AKT · Neurology/Seizures, delirium & paeds

Epilepsy

Tendency to recurrent unprovoked seizures (focal vs generalised)

Overview

A tendency to recurrent UNPROVOKED seizures. Classification (focal vs generalised) drives drug choice. The high-yield exam points: sodium valproate is highly teratogenic (avoid in women of childbearing potential), and the first-line drugs differ by seizure type.

Recognise

Generalised tonic-clonic: LOC, stiffening then jerking, tongue-biting, incontinence, post-ictal confusion
Focal (e.g. temporal lobe): aura (déjà vu, rising epigastric sensation), automatisms, ± progression
Absence (children): brief blank stares; myoclonic: brief jerks; atonic: drops

Red flags

Status epilepticus (≥5 min); first seizure needs assessment; pregnancy/teratogenicity; SUDEP risk

Differentials & how to tell them apart

Syncopeprodrome, rapid recovery, brief twitching only, situational/cardiac trigger

Psychogenic non-epileptic seizuresnormal EEG/ictal video, no post-ictal confusion/prolactin rise, atypical features

TIAnegative symptoms (loss), no jerking/post-ictal phase

Hypoglycaemialow glucose — a provoked seizure, reversible

Investigations

Clinical + EEG (supports type, does not exclude), MRI brain (focal/structural cause), ECG (exclude cardiac syncope), bloods/glucose. Diagnosis is clinical after the first unprovoked seizure assessment.

Management

Drug by seizure type: focal → lamotrigine/levetiracetam; generalised → valproate (lamotrigine/levetiracetam if childbearing potential)

1Classify the seizure type (focal vs generalised); start the appropriate first-line antiepileptic, usually after a second seizure or a high-recurrence-risk first seizure.Gate: Sodium valproate is highly TERATOGENIC and must be avoided in women/girls of childbearing potential unless under the pregnancy-prevention programme → use lamotrigine or levetiracetam instead
2Titrate to seizure freedom on monotherapy; counsel on SUDEP, driving (DVLA), and the specific risk of carbamazepine worsening absence/myoclonic seizures.

Generalised tonic-clonic: sodium valproate (men) / lamotrigine or levetiracetam (women of childbearing potential) — valproate teratogenic

Focal: lamotrigine or levetiracetam first-line — (carbamazepine an alternative)

Absence: ethosuximide or sodium valproate — (avoid carbamazepine — worsens absence)

Key points

Valproate = teratogenic (avoid in women of childbearing potential). Match the drug to the type (carbamazepine can WORSEN absence/myoclonic). Distinguish from syncope and non-epileptic attacks (normal EEG, no prolactin rise).

Monitor & prognosis

Seizure frequency, drug levels/side effects, pregnancy planning, DVLA status.

Most achieve control on monotherapy.

Source: NICE NG217 (epilepsies)