II. Indications: Definite for Seizure Prophylaxis medication
- With structural Lesion
- Brain Tumor
- Meningioma
- Glioma
- Neoplastic
- Arteriovenous Malformation
- Infection
- Brain Abscess
- Herpes Encephalitis
- Brain Tumor
- Without Structural lesion
- Single Seizure followed by Second Seizure more than 24 hours apart
- History of Epilepsy in sibling
- Electroencephalogram with definite epileptic pattern
- History of prior acute Seizure
- Seizure in context of illness
- Childhood Febrile Seizure
- History of Brain injury
- Todd's postictal paresis
- Status Epilepticus at onset
III. Indications: Possible for Seizure Prophylaxis medication
- Unprovoked Seizure (none of the above risk factors)
IV. Indications: Not recommended for Seizure Prophylaxis
- Alcohol Withdrawal or Drug Withdrawal
- Stimulant Abuse or Substance Abuse
-
Seizure in context of acute illness
- High fever
- Hypoglycemia
- Electrolyte abnormality
- Hypoxia
- Postimpact Seizure
- Single Seizure immediately post acute Head Injury
- Specific benign Epilepsy syndrome
- Febrile Convulsions
- Benign Epilepsy with centrotemporal spikes
-
Seizure provoked by excessive sleep deprivation
- Example: College student at exam time
V. Indications: Discontinuation of Seizure medications
- Children with Focal Seizures after Seizure free for 2 years on monotherapy
- Children with Generalized Seizures (including Absence Seizure) after Seizure free for 5 years on monotherapy
VI. Management: Antiepileptic Agent Selection
- See Status Epilepticus
- See specific Seizure types for optimal management
- Generalized Seizure (includes Generalized Tonic Clonic Seizure, Myoclonic Seizure)
- Absence Seizure
- Focal Seizure (includes simple and Complex Partial Seizure)
- Antiepileptic Medications used for Prophylaxis
- Carbamazepine (Tegretol)
- Phenobarbital
- Phenytoin (Dilantin)
- Gabapentin (Neurontin)
- Lamotigrine (Lamictal)
- Levetiracetam (Keppra)
- Mood effects (irritability, depressed mood) are common
- Lacosamide (Vimpat)
- Generic in 2022
- Considered a well tolerated, first-line agent in Seizure Prophylaxis
- Ocarbazepine (Trileptal)
- Topiramate (Topamax)
- Valproic Acid (Depakene)
- Vigabatrin (Sabril)
- Zonisamide (Zonegran)
VII. Management: Seizure on Antiepileptic agent
- Consider Antepileptic agent related causes
- Noncompliance (not taking medication or missed doses)
- Medication not ideally suited for patient's Seizure type
- Subtherapeutic dose
- Consider that a child's dose may not have increased with their growth
- Consider Seizure triggers
- Testing
- Antiepileptic drug levels
- Atypical Seizures may warrant additional testing
- Medications
- Treat Status Epilepticus if present
- Administer antiepileptic drug in the emergency department (if missed doses)
- Consider discussing dosing with neurology consultant
VIII. Precautions: Suicidal Ideation
- Seizure Disorder itself increases risk of Suicidal Ideation by 3 fold over baseline
- Anticonvulsant use has also been associated with increased Suicidal Ideation
IX. References
- Nocera, Valente, Amanullah (2018) Crit Dec Emerg Med 32(11): 3-9