing the Right Anti-Epileptic Medication for Seizure Control

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• Epilepsy Treatment Goal: No Seizures, No Side Effects
• Seizure Type Importance in Medication Selection
• New vs Old Anti-Epileptic Medications
• Generalized Epilepsy Drugs and Broad-Spectrum Options
• The Necessity of Expert Diagnosis and EEG Interpretation
• Full Transcript

Epilepsy Treatment Goal: No Seizures, No Side Effects

The primary goal in epilepsy treatment is complete seizure control without medication side effects. Dr. Tracey Milligan, MD, states this objective simply as "no epileptic seizures, no side-effects." This principle guides every decision a neurologist makes when selecting a therapy. Achieving this balance is the cornerstone of effective long-term epilepsy management and patient quality of life.

Seizure Type Importance in Medication Selection

Choosing the correct anti-epileptic medication depends entirely on the specific type of epilepsy a patient has. Dr. Tracey Milligan, MD, emphasizes that physicians pick drugs based on whether seizures are focal or generalized. Focal epileptic seizures begin in one specific part of the brain. Generalized epileptic seizures involve networks on both sides of the brain simultaneously. Some medications are effective for both seizure types, known as broad-spectrum anti-epileptic drugs.

New vs Old Anti-Epileptic Medications

Newer anti-epileptic medications often provide a significant advantage in side effect profiles. Dr. Tracey Milligan, MD, explains that newer drugs work just as effectively as older medications. However, they generally have fewer adverse effects. Accessibility remains a global issue, as newer medications are not available in many parts of the world. When available, physicians prefer newer anti-epileptic medications that are effective for the majority of patients and better tolerated.

Generalized Epilepsy Drugs and Broad-Spectrum Options

Several key medications are first-line treatments for generalized epilepsy. Dr. Tracey Milligan, MD, lists divalproex sodium (Depakote or valproic acid) as a primary option. However, valproic acid is teratogenic and avoided in women of childbearing age due to birth defect risks. Other effective broad-spectrum anti-epileptic medications include Levetiracetam, Lamotrigine, Zonisamide, and Topiramate. These drugs are crucial when a patient with generalized epilepsy is misdiagnosed and fails to respond to focal seizure medications like carbamazepine or phenytoin.

The Necessity of Expert Diagnosis and EEG Interpretation

An accurate diagnosis by an epilepsy specialist is essential for choosing the right medication. Dr. Tracey Milligan, MD, underscores that the correct choice depends on the patient’s clinical history and EEG information. Dr. Anton Titov, MD, agrees, noting that only an epilepsy expert can guarantee an EEG is interpreted correctly. Many anti-epileptic medications are widely available, but a knowledgeable expert must make the final selection to achieve seizure freedom.

Full Transcript

Dr. Anton Titov, MD: There are many anti-epileptic medications to treat epilepsy. How does one choose the correct anti-epileptic medications for different patients and different types of epilepsy?

Dr. Tracey Milligan, MD: Our goal is to select epilepsy therapy medications that are going to work well and not cause side effects. Our goal in the treatment of epilepsy is always "no epileptic seizures, no side-effects".

Dr. Anton Titov, MD: Which anti-epileptic medications are the most likely to achieve this goal?

Dr. Tracey Milligan, MD: It really depends on the type of epilepsy. We pick anti-epilepsy medications according to a specific type of epileptic seizures that the patient has. For example, I mentioned that there are focal epileptic seizures. They begin in one very specific part of the brain.

There are also generalized epileptic seizures. Sometimes we don't know where epileptic seizures originate. Sometimes we do not understand what type of epilepsy a patient has. It is important to choose anti-epilepsy medication that will work for both types. We have a list of anti-epileptic medications that will do that.

Also, we have some of the newer anti-epileptic medications. The newer anti-epileptic medications work just as well as the older anti-epileptic medications. But they have fewer side effects.

In many parts of the world, the newer anti-epileptic medications are not available. So a physician has to choose the best older epilepsy medication. Sometimes a patient has access to new anti-epileptic medications. Then, in general, new medications have fewer side effects.

So we pick anti-epileptic medications that we know have a tendency towards fewer side effects. We prefer medications that will work well. They will be effective in the majority of epilepsy patients.

Dr. Anton Titov, MD: What are the major classes of anti-epileptic medications? What are common medications that could be used to treat epilepsy?

Dr. Tracey Milligan, MD: There are medications that we think of working best for generalized epilepsy. In generalized epilepsy, epileptic seizures are beginning on both sides of the brain. The network involving both sides of the brain is a source of epileptic seizures.

One of those anti-epileptic medications is divalproex sodium. The brand name for that is Depakote. That is the anti-epilepsy medication that I used in my patient. I discussed her story previously. She had been taking anti-epileptic medication like carbamazepine for most of her life.

When I saw her, she was taking carbamazepine and gabapentin. All these anti-epileptic medications are popular. They have been on the market for a long time.

Yes, they have been widely available. Divalproex sodium is also a common medication. Valproic acid is another name. It works on the generalized epilepsy. In this patient, Depakote worked very well.

We avoid Valproic acid anti-epilepsy medication in younger women of childbearing age. Because Valproic acid is teratogenic. It means it can cause birth defects. But in an 82-year-old woman, that was not a concern.

Other anti-epileptic medications that work well for generalized epilepsy include Levetiracetam, Lamotrigine, Zonisamide, and Topiramate. Those medications have been around not quite as long as valproic acid. But they have been available for quite some time. They can work well when other anti-epileptic medications do not work.

Sometimes patients have a generalized epilepsy. But they are misdiagnosed with a focal epilepsy. A patient may continue to have epileptic seizures despite taking carbamazepine or phenytoin or an anti-epilepsy medication like that.

Then it is important to consider also whether they might do better on a broad spectrum anti-epileptic medication. That again underscores the necessity to see a proper epilepsy treatment expert. This expert has to be very knowledgeable.

Expert must have knowledge specifically in the treatment of epilepsy. Because a lot of anti-epileptic medications are widely available. But it is the correct choice that has to be made for each patient.

Dr. Anton Titov, MD: Correct choice of medication strictly depends on the exact patient’s type of seizures. Correct choice of medications also depends on clinical history and EEG information.

Dr. Tracey Milligan, MD: Absolutely! Knowing the correct anti-epilepsy medication for a patient can also depend on the EEG interpretation. The EEG interpretation sometimes can be done easily by a non-expert. But there are some variations of EEG that really do require an expert eye.

Dr. Anton Titov, MD: Only an epilepsy expert can guarantee that EEG is interpreted correctly.