Epilepsy

Please expand the topics below for more information.

Also see our Medication Safety webpage.

Antiepileptic drugs: updated advice on switching between different manufacturers’ products (MHRA November 2017)

• Category 1 – Carbamazepine, Phenobarbital, Phenytoin, Primidone – Ensure that the patient is maintained on a specific manufacturer’s product.
• Category 2 – Clobazam, Clonazepam, Eslicarbazepine, Lamotrigine, Oxcarbazepine, Perampanel, Retigabine, Rufinamide, Topiramate, Valproate, Zonisamide – Base the need for continued supply of a particular manufacturer’s product on clinical judgement and consultation with patient and/or carer, taking into account factors such as seizure frequency and treatment history. Take into account patient/carer-related factors such as their negative perceptions about alternative products and/or other issues related to the patient should also be taken into account.

• Category 3 – Brivaracetam, Ethosuximide, Gabapentin, Lacosamide, Levetiracetam, Pregabalin, Tiagabine, Vigabatrin – The potential for clinically relevant differences to exist between different manufacturers’ products is considered to be extremely low. However, consider other patient/carer-related factors, such as negative perceptions about alternative products and/or other issues related to the patient.

Update on MHRA review into safe use of valproate (MHRA December 2022)

Valproate is approved in the UK to treat epilepsy and bipolar disorder. Because of the known risk of birth defects and neurodevelopmental disorders following use of valproate in pregnancy, valproate should only be used in women of child-bearing potential if a Pregnancy Prevention Programme is in place, which includes a requirement to use effective contraception. Valproate should not be used in female children and women of childbearing potential unless other treatments are ineffective or not tolerated.

The Commission on Human Medicines (CHM) has advised that no one under the age of 55 should be initiated on valproate unless two specialists independently consider and document that there is no other effective or tolerated treatment. Where possible, existing patients should be switched to another treatment unless two specialists independently consider and document that there is no other effective or tolerated treatment or the risks do not apply.

Decision support tool: is valproate the right epilepsy treatment for me?

This tool is for anyone who could become pregnant, considering or taking valproate for epilepsy. It has been produced as part of NHS-wide effort to reduce use of valproate in people who can get pregnant, and to help those that do continue with valproate to prevent pregnancies.

Medication Safety webpage

NHS Somerset Contraception formulary

NHS Somerset Contraception webpage

NHS Somerset Medicines used in Pregnancy webpage

Antiepileptics: risk of suicidal thoughts and behaviour (MHRA December 2014)

Antiepileptic treatment is associated with a small risk of suicidal thoughts and behaviour; available data suggest that the increased risk applies to all antiepileptics and is seen as early as 1 week after starting treatment.

Patients should be alert to any mood changes, distressing thoughts, or feelings about suicide or harming themselves at any point during treatment – they should be advised to seek medical advice if they develop such thoughts or behaviour, and should be referred for appropriate treatment if necessary.

The available evidence does not define whether the risk of suicidal thoughts and behaviour differs between antiepileptics – patients should not stop or switch treatment on the basis of this information and without speaking to a healthcare professional.

NHS Somerset Mental Health prescribing website

Antiepileptics: adverse effects on bone (MHRA December 2014)

Data suggests that long-term use of carbamazepine, phenytoin, primidone, and sodium valproate is associated with decreased bone mineral density that may lead to osteopenia, osteoporosis, and increased fractures.

Vitamin D supplementation alone or with calcium does not reduce fracture incidence among community-dwelling adults without known vitamin D deficiency, osteoporosis, or prior fracture.
Bisphosphonates remain first line treatment option for people with osteoporosis or high risk of fractures.
NHS Somerset have approved the use of Bisphosphonates (off-label) to address significant unmet need for people with high risk of fracture such as those with a diagnosis of osteopenia.

NHS Somerset Bone metabolism disorders

• 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
  • 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.
• 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.

For further guidance on managing withdrawal of benzodiazepines and gabapentinoids see [NG215] Medicines associated with dependence or withdrawal symptoms: safe prescribing and withdrawal management for adults

• 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 (off-label uses of lamotrigine in children under 13 years and levetiracetam in adults and children).
• 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 (off-label uses of lamotrigine in children under 13 years and levetiracetam in adults and children).
• 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.
• 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 (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).
• 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 (off-label uses of brivaracetam in adults and children, lacosamide in children under 4 years, and zonisamide in adults and children).
• 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.
• 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.

• 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 (off-label uses of lamotrigine in children under 13 years, and levetiracetam in children and young people under 16 years).
• 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 (off-label uses of oxcarbazepine in children under 6 years, and zonisamide in children).
• If second line monotherapies tried are unsuccessful in people with focal seizures, consider lacosamide as third line monotherapy (off-label use of lacosamide in children under 4 years).
• 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 (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).
• 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 TA guidance, see below) NHS Somerset classified as amber following initiation at MDT in secondary care.
  • eslicarbazepine acetate
  • perampanel
  • pregabalin
  • sodium valproate, except in women and girls able to have children.

Cenobamate for treating focal onset seizures in epilepsy Technology appraisal guidance (TA753 December 2021)

• If the first choice is unsuccessful, consider the other second line add-on options (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).
• 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 (off-label use of tiagabine in children under 12 years).
• 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.

• 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 (off-label uses of levetiracetam as monotherapy for adults and children, and as an add-on therapy for children under 12 years).
• 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.
• 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 (off-label uses of lamotrigine in children under 2 years, and levetiracetam in adults and children).
• 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

• 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). (off-label use of lamotrigine in children under 13 years).
• 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. (off-label use of lamotrigine as monotherapy in children under 13 years and add-on therapy in children under 2 years).
• 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. (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).
• 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.
• 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 (not licensed for use in the UK).
• Be aware that the following antiseizure medications may exacerbate seizures in people with tonic or atonic seizures:
  • carbamazepine
  • gabapentin
  • oxcarbazepine
  • pregabalin
  • tiagabine
  • vigabatrin

• 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 (off-label uses of lamotrigine in children under 13 years, and levetiracetam in adults and children).
• 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 (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).
• 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 (off-label use of perampanel for children under 7 years).
• 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.

Antiseizure medications for childhood-onset epilepsy syndromes are considered off-label unless they are authorised for the specific syndrome.

• Consider sodium valproate as first line treatment for people with Dravet syndrome. Be aware that sodium valproate should be used with caution in women and girls, but it is recommended as first line treatment for Dravet syndrome because of the severity of the syndrome and the lack of evidence for other effective first-line treatment options.
• If sodium valproate first line monotherapy is started or continued for Dravet syndrome 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):
  • discuss the potential risks and benefits of treatment, including the risks to an unborn child
  • take into account the likelihood of pregnancy and put in place a pregnancy prevention programme, if appropriate.
• If sodium valproate alone is unsuccessful as first line monotherapy for Dravet syndrome, consider triple therapy with stiripentol (named patient only) and clobazam as first line add-on therapy. Carefully titrate the additional drugs and review treatment frequently, including monitoring for adverse effects such as sedation (off-label uses of clobazam as add-on therapy in children under 6 months, and stiripentol when it is started in adults over 18 years).
• If triple therapy is unsuccessful for Dravet syndrome and the child is over 2 years, consider cannabidiol in combination with clobazam as a second line add-on treatment option in line with NICE’s technology appraisal guidance on cannabidiol with clobazam for treating seizures associated with Dravet syndrome.

Cannabidiol with clobazam for treating seizures associated with Dravet syndrome Technology appraisal guidance (TA614 December 2019)

NHS Somerset classify cannabidiol for seizures associated with Dravet syndrome as Red (specialist prescribing only) as per traffic light guidance.

• If triple therapy is unsuccessful for Dravet syndrome in a child aged under 2 years or second line treatment is unsuccessful in a child aged over 2 years, consider 1 of the following add-on options under the supervision of a ketogenic diet team or a neurologist with expertise in epilepsy, as appropriate:
  • ketogenic diet
  • levetiracetam
  • topiramate.
  If the first choice is unsuccessful, consider the other add-on options (off-label uses of levetiracetam and topiramate).
• If all other treatment options for Dravet syndrome are unsuccessful, consider potassium bromide (named patient only) under the guidance of a neurologist with expertise in epilepsy (not licensed for use in the UK).
• Be aware that the following medications may exacerbate seizures in people with Dravet syndrome:
  • carbamazepine
  • gabapentin
  • lacosamide
  • lamotrigine
  • oxcarbazepine
  • phenobarbital
  • pregabalin
  • tiagabine
  • vigabatrin.

Fenfluramine for treating seizures associated with Dravet syndrome Technology appraisal guidance (TA808 July 2022)

NHS Somerset classify fenfluramine for seizures associated with Dravet syndrome as Red (specialist prescribing only) as per traffic light guidance.

• Consider sodium valproate as first line treatment for people with Lennox–Gastaut syndrome. Be aware that sodium valproate should be used with caution in women and girls, but it is recommended as first line treatment for Lennox–Gastaut syndrome because of the severity of the syndrome and the lack of evidence for other effective first-line treatment options.
• If sodium valproate treatment is started or continued for Lennox–Gastaut syndrome in women and girls able to have children who are likely to need treatment when they are old enough to have children):
  • discuss the risks and benefits of treatment, including the risks to an unborn child
  • take into account the likelihood of pregnancy and put in place a pregnancy prevention programme, if appropriate.
• If first line treatment is unsuccessful, consider lamotrigine as a second-line monotherapy or add-on treatment for people with Lennox–Gastaut syndrome (off-label as monotherapy in children under 13 years and add-on therapy for children under 2 years).
• If second line treatment is unsuccessful, consider the following as third-line add-on treatment options for people with Lennox–Gastaut syndrome:
  • cannabidiol in combination with clobazam if the child is over 2 years, in line with NICE’s technology appraisal guidance on cannabidiol with clobazam for treating seizures associated with Lennox–Gastaut syndrome
  • clobazam
  • rufinamide
  • topiramate.
  (off-label uses of clobazam as add-on therapy in children under 6 months, rufinamide in children under 1 year, and topiramate in children under 2 years).
• When starting an add-on treatment in people with Lennox–Gastaut syndrome, carefully titrate the additional medicine and review treatment frequently, including monitoring for adverse effects such as sedation.
• If seizures continue with third line treatments for Lennox–Gastaut syndrome, consider a ketogenic diet as an add-on treatment under the supervision of a ketogenic diet team.
• If all other treatment options for Lennox–Gastaut syndrome are unsuccessful, consider felbamate as add-on treatment under the supervision of a neurologist with expertise in epilepsy (not licensed for use in the UK).
• Be aware that the following medications may exacerbate seizures in people with Lennox–Gastaut syndrome:
  • carbamazepine
  • gabapentin
  • lacosamide
  • lamotrigine
  • oxcarbazepine
  • phenobarbital
  • pregabalin
  • tiagabine
  • vigabatrin

• Offer combination therapy with high-dose oral prednisolone and vigabatrin as first line treatment for infantile spasms that are not due to tuberous sclerosis, unless the child is at high risk of steroid-related side effects (off-label use of vigabatrin in combination with prednisolone).
• Consider vigabatrin alone as first-line treatment for infantile spasms in children at high risk of steroid-related side effects.
• Offer vigabatrin alone as first line treatment for infantile spasms due totuberous sclerosis. If vigabatrin is ineffective after 1 week, add high-dose oral prednisolone (off-label use of vigabatrin in combination with prednisolone).
• Before starting oral prednisolone for infantile spasms:
  • discuss the possible side effects of steroid treatment with parents and carers
  • test whether the child has antibodies to the varicella zoster virus
  • give the parents and carers a steroid card and information about when to seek medical help for side effects.
• When using oral prednisolone to treat infantile spasms, follow the advice in the BNF for children on prednisolone dosages. Monitor blood pressure and urinary glucose weekly during treatment.
• When using vigabatrin to treat infantile spasms, increase the dose as outlined in the BNF for children on vigabatrin. Discuss further dose increases with a tertiary paediatric neurologist if the spasms do not stop (clinically and on EEG).
• If first line treatment for infantile spasms is unsuccessful, discuss further treatment with a tertiary paediatric epilepsy specialist.
• Consider the following as a second line monotherapy or add-on treatment options for infantile spasms, guided by a ketogenic diet team or tertiary paediatric epilepsy specialist, as appropriate:
  • ketogenic diet
  • levetiracetam
  • nitrazepam
  • sodium valproate
  • topiramate.
  If the first choice is unsuccessful, consider the other second line options (off-label uses of levetiracetam, nitrazepam and topiramate)

• Consider lamotrigine or levetiracetam as first line treatment for self-limited epilepsy with centrotemporal spikes. If either lamotrigine or levetiracetam is unsuccessful, try the other of these options (off-label uses of lamotrigine in children under 13 years, and levetiracetam in children under 16 years).
• If first line treatments for self-limited epilepsy with centrotemporal spikes are unsuccessful, consider the following as second line monotherapy treatment options:
  • carbamazepine
  • oxcarbazepine
  • zonisamide.
  If the first choice is unsuccessful, consider the other second line monotherapy options (off-label uses for oxcarbazepine in children under 6 years, and zonisamide in adults and children).
• If second line treatments tried are unsuccessful for self-limited epilepsy with centrotemporal spikes, consider sulthiame as monotherapy or add-on treatment, but only after discussion with a tertiary paediatric neurologist (not licensed for use in the UK).
• Be aware that carbamazepine, oxcarbazepine and lamotrigine may rarely exacerbate seizures or the development of another epilepsy syndrome, or affect cognitive performance, in a small number of children and young people with self-limited epilepsy with centrotemporal spikes.
• If there is concern about the school performance of a child or young person having antiseizure medication, seek guidance from an epilepsy specialist and consider:
  • sleep electroencephalogram (EEG) to exclude exacerbation of epileptic activity (electrical status epilepticus during sleep) and
  • neuropsychology assessment to review academic performance.
• If a child or young person having antiseizure medication treatment develops other seizure types, consider a sleep EEG to exclude exacerbation of epileptic activity (developmental epileptic encephalopathy with spike-wave activation in sleep).
• Offer follow up at a frequency and with a healthcare professional appropriate to the child or young person’s individual needs. Discuss discontinuing treatment if a child or young person with self-limited epilepsy with centrotemporal spikes is seizure-free for at least 2 years or at age 14 years.

• Consider levetiracetam or sodium valproate as first line treatments for epilepsy with myoclonic-atonic seizures. If either levetiracetam or sodium valproate is unsuccessful, try the other of these options (off-label use of levetiracetam).
• If sodium valproate is started or continued for epilepsy with myoclonic-atonic seizures in girls or women able to have children (including young girls who are likely to need treatment when they are old enough to have children):
  • discuss the risks and benefits of treatment, including the risks to an unborn child
  • take into account the likelihood of pregnancy and put in place a pregnancy prevention programme, if appropriate.
• If first line treatments for epilepsy with myoclonic-atonic seizures are unsuccessful, consider a ketogenic diet as a second line monotherapy or add-on treatment, under the supervision of a ketogenic diet team.
• If second line treatment for epilepsy with myoclonic-atonic seizures is unsuccessful, consider the following as third line monotherapy or add-on treatment options:
  • clobazam
  • ethosuximide
  • topiramate
  • zonisamide.
  If the first choice is unsuccessful, consider the other third line options (off-label uses of clobazam as monotherapy in adults and children, and add-on therapy in children under 6 months, and topiramate and zonisamide in adults and children).
• Do not use any of the following medications because they may exacerbate seizures in people with epilepsy with myoclonic-atonic seizures:
  • carbamazepine
  • gabapentin
  • oxcarbazepine
  • phenytoin
  • pregabalin
  • vigabatrin.
• Consider discontinuing antiseizure medication treatment in children with epilepsy with myoclonic-atonic seizures who are seizure-free for 2 years.

• Provide resuscitation and immediate emergency treatment for children, young people and adults who have convulsive status epilepticus (seizures lasting 5 minutes or more).
• If the person with convulsive status epilepticus has an individualised emergency management plan that is immediately available, administer medication as detailed in the plan.
• If the person with convulsive status epilepticus does not have an individualised emergency management plan immediately available:
  • give a benzodiazepine (buccal midazolam or rectal diazepam) immediately as first-line treatment in the community or
  • use intravenous lorazepam if intravenous access and resuscitation facilities are immediately available.
• Be aware of the possible underlying causes of status epilepticus, including hypoglycaemia, eclampsia and alcohol withdrawal, which may need to be treated with additional medication.
• Be alert to non-adherence to antiseizure medication, which can also be a cause of status epilepticus.
• Be aware that non-epileptic seizures (dissociative seizures) can be similar in presentation to convulsive status epilepticus.
• If convulsive status epilepticus does not respond to the first dose of benzodiazepine:
  • call emergency services in the community or
  • seek expert guidance in hospital.
• Continue to follow the person’s individualised emergency management plan, if this is immediately available, or give a second dose of benzodiazepine if the seizure does not stop within 5 to 10 minutes of the first dose.
• If convulsive status epilepticus does not respond to 2 doses of a benzodiazepine, give any of the following medicines intravenously as a second line treatment:
  • levetiracetam
  • phenytoin
  • sodium valproate.
  Take into account that levetiracetam may be quicker to administer and have fewer adverse effects than the alternative options (off-label use of levetiracetam).
• If convulsive status epilepticus does not respond to a second line treatment, consider trying an alternative second line treatment option under expert guidance.
• If convulsive status epilepticus does not respond to the second line treatment options tried, consider the following third line options under expert guidance:
  • phenobarbital or
  • general anaesthesia.
• After an episode of convulsive status epilepticus, agree an emergency management plan with the person if they do not already have one and there is concern that status epilepticus may recur.

• Manage repeated or cluster seizures (typically 3 or more self-terminating seizures in 24 hours) as a medical emergency.
• If a person has repeated or cluster seizures:
  • follow their individualised emergency management plan, if this is immediately available or
  • consider giving a benzodiazepine, such as clobazam or midazolam, immediately if they do not have an individualised emergency management plan immediately available.
• Seek expert guidance if the person has further episodes of repeated or cluster seizures.
• Agree an individualised emergency management plan with the person after repeated or cluster seizures if they do not have one already and there is concern that repeated or cluster seizures may recur.

• For convulsive seizures that continue for 5 minutes or more, follow the recommendations in the section on status epilepticus.
• Manage prolonged convulsive seizures (any convulsive seizure that continues for more than 2 minutes longer than a person’s usual seizure) as a medical emergency.
• If a person has a prolonged convulsive seizure:
  • follow their individualised emergency management plan if this is immediately available or
  • consider giving a benzodiazepine, such as midazolam or clobazam, immediately if they do not have an individualised emergency management plan immediately available.
• After a prolonged convulsive seizure, agree an emergency management plan with the person if they do not already have one and there is concern that prolonged convulsive seizures may recur.
• After a prolonged non-convulsive seizure (a non-convulsive seizure that continues for more than 2 minutes longer than a person’s usual seizure), agree an emergency management plan with the person if they do not already have one and there is concern that prolonged non-convulsive seizures may recur.