Synopsis
Choose antiseizure treatment from the electroclinical syndrome and the person’s wider risks, titrate one medicine transparently, monitor meaningful outcomes and toxicity, and recognise when specialist or tertiary review is preferable to serial empirical prescribing.
- Confirm that recurrent events are epileptic, classify each seizure using the 2025 ILAE classes, and formulate epilepsy type separately as focal, generalized, combined generalized and focal, or unknown before selecting a medicine; the wrong narrow-spectrum agent can aggravate absence or myoclonus.
- NICE first-line monotherapy for focal seizures is lamotrigine or levetiracetam, with the other considered if the first is unsuccessful; comorbidity and reproductive safety often decide between them.
- For generalised tonic-clonic seizures, NICE offers lamotrigine, levetiracetam or sodium valproate, but valproate is subject to stringent MHRA restrictions and lamotrigine can occasionally worsen myoclonus.
Key red flags
New or worsening myoclonus, absence or generalised convulsions after a sodium-channel medicine should prompt urgent review of the electroclinical classification and possible medicine-induced aggravation.
Investigation priorities
Define what improvement or failure will mean before medication changes alter the clinical picture.
Management branches
Epilepsy is confirmed or treatment after a first seizure is justified by the recurrence-risk assessment.
- 1. Define seizure type and possible syndrome, revisiting witness, EEG and MRI evidence when focal and generalised features conflict.
- 2. Compare recommended options against pregnancy potential, contraception, mood, cognition, weight, organ function, interactions, occupation and the person’s treatment priorities.
Key medicines
LamotrigineFor monotherapy a common start is 25 mg once daily for 14 days, then 50 mg once daily for 14 days before gradual increases; valproate and enzyme inducers require substantially different schedules from the current BNF.
LevetiracetamA common adult initiation is 250–500 mg twice daily with titration to response; reduce maintenance dosing in renal impairment and follow the BNF and specialist plan.