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Epilepsy

NICE guideline [NG217] Epilepsies in children, young people and adults. Last updated: Jan 2025.

Guidelines

Refer urgently (appointment within 2 weeks) if:
  • After first seizure
  • Seizure recurrence after a period of remission

A standard workup for suspected epilepsy includes:
 
Test Notes
12-lead ECG  
Neuroimaging
  • 1st line: MRI
  • 2nd line: CT
Electroencephalogram (EEG)
  • 1st line: awake EEG within 72 hours (+/- provoking manoeuvres during EEG)
  • 2nd line: sleep-deprived EEG
  • 3rd line: ambulatory EEG (up to 48 hours)

Test Indications
Genetic testing (whole genome sequencing)
  • <2 y/o onset, or
  • Clinical features suggestive of genetic epilepsy syndrome (e.g. Dravet syndrome), or
  • Additional clinical features - learning disability / autism spectrum disorder / structural abnormality (e.g. dysmorphism or congenital malformation) / unexplained cognitive or memory decline
Antibody testing (e.g. anti-NMDA, anti-GABA)
  • Autoimmune encephalitis suspected

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

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

Note that MHRA advice that sodium valproate should NOT be started for the first time in males or females that 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 epilepsies, 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:
  • Lamotrigine, or
  • Levetiracetam, or
  • Sodium valproate
Focal seizure Monotherapy of:
  • Lamotrigine, or
  • Levetiracetam
Absence seizure Monotherapy of ethosuximide
Myoclonic seizure Monotherapy of:
  • Levetiracetam, or
  • Sodium valproate
Tonic or atonic seizure Monotherapy of:
  • Lamotrigine, or
  • Sodium valproate
Idiopathic generalised epilepsies Monotherapy of:
  • Lamotrigine, or
  • Levetiracetam, or
  • Sodium valproate
 

Be aware that certain anti-epileptic drugs may exacerbate seizures in people with absence seizure:

  • Phenytoin
  • Carbamazepine, oxcarbazepine
  • Pregabalin, gabapentin
  • Phenobarbital
  • Tiagabine
  • Vigabatrin

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 medicine: 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.

References

Author: Adams Lau
Reviewer:
Last edited: 16/07/25