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Overview

This Guidelines summary covers diagnosing and managing epilepsy in children, young people, and adults in primary care. For a complete set of recommendations, refer to the full guideline.

This guideline updates and replaces NICE guideline CG137.

Refer to the full guideline for recommendations on the following topics:

  • support and monitoring for women planning pregnancy or who are pregnant
  • discontinuing antiseizure medication
  • treating childhood-onset epilepsies
  • treating status epilepticus, repeated or cluster seizures, and prolonged seizures
  • non-pharmacological treatments
  • psychological, neurobehavioural, cognitive and developmental comorbidities in epilepsy
  • reducing the risk of epilepsy-related death, including sudden unexpected death in epilepsy
  • service provision and transition.

View this summary online at guidelines.co.uk/456970.article

Diagnosis and assessment of epilepsy

Referral after a first seizure or remission and assessing risk of a second seizure

Referral after a first seizure

For recommendations on immediate guidance and referral for children under 2 years with suspected or confirmed infantile spasms, see the section on infantile spasms syndrome in the full guideline.

  • Refer children, young people and adults urgently (for an appointment within 2 weeks) for an assessment after a first suspected seizure:
    • For adults, refer to a clinician with expertise in assessing first seizures and diagnosing epilepsy.
    • For children and young people, refer to a paediatrician with expertise in assessing first seizures and diagnosing epilepsy.

Referral after remission

  • Refer children, young people and adults urgently (for an appointment within 2 weeks) for an assessment if they have a seizure recurrence after a period of remission.

Assessing the risk of a second seizure

  • When a child, young person or adult presents with a first seizure, carry out an individualised assessment of their risk of a second seizure.
  • In adults, assessment should include checking for the following modifiable factors that may increase the risk of a second seizure:
    • an underlying mental health problem (such as depression, anxiety, psychosis and alcohol or substance misuse)
    • vascular risk factors (for example, diabetes, hypertension, atrial fibrillation)
    • sepsis.
  • Be aware that children presenting with a first afebrile seizure (seizure without a fever) are at an increased risk of further afebrile seizures, especially within 6 to 12 months, compared with children with a febrile seizure (seizure with a fever).
  • Be aware that children presenting with complicated febrile seizures (febrile seizures that last longer than 10 minutes or febrile seizures associated with other features, such as weakness, on one side of the body) may be at higher risk of epilepsy, especially if other predisposing risk factors for epilepsy are present.
  • Using a person-centred approach, discuss with the person, and their family and carers if appropriate, their individualised risks for further seizures. This should include any mental, physical and social factors identified as possible risk factors and how these may be modified.

Information and support after a first seizure

  • After a first seizure, give the person, and their family and carers if appropriate, information about:
    • how to recognise a further seizure
    • first aid and initial safety guidance in case of another seizure (see safety issues in box 1 in the full guideline)
    • any changes they can make to reduce their risk of another seizure
    • who they should contact if they have a further seizure while awaiting their appointment for assessment and diagnosis.
  • After a first afebrile seizure in a child, explain to their parents or carers how to self-refer the child urgently if they have a further seizure.

Specialist assessment and diagnosis

See also NICE’s guideline on transient loss of consciousness (‘blackouts’) in over 16s for recommendations on initial assessment of people after a suspected transient loss of consciousness. In particular, see the recommendations on performing electrocardiogram (ECG) in the section on obtaining patient history, physical examination and tests and on features suggestive of epileptic seizures in the section on suspected epilepsy.

  • Take a detailed history from the child, young person or adult after a first suspected seizure, and from their families and carers if appropriate, and carry out a physical examination. If possible, use eyewitness accounts and video footage of the seizure to inform the assessment.
  • Evaluate people after a first suspected seizure with a 12-lead ECG to help identify cardiac-related conditions that could mimic an epileptic seizure.
  • Be aware that metabolic disturbance, including hypoglycaemia, can result in seizures.
  • Offer brain neuroimaging tests if an underlying structural cause is suspected (see also the section on neuroimaging in the full guideline).

For recommendations on electroencephalogram (EEG), neuroimaging, genetic testing, antibody testing, and information and support, refer to the full guideline.

Principles of treatment, safety, monitoring, and withdrawal

Treatment with antiseizure medications

See also the section on antiseizure medications for women and girls for special considerations for this group.

  • Develop an individualised antiseizure medication treatment strategy with the person, and their family and carers if appropriate, taking into account:
    • sex
    • age
    • seizure type
    • epilepsy syndrome
    • whether treatment is needed
    • risks and benefits of antiseizure medications, including their importance in reducing the risk of epilepsy-related death
    • possible interactions with any other medicines taken
    • any comorbidities
    • the preferences of the person, and their family or carers if appropriate
    • personal circumstances, such as education, employment, likelihood of pregnancy, driving, alcohol use, travel
    • how and when antiseizure medicines need to be taken.

      See also NICE’s guidelines on shared decision making and decision making and mental capacity.
  • Take into account any particular issues for older people starting an antiseizure medication, especially those with comorbidities, for example:
    • check for possible interactions with other medicines they are taking
    • use a tailored approach to dosage and titration, usually starting at a lower dose and increasing slowly
    • check if the person would benefit from an approach that takes into account multimorbidity; for more information, see NICE’s guideline on multimorbidity.
  • Use a single antiseizure medication (monotherapy) to treat epilepsy whenever possible.
  • Review the diagnosis of epilepsy if seizures continue despite an optimal dose of a first-line antiseizure medication.
  • If first-line monotherapy is unsuccessful and epilepsy diagnosis remains confirmed, try monotherapy with another antiseizure medication, using caution during the changeover period:
    • Increase the dose of the second medicine slowly while maintaining the dose of the first medicine.
    • If the second medicine is successful, slowly taper off the dose of the first medicine.
    • If the second medicine is unsuccessful, slowly taper off the dose of the second medicine and consider an alternative.
  • If monotherapy is unsuccessful, consider trying an add-on treatment.
  • When starting an add-on treatment, carefully titrate the additional medicine and review treatment frequently, including monitoring for adverse effects such as sedation.
  • If trials of add-on treatment do not result in a reduction in seizures, use the regimen that provides the best balance between effectiveness and tolerability of side effects.
  • Discuss with the person, and their family and carers as appropriate, the benefits of taking as few medicines as possible to maintain seizure freedom or control.

When to start antiseizure medication

  • Start treatment with an antiseizure medication once the diagnosis of epilepsy is confirmed.
  • Consider starting treatment after a first unprovoked seizure if any of the following apply:
    • an examination identifies signs of neurological deficit
    • the electroencephalogram (EEG) shows unequivocal epileptic activity
    • after a discussion of the risk of further seizures, the person or their family or carers consider the risk unacceptable
    • brain imaging shows a structural abnormality.

Safety considerations

See the section on antiseizure medications for women and girls for additional safety considerations for this group.

  • Follow Medicines and Healthcare products Regulatory Agency (MHRA) safety advice on switching between different manufacturers’ products of a particular antiseizure medication.
  • Be aware that phenytoin is associated with an increased risk of serious skin reactions in people of Han Chinese or Thai family background.
  • Be aware that carbamazepine and potentially medicines with a similar chemical structure (such as oxcarbazepine and eslicarbazepine acetate) are associated with an increased risk of serious skin reactions in people of Han Chinese, Thai, European or Japanese family background.
  • Be aware that long-term treatment with some antiseizure medications (such as carbamazepine, phenytoin, primidone and sodium valproate) is associated with decreased bone mineral density and increased risk of osteomalacia. Follow the MHRA safety advice on antiepileptics: adverse effects on bone and consider vitamin D and calcium supplementation for people at risk.

Antiseizure medications for women and girls

  • Give women and girls with epilepsy information and support that is tailored to their age-specific and developmental needs. Review regularly information provided about:
    • contraception
    • folic acid supplementation
    • conception
    • pregnancy
    • breastfeeding
    • caring for children
    • menopause.
  • Discuss with women and girls with epilepsy who are able to have children (including young girls who are likely to need treatment when they are able to have children), and their families or carers if appropriate, the risks to an unborn child of taking antiseizure medications during pregnancy, such as congenital malformations, neurodevelopmental impairments and fetal growth restriction.
  • Assess the risks and benefits of treatment with individual antiseizure medications when prescribing antiseizure medications for women and girls who are able to have children, now or in the future. Take into account the latest data on the risks to the unborn child and be aware that there are important uncertainties about the risks, particularly with newer drugs. Follow the MHRA safety advice on antiepileptic drugs in pregnancy.
  • Specifically, discuss the risks to the unborn child of using sodium valproate during pregnancy, including the increased risk with higher doses and polytherapy. Follow the MHRA safety advice on valproate use by women and girls.
  • Be aware that some antiseizure medications, for example, carbamazepine, oxcarbazepine, phenytoin and topiramate, can impair the effectiveness of hormonal contraceptives. Refer to the summary of product characteristics (SPC) and BNF or BNF for children for individual drug advice on the interactions between antiseizure medications and contraception.
  • Be aware that oestrogen-containing hormonal contraceptives and hormone replacement therapy can impair the effectiveness of lamotrigine.
  • Explain that breastfeeding for most women and girls taking antiseizure medications is generally safe and should be encouraged. Support each mother to choose a feeding method that bests suits her and her family.
  • Prescribers should consult individual drug advice in the SPC and the BNF or BNF for children when prescribing antiseizure medications for women and girls who are breastfeeding. Decisions about antiseizure therapy and breastfeeding should be made between the woman or girl and the prescriber, and take into account the benefits of breastfeeding alongside the potential risks of the medication affecting the child.

Monitoring and review

  • Arrange regular (at least annual) monitoring reviews for adults with epilepsy and any of the following:
    • a learning disability
    • drug-resistant epilepsy
    • a high risk of sudden unexpected death in epilepsy (SUDEP; see the section on reducing the risk of epilepsy-related death in the full guideline)
    • a serious comorbidity, such as complex psychosocial, cognitive or mental health problems
    • who are taking antiseizure medications associated with long-term side effects or drug interactions
    • who are able to get pregnant and are taking valproate or any other high-risk teratogenic antiseizure medication (see also the MHRA safety advice on antiepileptic drugs in pregnancy).
  • Discuss monitoring reviews with children and young people with epilepsy and their families and carers if appropriate, and agree a frequency for regular reviews that is:
    • individually tailored to the child or young person’s needs, preferences and the nature of their epilepsy and
    • at least every 12 months.
  • Consider monitoring antiseizure medication levels in people with epilepsy and any of the following:
    • uncontrolled seizures
    • side effects from their medication
    • a specific clinical condition needing closer supervision (such as pregnancy or renal failure)
    • poor adherence to medication.
  • Explain to people with epilepsy and, if appropriate, their families and carers, that they can ask for a review of their care if they have concerns, need support or their care needs change, for example, to support medicines withdrawal, pregnancy planning or to review treatment if seizures recur. Provide contact details and information on how to access epilepsy services.

Treating epileptic seizures in children, young people and adults

Generalised tonic-clonic seizures

Monotherapy

  • Offer sodium valproate as first-line monotherapy for generalised tonic-clonic seizures in:
    • boys and men
    • girls aged under 10 years and who are unlikely to need treatment when they are old enough to have children
    • women who are unable to have children.
  • Offer lamotrigine or levetiracetam as first-line monotherapy for generalised tonic-clonic seizures in women and girls able to have children (including young girls who are likely to need treatment when they are old enough to have children). If the first choice is unsuccessful, offer the other of these options.

    In April 2022, these were off-label uses of lamotrigine in children under 13 years and levetiracetam in adults and children. See NICE’s information on prescribing medicines.
  • If first-line monotherapy with sodium valproate is unsuccessful for generalised tonic-clonic seizures, offer lamotrigine or levetiracetam as second-line monotherapy treatment. If the first choice is unsuccessful, try the other of these options.

    In April 2022, these were off-label uses of lamotrigine in children under 13 years and levetiracetam in adults and children. See NICE’s information on prescribing medicines.
  • Do not offer sodium valproate monotherapy for generalised tonic-clonic seizures in women and girls able to have children (including young girls who are likely to need treatment when they are old enough to have children), unless:
    • other treatment options are unsuccessful
    • the risks and benefits have been fully discussed, including the risks to an unborn child
    • the likelihood of pregnancy has been taken into account and a pregnancy prevention programme put in place, if appropriate.

      Follow the MHRA safety advice on valproate use by women and girls.

Add-on treatment

For guidance on safe prescribing and managing withdrawal of clobazam in adults, see NICE’s guideline on medicines associated with dependence or withdrawal symptoms.

  • If monotherapy is unsuccessful in people with generalised tonic-clonic seizures, consider 1 of the following first-line add-on treatment options:
    • clobazam
    • lamotrigine
    • levetiracetam
    • perampanel
    • sodium valproate, except in women and girls able to have children
    • topiramate.
  • If the first choice is unsuccessful, consider the other first-line add-on options.

    In April 2022, these were off-label uses of clobazam as add-on therapy in children under 6 months, lamotrigine in children under 2 years, levetiracetam in children under 12 years, perampanel in children under 7 years, and topiramate in children under 2 years. See NICE’s information on prescribing medicines.
  • If first-line add-on treatments tried are unsuccessful in people with generalised tonic-clonic seizures, consider 1 of the following second-line add-on treatment options:
    • brivaracetam
    • lacosamide
    • phenobarbital
    • primidone
    • zonisamide.

      If the first choice is unsuccessful, consider the other second-line add-on options.

      In April 2022, these were off-label uses of brivaracetam in adults and children, lacosamide in children under 4 years, and zonisamide in adults and children. See NICE’s information on prescribing medicines.
  • Do not offer sodium valproate as an add-on treatment for generalised tonic-clonic seizures in women and girls able to have children (including young girls who are likely to need treatment when they are old enough to have children), unless:
    • other treatment options are unsuccessful
    • the risks and benefits have been fully discussed, including the risks to an unborn child
    • the likelihood of pregnancy has been taken into account and a pregnancy prevention programme put in place, if appropriate.

      Follow the MHRA safety advice on valproate use by women and girls.

Other treatment considerations

  • Be aware that the following antiseizure medications may exacerbate seizures in people with absence or myoclonic seizures, including in juvenile myoclonic epilepsy:
    • carbamazepine
    • gabapentin
    • lamotrigine (for myoclonic seizures)
    • oxcarbazepine
    • phenytoin
    • pregabalin
    • tiagabine
    • vigabatrin.

For recommendations on focal seizures with or without evolution to bilateral tonic-clonic seizures, absence seizures, myoclonic seizures, tonic or atonic seizures, and idiopathic generalised epilepsies, view the online summary at guidelines.co.uk/456970.article

Focal seizures with or without evolution to bilateral tonic-clonic seizures

Monotherapy

  • Consider lamotrigine or levetiracetam as first-line monotherapy for people with focal seizures. If the first choice is unsuccessful, consider the other of these options.

    In April 2022, these were off-label uses of lamotrigine in children under 13 years, and levetiracetam in children and young people under 16 years. See NICE’s information on prescribing medicines.
  • If first-line monotherapies are unsuccessful in people with focal seizures, consider 1 of the following second-line monotherapy options:
    • carbamazepine
    • oxcarbazepine
    • zonisamide.

      If the first choice is unsuccessful, consider the other second-line monotherapy options.

      In April 2022, these were off-label uses of oxcarbazepine in children under 6 years, and zonisamide in children. See NICE’s information on prescribing medicines.
  • If second-line monotherapies tried are unsuccessful in people with focal seizures, consider lacosamide as third-line monotherapy.

    In April 2022, this was an off-label use of lacosamide in children under 4 years. See NICE’s information on prescribing medicines.

Add-on treatment

For guidance on safe prescribing of pregabalin in adults, see NICE’s guideline on medicines associated with dependence or withdrawal symptoms.

  • If monotherapy is unsuccessful in people with focal seizures, consider 1 of the following first-line add-on treatment options:
    • carbamazepine
    • lacosamide
    • lamotrigine
    • levetiracetam
    • oxcarbazepine
    • topiramate
    • zonisamide.

      If the first choice is unsuccessful, consider the other first-line add-on options.

      In April 2022, these were off-label uses of lacosamide in children under 4 years, lamotrigine in children under 2 years, levetiracetam in children under 4 years, oxcarbazepine in children under 6 years, topiramate in children under 2 years, and zonisamide in children under 6 years. See NICE’s information on prescribing medicines.
  • If first-line add-on treatments tried are unsuccessful in people with focal seizures, consider 1 of the following second-line add-on treatment options:
    • brivaracetam
    • cenobamate (in line with NICE’s technology appraisal guidance on cenobamate for treating focal onset seizures in epilepsy)
    • eslicarbazepine acetate
    • perampanel
    • pregabalin
    • sodium valproate, except in women and girls able to have children.

      If the first choice is unsuccessful, consider the other second-line add-on options.

      In April 2022, these were off-label uses of brivaracetam in children under 4 years, eslicarbazepine acetate in children under 6 years, perampanel in children under 4 years, and pregabalin in children. See NICE’s information on prescribing medicines.
  • If second-line add-on treatments tried are unsuccessful in people with focal seizures, consider 1 of the following third-line add-on treatment options:
    • phenobarbital
    • phenytoin
    • tiagabine
    • vigabatrin.

      If the first choice is unsuccessful, consider the other third-line add-on options.

      In April 2022, this was an off-label use of tiagabine in children under 12 years. See NICE’s information on prescribing medicines.
  • Do not offer sodium valproate as an add-on treatment for focal seizures in women and girls able to have children (including young girls who are likely to need treatment when they are old enough to have children), unless:
    • other treatment options are unsuccessful
    • the risks and benefits have been fully discussed, including the risks to an unborn child
    • the likelihood of pregnancy has been taken into account and a pregnancy prevention programme put in place, if appropriate.

      Follow the MHRA safety advice on valproate use by women and girls.

Absence seizures

Absence seizures (including childhood absence epilepsy)

  • Offer ethosuximide as first-line treatment for absence seizures.
  • If first-line treatment is unsuccessful, offer sodium valproate as second-line monotherapy or add-on treatment for absence seizures in:
    • boys of all ages
    • girls aged under 10 years and who are unlikely to need treatment when they are old enough to have children
    • women who are unable to have children.
  • If second-line treatment is unsuccessful for absence seizures, consider lamotrigine or levetiracetam as a third-line monotherapy or add-on treatment options. If the first choice is unsuccessful, consider the other of these options.

    In April 2022, these were off-label uses of lamotrigine in children under 2 years and levetiracetam in adults and children. See NICE’s information on prescribing medicines.
  • Be aware that the following antiseizure medications may exacerbate seizures in people with absence seizures:
    • carbamazepine
    • gabapentin
    • oxcarbazepine
    • phenobarbital
    • phenytoin
    • pregabalin
    • tiagabine
    • vigabatrin.

Absence seizures with other seizure types

  • Consider sodium valproate as first-line treatment for absence seizures with other seizure types (or at risk of these) in:
    • boys and men
    • girls aged under 10 years and who are unlikely to need treatment when they are old enough to have children
    • women who are unable to have children.
  • Consider lamotrigine or levetiracetam as first-line treatment options in women and girls able to have children (including young girls who are likely to need treatment when they are old enough to have children) with absence seizures and other seizure types (or at risk of these). If the first choice is unsuccessful, consider the other of these options.

    In April 2022, these were off-label uses of levetiracetam as monotherapy for adults and children, and as an add-on therapy for children under 12 years. See NICE’s information on prescribing medicines.
  • Do not offer sodium valproate for absence seizures with other seizure types (or at risk of these) in women and girls able to have children (including young girls who are likely to need treatment when they are old enough to have children), unless:
    • other treatment options are unsuccessful
    • the risks and benefits have been fully discussed, including the risks to an unborn child
    • the likelihood of pregnancy has been taken into account and a pregnancy prevention programme put in place, if appropriate.

      Follow the MHRA safety advice on valproate use by women and girls.
  • If first-line treatments tried are unsuccessful for absence seizures and other seizure types (or at risk of these), consider:
    • lamotrigine or levetiracetam as a second-line monotherapy or add-on treatment options or
    • ethosuximide as a second-line add-on treatment.

      If the first choice is unsuccessful, consider the other second-line options.

      In April 2022, these were off-label uses of lamotrigine in children under 2 years, and levetiracetam in adults and children. See NICE’s information on prescribing medicines.
  • Be aware that the following antiseizure medications may exacerbate seizures in people with absence seizures and other seizure types (or at risk of these):
    • carbamazepine
    • gabapentin
    • oxcarbazepine
    • phenobarbital
    • phenytoin
    • pregabalin
    • tiagabine
    • vigabatrin.

Myoclonic seizures

Specialist involvement

  • If a child under 4 years has myoclonic seizures, either seek guidance on treatment from or refer to a tertiary paediatric neurologist.

First-line treatment

  • Offer sodium valproate as first-line treatment for myoclonic seizures in:
    • boys and men
    • girls aged under 10 years and who are unlikely to need treatment when they are old enough to have children
    • women who are unable to have children.
  • Offer levetiracetam as first-line treatment for myoclonic seizures in women and girls able to have children (including young girls who are likely to need treatment when they are old enough to have children).

    In April 2022, this was an off-label use of levetiracetam. See NICE’s information on prescribing medicines.

Second- and third-line treatments

For guidance on safe prescribing and managing withdrawal of clobazam and clonazepam in adults, see NICE’s guideline on medicines associated with dependence or withdrawal symptoms.

  • If sodium valproate is unsuccessful as first-line treatment for myoclonic seizures, offer levetiracetam as a second-line monotherapy or add-on treatment.

    In April 2022, these were off-label uses of levetiracetam as monotherapy for adults and children, and as an add-on therapy for children under 12 years. See NICE’s information on prescribing medicines.
  • If levetiracetam is unsuccessful for myoclonic seizures, consider 1 of the following as monotherapy or add-on treatment options:
    • brivaracetam
    • clobazam
    • clonazepam
    • lamotrigine
    • phenobarbital
    • piracetam
    • topiramate
    • zonisamide.

      If the first choice is unsuccessful, consider any other of these options.

      In April 2022, these were off-label uses for brivaracetam in adults and children, clobazam as monotherapy in adults and children, clobazam as add-on therapy in children under 6 months, clonazepam solution in children, lamotrigine as monotherapy for children under 13 years and add-on therapy for children under 2 years, piracetam in children, topiramate in adults and children, and zonisamide in adults and children. See NICE’s information on prescribing medicines.
  • Do not offer sodium valproate for myoclonic seizures in women and girls able to have children (including young girls who are likely to need treatment when they are old enough to have children), unless:
    • other treatment options are unsuccessful
    • the risks and benefits have been fully discussed, including the risks to an unborn child
    • the likelihood of pregnancy has been taken into account and a pregnancy prevention programme put in place, if appropriate.

      Follow the MHRA safety advice on valproate use by women and girls.

Other treatment considerations

  • Be aware that lamotrigine can occasionally exacerbate myoclonic seizures.
  • Do not use any of the following antiseizure medications in people with myoclonic seizures because they may exacerbate seizures:
    • carbamazepine
    • gabapentin
    • oxcarbazepine
    • phenytoin
    • pregabalin
    • tiagabine
    • vigabatrin.

Tonic or atonic seizures

Specialist involvement

  • Ensure that people with a diagnosis of tonic or atonic seizures are assessed by a neurologist with expertise in epilepsy to:
    • diagnose the syndrome if possible and
    • advise on investigation and treatment.

First-line treatment

  • Offer sodium valproate as first-line treatment for tonic or atonic seizures in:
    • boys and men
    • girls aged under 10 years and who are unlikely to need treatment when they are old enough to have children
    • women who are unable to have children.
  • Consider lamotrigine as first-line treatment for tonic or atonic seizures in women and girls able to have children (including young girls who are likely to need treatment when they are old enough to have children).

    In April 2022, this was an off-label use of lamotrigine in children under 13 years. See NICE’s information on prescribing medicines.

Second- and third-line treatments

For guidance on safe prescribing and managing withdrawal of clobazam in adults, see NICE’s guideline on medicines associated with dependence or withdrawal symptoms.

  • If sodium valproate is unsuccessful as first-line treatment for tonic or atonic seizures, consider lamotrigine as a second-line monotherapy or add-on treatment.

    In April 2022, this was an off-label use of lamotrigine as monotherapy in children under 13 years and add-on therapy in children under 2 years. See NICE’s information on prescribing medicines.
  • If lamotrigine is unsuccessful for treating tonic or atonic seizures, consider 1 of the following as monotherapy or add-on treatment options:
    • clobazam
    • rufinamide
    • topiramate.

      If the first choice is unsuccessful, consider any other of these options.

      In April 2022, these were off-label uses for clobazam as monotherapy in adults and children, clobazam as add-on therapy in children under 6 months, rufinamide, and topiramate as monotherapy in children under 6 years, and topiramate as add-on therapy in children under 2 years. See NICE’s information on prescribing medicines.
  • Do not offer sodium valproate for tonic or atonic seizures in women and girls able to have children (including young girls who are likely to need treatment when they are old enough to have children), unless:
    • other treatment options are unsuccessful
    • the risks and benefits have been fully discussed, including the risks to an unborn child
    • the likelihood of pregnancy has been taken into account and a pregnancy prevention programme put in place, if appropriate.

      Follow the MHRA safety advice on valproate use by women and girls.

Further treatment options

  • If third-line treatment is unsuccessful for tonic or atonic seizures in children, consider a ketogenic diet as an add-on treatment under the supervision of a ketogenic diet team.
  • If all other treatment options for tonic or atonic seizures are unsuccessful, consider felbamate as an add-on treatment under the supervision of a neurologist with expertise in epilepsy.

    In April 2022, felbamate was not licensed for use in the UK. See NICE’s information on prescribing medicines.

Other treatment considerations

  • Be aware that the following antiseizure medications may exacerbate seizures in people with tonic or atonic seizures:
    • carbamazepine
    • gabapentin
    • oxcarbazepine
    • pregabalin
    • tiagabine
    • vigabatrin.

Idiopathic generalised epilepsies

First-line treatment

  • Offer sodium valproate as first-line treatment for idiopathic generalised epilepsies in:
    • boys and men
    • girls aged under 10 years and who are unlikely to need treatment when they are old enough to have children
    • women who are unable to have children.
  • Offer lamotrigine or levetiracetam as first-line treatment for idiopathic generalised epilepsies in women and girls able to have children (including young girls who are likely to need treatment when they are old enough to have children). If the first choice is unsuccessful, offer the other of these options.

    In April 2022, these were off-label uses of lamotrigine in children under 13 years, and levetiracetam in adults and children. See NICE’s information on prescribing medicines.

Second-line treatment

  • If first-line treatments are unsuccessful for idiopathic generalised epilepsies, consider lamotrigine or levetiracetam as a second-line monotherapy or add-on treatment options. If the first choice is unsuccessful, consider the other of these options.

    In April 2022, these were off-label uses of lamotrigine as monotherapy in children under 13 years and add-on therapy for children under 2 years, and levetiracetam as monotherapy in adults and children and add-on therapy for children under 12 years. See NICE’s information on prescribing medicines.
  • If second-line treatments tried are unsuccessful for idiopathic generalised epilepsies, consider perampanel or topiramate as third-line add-on treatment options. If the first choice is unsuccessful, consider the other of these options.

    In April 2022, this was an off-label use of perampanel for children under 7 years. See NICE’s information on prescribing medicines.
  • Do not offer sodium valproate for idiopathic generalised epilepsies in women and girls able to have children (including young girls who are likely to need treatment when they are old enough to have children), unless:
    • other treatment options are unsuccessful
    • the risks and benefits have been fully discussed, including the risks to an unborn child
    • the likelihood of pregnancy has been taken into account and a pregnancy prevention programme put in place, if appropriate.

      Follow the MHRA safety advice on valproate use by women and girls.

Refer to the full guideline for recommendations on the following topics:

  • support and monitoring for women planning pregnancy or who are pregnant
  • discontinuing antiseizure medication
  • treating childhood-onset epilepsies
  • treating status epilepticus, repeated or cluster seizures, and prolonged seizures
  • non-pharmacological treatments
  • psychological, neurobehavioural, cognitive and developmental comorbidities in epilepsy
  • reducing the risk of epilepsy-related death including sudden unexpected death in epilepsy
  • service provision and transition.

 

© NICE 2022. Epilepsies in children, young people and adults. Available from: www.nice.org.uk/guidance/ng217. All rights reserved. Subject to Notice of rights.

NICE guidance is prepared for the National Health Service in England. All NICE guidance is subject to regular review and may be updated or withdrawn. NICE accepts no responsibility for the use of its content in this product/publication

Published date: 27 April 2022.

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