Treatment of epilepsy
When to initiate treatment?
The need to treat epilepsy is ominous except in certain situations where the approach might be slightly conservative. These include:
a. First seizure
b. Benign epileptic syndromes
c. Seizure not timely classifiable as epilepsy.

The risk factors where AED treatment may be considered after first seizures include.
1. Symptomatic seizures due to underlying etiology (atrophy, inflammatory granuloma, infarct, migration defect).
2. Partial seizures with greater relapse risk than generalized tonic clonic events.
3. Abnormal epileptiform discharges on the EEG
4. Positive family history of epilepsy
5. Seizures associated with severe head injury
6. Myoclonic seizures
7. Absence seizures.

Siezure type and anti epileptic drugs of choice
Partial seizures	Carbamazepine (CBZ) Phenytoin (PHT) Phenobarbitone (PB) Newer AED Clobazam (CLBZ) Lamotrigine (LTG) Vigabatrin (VGB)
Generalised Tonic Clonic Seizures	Sodium Valproate (VPA) Phenytoin (PHT) Carbamazepine (CBZ)
Petit Mal	Ethosunimide (ET) Valproic acid (VPA)
Myoclonic seizures	Valproic acid (VPA) Benzodiazepines (BZD) (Clonazepam)
Mixed Seizures	Valproic acid (VPA)

Anti epileptic drugs:

General principles in the treatment of epilepsy
1. Monotherapy is the rule;
2. Start with single drug start with low does and increase dose gradually
3. Caution patient about possible risk of seizure in early phase due to non attainment of blood levels and steady state.
4. Stress compliance with AED.
5. In case of seizure recurrence, increase dose to maximum pharmacological dose or maximum tolerated dose level.
6. In case of non-response switch to alternate AED.
7. It must be realised that changing the drug is effective in controlling the seizures in only 20% of patient who did not respond to the initial drug.
8. In case of non response, check compliance by history, drug levels, drug interactions, intercurrent precipitating events, reevaluate diagnosis, exclude progressive neurological disease. If a single drug does not control seizures in the highest tolerated dose, change to another while gradually opening off the first drug.