The majority of epileptic seizures are controlled by medication, particularly anticonvulsant drugs. The type of treatment prescribed will depend on several factors, including the frequency and severity of the seizures and the person's age, overall health, and medical history. An accurate diagnosis of the type of epilepsy is also critical to choosing the best treatment.
Many drugs are available to treat epilepsy. Although generic drugs are safely used for most medications, anticonvulsants are one category where doctors proceed with caution. As a result, it is acceptable to start taking a generic anticonvulsant medication, but if the desired control is not achieved, the patient should be switched to the brand-name drug.
There are only three (3) available medications used to treat epilepsy in Swaziland:
| Generic name (brand name in brackets) | Average daily dosage range for adults | Use/effectiveness | Available as | Possible side effects |
| Carbamazepine (Tegretol) | Initially 100mg at night increased to 400-1600mg dived into 2-4 doses a day. The slow release formulation is better tolerated .(up to 2400mg in certain cases | Effective against partial and generalized tonic clonic seizures | Controlled release tablets, suspension, tablets | Double vision, unsteadiness, fatigue an allergic rash affects a minority serious liver and bone marrow problems rare occur |
| Sodium Valproate (Epilim) | 500-2500mg divided into1-2 doses a day | First line therapy of tonic clonic absence, and myclonic seizures also effective against partial seizures | Tablets, sugar free syrup | Drowsiness, tremor, irritability, hair loss, weight gain, and possible polycystic ovary syndrome. Liver and pancreas damage are rare |
| Phenobarbital | 30-180mg divided into 1-2 doses a day | Effective against partial, generalized tonic clonic and sometimes other generalized seizures | Paediatric syrup, tablets | Tiredness, sedation, mental slowing may occur even at low doses. In the elderly restlessness is seen and children may exhibit hyperactivity. |
The choice of drug is most often based on factors like the patient's tolerance of side effects, other illnesses he or she might have, and the medication's delivery method. Although the different types of epilepsy vary greatly, in general, medications can control seizures in about 70% of patients.
As is true of all drugs, the drugs used to treat epilepsy have side effects. The occurrence of side effects depends on the dose, type of medication, and length of treatment. The side effects are usually more common with higher doses, but tend to be less severe with time as the body adjusts to the medication. Anti-epileptic drugs are usually started at lower doses and increased gradually to make this adjustment easier. One of the best rules in medicine is to ''go low and go slow.''
In some types of epilepsy, patients can be taken off treatment after a few years, while other types of epilepsy require lifelong treatment. With few exceptions, patients who are seizure-free for a certain period should be re-evaluated to determine whether the drug can be discontinued. How long the seizure-free period should be varies among the types of epilepsy and is controversial even for a given type. The decision to discontinue a medication also depends on more than the length of the seizure-free period.
What is clear, however, is that epilepsy drugs should at least be considered for discontinuation in patients who are seizure-free for 10 years. If a medication is going to be discontinued, it should be weaned gradually to avoid triggering a seizure.
Most patients with epilepsy do not require surgery. However, if seizures are not controlled after a trial of two or three medications (usually accomplished within two years) then re-evaluation is suggested. This information is critical in deciding if epilepsy surgery is an option.
Before surgery is considered, a comprehensive pre-surgical exam is performed. This evaluation is performed to ensure that the operation will likely improve the seizures and will not cause damage to essential functions such as speech and memory. The evaluation requires prolonged EEG-video monitoring and other tests to pinpoint the exact location of the injured brain cells causing the seizures. The location of the damaged cells determines whether the surgery can be performed and what technique should be used.
The multidisciplinary evaluation is directed by a neurologist specializing in epilepsy (an epileptologist). A patient's eligibility for surgery is determined jointly by the neurosurgeon, neuroradiologist, neuropsychologist, social worker, and epileptologist. The decision to have the surgery is made jointly by the patient and the epileptologist after carefully reviewing the risks and benefits of the procedure.
Surgery is most commonly performed to treat partial epilepsy, since only one area of the brain is involved. During surgery, the area of the brain that triggers the seizures (usually a portion of the anterior temporal lobe) is removed. After surgery, some patients will be completely free of seizures; in others, the seizures will be better controlled. A few patients may need additional surgery.
Surgery is also done to implant devices. In vagus nerve stimulation (VNS), a device that electronically stimulates the vagus nerve (which controls activity between the brain and major internal organs) is implanted under the skin. This reduces seizure activity in some patients with partial seizures. There’s also the responsive neurostimulation device (RNS), which consists of a small neurostimulator implanted within the skull under the scalp. The neurostimulator is connected to one or two wires (called electrodes) that are placed where the seizures are suspected to originate within the brain or on the surface of the brain. The device detects abnormal electrical activity in the area and delivers electrical stimulation to normalize brain activity before seizure symptoms begin.
The ketogenic diet - a high-fat, low-carb plan - has received much attention lately and is effective for treating certain types of epilepsy. Specifically, it is used most frequently in children with seizures that have not responded to medical therapy. However, the diet requires careful planning and may be difficult to follow, so it is usually not recommended in older children or adults. The diet is usually started in the hospital, and when successful, it is most often maintained for two to three years.
