Epilepsy Seizure Control: Medications, Surgery, and Neuromodulation

Antiseizure Medications (ASMs) — First Line

Approximately 70% achieve control with monotherapy. Selection depends on seizure type, syndrome, comorbidities, age, sex, and drug interactions.

Seizure Type	Preferred ASMs
Focal	Lamotrigine, levetiracetam, carbamazepine, oxcarbazepine, lacosamide
Generalized tonic-clonic	Valproate, levetiracetam, lamotrigine, topiramate
Absence	Ethosuximide, valproate, lamotrigine
Myoclonic	Valproate, levetiracetam, topiramate, zonisamide

Special Populations

• Women of childbearing age: Avoid valproate (teratogenicity); folate 4 mg; lamotrigine or levetiracetam preferred
• Elderly: Lower doses, avoid enzyme inducers, monitor for falls
• Renal/hepatic impairment: Dose adjust (levetiracetam, gabapentin, lacosamide for renal)

Drug-Resistant Epilepsy (DRE)

Failure of two appropriate ASMs → evaluate for:

Surgery (Curative Potential)

• Resective: Temporal lobectomy, lesionectomy (MRI-visible lesion)
• Disconnective: Hemispherotomy, corpus callosotomy (palliative for drop attacks)
• Laser interstitial thermal therapy (LITT): Minimally invasive

Neuromodulation

• VNS: Open-label ~50% responder rate; closed-loop not available
• RNS (NeuroPace): Responsive stimulation; focal onset; ~60% seizure reduction
• DBS: Anterior nucleus of thalamus; investigational in the U.S.

Dietary Therapy

• Ketogenic diet (classic 4:1, modified Atkins, LGIT) — especially for pediatric refractory epilepsy
• Requires dietitian supervision and monitoring

Complementary

CBD (Epidiolex) for Lennox-Gastaut, Dravet, and tuberous sclerosis complex; stress reduction, sleep hygiene, seizure diaries.

Multidisciplinary Care

Epileptologist, neurosurgeon, neuropsychologist, dietitian, social worker, EEG technologist.