II. Indications: Definite for Seizure Prophylaxis medication

  1. With structural Lesion
    1. Brain Tumor
      1. Meningioma
      2. Glioma
      3. Neoplastic
    2. Arteriovenous Malformation
    3. Infection
      1. Brain Abscess
      2. Herpes Encephalitis
  2. Without Structural lesion
    1. Single Seizure followed by Second Seizure more than 24 hours apart
    2. History of Epilepsy in sibling
    3. Electroencephalogram with definite epileptic pattern
    4. History of prior acute Seizure
      1. Seizure in context of illness
      2. Childhood Febrile Seizure
    5. History of Brain injury
      1. Head Trauma
      2. Cerebrovascular Accident
      3. CNS Infection
    6. Todd's postictal paresis
    7. Status Epilepticus at onset

III. Indications: Possible for Seizure Prophylaxis medication

  1. Unprovoked Seizure (none of the above risk factors)

IV. Indications: Not recommended for Seizure Prophylaxis

  1. Alcohol Withdrawal or Drug Withdrawal
  2. Stimulant Abuse or Substance Abuse
  3. Seizure in context of acute illness
    1. High fever
    2. Hypoglycemia
    3. Electrolyte abnormality
    4. Hypoxia
  4. Postimpact Seizure
    1. Single Seizure immediately post acute Head Injury
  5. Specific benign Epilepsy syndrome
    1. Febrile Convulsions
    2. Benign Epilepsy with centrotemporal spikes
  6. Seizure provoked by excessive sleep deprivation
    1. Example: College student at exam time

V. Indications: Discontinuation of Seizure medications

  1. Children with Focal Seizures after Seizure free for 2 years on monotherapy
  2. Children with Generalized Seizures (including Absence Seizure) after Seizure free for 5 years on monotherapy

VI. Management: Antiepileptic Agent Selection

  1. See Status Epilepticus
  2. See specific Seizure types for optimal management
    1. Generalized Seizure (includes Generalized Tonic Clonic Seizure, Myoclonic Seizure)
    2. Absence Seizure
    3. Focal Seizure (includes simple and Complex Partial Seizure)
  3. Antiepileptic Medications used for Prophylaxis
    1. Carbamazepine (Tegretol)
    2. Phenobarbital
    3. Phenytoin (Dilantin)
    4. Gabapentin (Neurontin)
    5. Lamotigrine (Lamictal)
    6. Levetiracetam (Keppra)
      1. Mood effects (irritability, depressed mood) are common
    7. Lacosamide (Vimpat)
      1. Generic in 2022
      2. Considered a well tolerated, first-line agent in Seizure Prophylaxis
    8. Ocarbazepine (Trileptal)
    9. Topiramate (Topamax)
    10. Valproic Acid (Depakene)
    11. Vigabatrin (Sabril)
    12. Zonisamide (Zonegran)

VII. Management: Seizure on Antiepileptic agent

  1. Consider Antepileptic agent related causes
    1. Noncompliance (not taking medication or missed doses)
    2. Medication not ideally suited for patient's Seizure type
    3. Subtherapeutic dose
      1. Consider that a child's dose may not have increased with their growth
  2. Consider Seizure triggers
    1. Recent illness
    2. Sleep deprivation
    3. Alcohol
  3. Testing
    1. Antiepileptic drug levels
    2. Atypical Seizures may warrant additional testing
      1. See Seizure Indications for Neuroimaging
      2. Electroencephalogram
  4. Medications
    1. Treat Status Epilepticus if present
    2. Administer antiepileptic drug in the emergency department (if missed doses)
      1. Consider discussing dosing with neurology consultant

VIII. Precautions: Suicidal Ideation

  1. Seizure Disorder itself increases risk of Suicidal Ideation by 3 fold over baseline
  2. Anticonvulsant use has also been associated with increased Suicidal Ideation
    1. Kuehn (2008) JAMA 299(10):1121-2 [PubMed]

IX. References

  1. Nocera, Valente, Amanullah (2018) Crit Dec Emerg Med 32(11): 3-9

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