Epilepsy Protocol

Aims in Epilepsy Management

• rapid, accurate diagnosis with classification of seizure type and epilepsy syndrome if possible.
• to control seizures either by avoidance of trigger factors or by use of appropriate antiepileptic drugs.
• to ensure patients receive adequate information about their condition including their seizure type, investigations, safety precautions, side effects of drugs, driving restrictions, preconceptual and contraception advice.
• to provide support for patients and their carers.

Outline of Epilepsy Management

NEW CASES (1-2 per year per GP)

The GP should:

• obtain a clear account of the attack including any witness account and relevant history including trigger factors, alcohol or drug abuse, social circumstances, past history and family history.
• refer to specialist for confirmation of diagnosis, classification of seizure type, investigation and guidance on treatment.
• give preliminary advice about driving, work/leisure, reasons for referral and first aid if further seizure occurs. A witness of the seizure should go to the first hospital appointment.

Treatment is not usually given after a single seizure but may be required is the diagnosis is not in doubt and the patient continues to have seizures.

ESTABLISHED CASES (10-20 per GP)

Patients should have at least an annual review to check:

• seizure control including the date of last seizure and frequency of attacks.
• side effects of drugs and patient compliance including drug levels if seizure control poor.
• education about epilepsy
• lifestyle including driving, contraception, pregnancy planning, employment and benefits
• any other problems

Diagnosis of Epilepsy
Epilepsy is an important diagnosis with major implications. It is better to wait than make a hasty diagnosis. 20% of patients diagnosed with epilepsy do not have epilepsy.

Seizures may be:

• partial
  • simple partial, the "aura"
  • complex partial (loss of awareness often with automatisms)
  • secondary generalised (partial or complex partial evolving to generalised

• generalised
  • absences
  • myoclonic jerks
  • primary generalised tonic-clonic seizures
  • atonic or tonic seizures

Antiepileptic Drugs

seizure type	first line drug	add on drugs
partial seizures	carbamazepine valproate	vigabactrin lamotrigine gabapentin topiramate
generalised seizures	valproate carbamazepine	lamotrigine phenytoin clonazepam
absence seizures	ethosuximide valproate	lamotrigine
myoclonus	valproate clonazepam	lamotrigine

How long to continue treatment?
This is a difficult issue in adults. Many patients with well controlled epilepsy have regained their driving license and do not want to risk having further seizures. Female patients wanting to start a family may wish to consider coming off treatment before conception to minimise the risk to the foetus. Decisions have to be made on an individual basis. Some epilepsy syndromes (especially juvenile myoclonic epilepsy) have such a high risk of recurrence off treatment that discontinuation is not recommended.

In most cases it is reasonable to consider stopping drugs after 2-3 years without seizures. An MRC trial of stopping treatment showed that the risk of further seizures was 43% in those who stopped and 10% in those that continued. The highest risk of recurrence was in the first four months after stopping. 80% who were going to have a further fit had done so by one year. Patients who decide to stop medication should be advised to stop driving during drug withdrawal and for six months after that. If they do have a seizure their licence will be withdrawn until they have been seizure free for another year.

Counselling
For advice to patients click here