Management

• Start initial stabilization steps for acute seizures as needed.

• Identify and treat rapidly reversible causes of seizures.

• Implement phased-based acute seizure management.

  • If < 5 minutes from seizure onset: monitor and prepare for benzodiazepine administration.

  • If the seizure lasts ≥ 5 minutes (i.e., status epilepticus): [34]

    • Urgently administer a parenteral benzodiazepine.

    • If no response to benzodiazepines: Start a parenteral antiepileptic drug.

Status epilepticus is a life‑threatening condition. If not interrupted, it can lead to cerebral edema, hyperthermia, rhabdomyolysis, and cardiovascular failure. If the time from seizure onset is unknown, begin management for status epilepticus.

Acute seizures are often self-limited and may not require immediate pharmacological intervention.

• Call for help and remove or control hazards (e.g., remove sharp objects in the patient's vicinity).

• Perform an ABCDE assessment; if needed, perform cardiopulmonary resuscitation.

• Initiate basic airway maneuvers, start oxygen therapy, and place the patient in the recovery position.

• Check POC glucose and vital signs.

• Remove cause or provoking factors (e.g., cessation of recreational drug use, treatment of underlying disorders).

• Assess for risk of recurrence; patients with a CNS insult or lesion , abnormality on brain imaging or EEG, or nocturnal seizure are at higher risk of recurrence.

  • Low risk of recurrence: shared decision-making with the patient; expectant management is usually appropriate. [32][33]

  • High risk of recurrence: Treat as epilepsy.

Long-term medical therapy following a first unprovoked seizure is not required unless the patient meets the criteria for epilepsy or is at high risk of recurrence.

After the confirmation of PNES diagnosis with video-EEG, anticonvulsants should be withdrawn under medical supervision.

Patients with PNES may benefit from cognitive behavioral therapy.

• Start, continue, or optimize long-term antiepileptic drugs.

• Monotherapy is preferred unless the seizures are not adequately controlled.

• Drug-resistant epilepsy may be managed with nonpharmacological methods (e.g., surgery, neurostimulation, ketogenic diet).

• AEDs reduce the risk of future seizures by raising the seizure threshold, which is pathologically lowered in individuals with epilepsy.

• Criteria for the choice of antiepileptic drugs:

  • Seizure type

  • Patient age

  • Comorbidities

• Monotherapy should be maintained if possible.

  • If initial monotherapy is ineffective, increase the dosage of the single agent or switch to an alternative agent before initiating combination therapy.

  • Approx. ⅔ of epilepsy patients become seizure-free with monotherapy. [55]

• Combination therapy should only be given if monotherapy fails.

  • In this case, drugs from different classes and/or with different pharmacologic modes of action should be tried.

  • Combining two or three of the standard antiepileptic drugs is usually safe.

• Failure of combination therapy : Consider nonpharmacological therapy.

• Evaluated on a case‑by‑case basis

• May be considered if the patient meets all of the following:

  • < 2 seizures/year

  • An inconspicuous provocation EEG

  • Normal psychological findings

  • No hereditary predisposition

• Generally possible after 2–5 seizure‑free years with normal EEG results

• Medications should be tapered with caution.

• Neurocognitive changes (e.g., sedation, headache, dizziness, tremor, memory impairment)

• Skin disorders (e.g., rash, SJS, DRESS)

• Psychiatric symptoms (e.g., depression, psychosis)

• Laboratory abnormalities (e.g., hyponatremia, neutropenia, thrombocytopenia)

• Gastrointestinal symptoms (e.g., nausea, vomiting, constipation)

• Weight gain or loss

• Indications: pharmacoresistant epilepsy

• Surgery

  • Resection (surgical removal of pathological lesions)

    • Patients with temporal lobe epilepsy (e.g., due to hippocampal sclerosis): resection of the anteromedial temporal lobe or of the amygdala and the hippocampus

    • Patients with severe intractable seizures due to structural cerebral abnormalities confined to one hemisphere: resection of an entire hemisphere (hemispherectomy)

  • Disconnection (surgical section of neuronal circuits)

    • Callosotomy: section of the corpus callosum [60]

      • Initially: partial disconnection only (usually the anterior ⅔)

      • If seizures persist: complete disconnection

    • Hemispherotomy: disconnection of the cortex of one hemisphere from the ipsilateral subcortical structures and cortex of the other hemisphere without removal of the affected hemisphere [61]

• Stimulation techniques: vagus nerve stimulation, deep brain stimulation

• Dietary measures: ketogenic diet [62]

Successful epilepsy therapy depends on determining whether the patient has focal or generalized seizures and prescribing medication accordingly.