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Chronic Epilepsy Management

Chronic Epilepsy Management: Epilepsy confirmed: choose or review antiseizure medication → Status epilepticus, pregnancy or children: use specialist car...

Pathway Overview

20 steps

Algorithm Steps

20 total

  1. 01Start

    Epilepsy confirmed: choose or review antiseizure medication

    Adults with epilepsy diagnosed by a specialist: 2 or more unprovoked seizures more than 24 h apart, or 1 unprovoked seizure with a high risk of recurrence. Adolescents and children: paediatric or epilepsy specialist.

  2. 02Warning

    Status epilepticus, pregnancy or children: use specialist care

    This pathway is for planned outpatient care of adults.

    • Seizure lasting 5 min or more, or repeated without recovery: status epilepticus pathway
    • Pregnant or planning pregnancy: epilepsy specialist and obstetric review; do not stop ASMs abruptly
    • Children and epilepsy syndromes: paediatric neurologist
  3. 03Action

    Classify seizure type and epilepsy syndrome

    ILAE 2017 classification. The seizure type decides the ASM.

    • Focal onset (aware or impaired awareness; may evolve to bilateral tonic-clonic)
    • Generalised onset: tonic-clonic, absence, myoclonic, tonic or atonic
    • Unknown onset: use a broad-spectrum ASM
    • Type or syndrome uncertain: refer to an epilepsy specialist
    • Name the syndrome if known (for example juvenile myoclonic epilepsy)
  4. 04Action

    Assess patient factors before choosing an ASM

    These factors change which ASM is safe.

    • Could the patient become pregnant? Contraception and pregnancy plans
    • Ancestry (HLA-B*15:02 risk with carbamazepine and related ASMs)
    • Other medicines: hormonal contraception, oral anticoagulants, other ASMs
    • Liver disease, renal impairment, older age
    • Mood and psychiatric history; bone health; driving and work
  5. 05Warning

    Could become pregnant: avoid valproate and topiramate

    Valproate carries a high risk of malformations and neurodevelopmental disorders: use only if other ASMs fail, with pregnancy prevention and specialist oversight. Carbamazepine, oxcarbazepine, phenytoin and topiramate reduce hormonal contraception. Oestrogen lowers lamotrigine levels.

    • Prefer lamotrigine or levetiracetam
    • Discuss contraception, folic acid and pregnancy plans at each review
    • Men on valproate: discuss partner contraception during treatment and for 3 months after, and family plans
  6. 06Decision

    Seizure type?

    Focal, or generalised or unknown onset

  7. Focal
  8. 07Warning

    Focal: test HLA-B*15:02 before carbamazepine if Asian ancestry

    Han Chinese, Thai, Malaysian, Filipino and some South Asian ancestry. If positive: avoid carbamazepine; use caution with oxcarbazepine, phenytoin and lamotrigine (SJS/TEN).

    • Consider HLA-A*31:01 testing before carbamazepine (for example Japanese or European ancestry)
    • Stop the ASM at once for blistering rash, mucosal ulcers or rash with fever
    • Risk of severe rash is highest in the first months of treatment
  9. 08Action

    Focal seizures: lamotrigine or levetiracetam first

    If both fail: carbamazepine, oxcarbazepine or zonisamide (second line), then lacosamide. Carbamazepine lowers levels of hormonal contraceptives, warfarin and DOACs.

    • Lamotrigine: follow the product information titration exactly (rash risk)
    • Levetiracetam: watch mood, irritability and suicidal thoughts
    • Carbamazepine: not in AV block. Carbamazepine or oxcarbazepine: hyponatraemia; many interactions
    • Lacosamide: PR prolongation; caution with conduction disease
    • Lamotrigine gave the best 12-month remission in SANAD II
  10. 09Action

    Start one ASM at a low dose and titrate

    Monotherapy. Titrate to the lowest effective dose as in the product information.

    • Judge response at the target dose, over a time that fits the usual seizure frequency
    • Discuss SUDEP risk and seizure safety from diagnosis
    • Drug levels only for uncontrolled seizures, toxicity, poor adherence, pregnancy or renal failure
    • Avoid switching between brands of some ASMs without advice
  11. 10Decision

    Seizure-free on a tolerated dose?

    Review seizures, side effects and adherence

  12. If Yes
    1. Seizure-free
    2. 11Action

      Seizure-free: continue ASM and review at least yearly

      Maintenance phase. Patient can ask for review at any time.

      • Ask about side effects, mood and suicidal thoughts
      • Past prolonged or cluster seizures: agree an emergency plan with a rescue benzodiazepine (for example buccal midazolam)
      • Driving (Austroads): private licence usually after 12 months seizure-free; commercial needs 10 years plus EEG criteria. Patient must tell the licensing authority
      • Explain SUDEP risk; support adherence; night supervision if nocturnal seizures
      • Carbamazepine, phenytoin, primidone or valproate long term: consider vitamin D and calcium
      • Review contraception and pregnancy plans
    3. 12Decision

      Seizure-free 2 years or more and wants to consider stopping?

      Individual decision; specialist input if in doubt

    4. If Yes
      1. 13Action

        Stopping ASM: individual risk assessment first

        Seizure-free for 2 years or more. Epilepsy specialist if any doubt about risk.

        • Discuss recurrence risk and SUDEP. Private drivers: do not drive during withdrawal and for 3 months after; commercial drivers: licensing authority decides
        • Taper one ASM at a time, usually over at least 3 months
        • Benzodiazepines and barbiturates: taper more slowly
        • Seizure recurs: reverse the last dose reduction and seek specialist advice
        • After epilepsy surgery: the surgery centre directs withdrawal
      2. 14Outcome

        Long-term review

        Review at least yearly; sooner if seizures recur, side effects occur or pregnancy is planned.

      If No
      1. Path rejoins step 14Shared downstream outcome
    If No
    1. Seizures continue
    2. 15Action

      Seizures continue: check adherence, diagnosis and dose

      Before any change of ASM.

      • Check adherence and triggers (sleep loss, alcohol, drugs, interacting medicines)
      • Review the diagnosis and seizure type; refer if in doubt
      • Increase the dose if tolerated
      • Check drug levels if non-adherence or toxicity is suspected
    3. 16Decision

      Seizure-free after dose change?

      Review after the new dose

    4. If Yes
      1. Controlled after adjustment
      2. Path rejoins step 11Shared downstream outcome
      If No
      1. 17Action

        Still uncontrolled: switch to or add a second ASM

        Not tolerated or no effect: switch. Partial response: add on. With valproate, start lamotrigine on the lower titration schedule (rash risk).

        • Switch: build up the new ASM, then taper the first
        • Add-on: titrate carefully; watch for sedation
        • Choose by seizure type; recheck pregnancy potential and HLA risk; absence or myoclonic: no carbamazepine, oxcarbazepine or phenytoin
        • Focal add-on: carbamazepine, lacosamide, lamotrigine, levetiracetam, oxcarbazepine, topiramate or zonisamide
        • Tonic-clonic add-on: clobazam, lamotrigine, levetiracetam, perampanel, topiramate or valproate (not topiramate or valproate if could become pregnant)
        • Intolerable side effects: refer to epilepsy specialist
      2. 18Decision

        Failed 2 appropriate, tolerated ASM schedules?

        ILAE definition of drug-resistant epilepsy

      3. If Yes
        1. Failed 2+ ASMs
        2. 19Warning

          Drug-resistant: refer to a comprehensive epilepsy centre

          Failure of 2 tolerated, appropriately chosen and used ASM schedules. Refer to be seen within 4 weeks.

          • Assess for resective epilepsy surgery, including when MRI is normal
          • Surgery not suitable: vagus nerve stimulation or ketogenic diet at a specialist centre
          • Confirm the diagnosis (video-EEG) and continue the best-tolerated regimen
        3. Path rejoins step 14Shared downstream outcome
        If No
        1. Try new ASM
        2. Path rejoins step 10Shared downstream outcome
  13. Generalised or unknown onset
  14. 20Action

    Generalised or unknown onset: broad-spectrum ASM

    Tonic-clonic: valproate, lamotrigine or levetiracetam. Valproate is most effective, but not for women who could become pregnant. Valproate is contraindicated in liver disease, POLG mitochondrial disease and urea cycle disorders. Absence only: ethosuximide first. Absence with tonic-clonic or other seizures (usual in adults): lamotrigine, levetiracetam or valproate; ethosuximide only as add-on.

    • Could become pregnant: lamotrigine or levetiracetam
    • Myoclonic seizures or JME: levetiracetam or valproate; lamotrigine may worsen myoclonus
    • Absence or myoclonic: avoid carbamazepine, oxcarbazepine, phenytoin, gabapentin, pregabalin, tiagabine, vigabatrin; absence: also phenobarbital
    • Men on valproate: discuss partner contraception and family plans
  15. Path rejoins step 09Shared downstream outcome

Guideline Source

NICE NG217 Epilepsies in children, young people and adults (2022, updated August 2026)

View Guideline

Clinical Safety Information

Clinical Decision Support — Not a Substitute for Clinical Judgment

Individual patient factors may require deviation from these recommendations.

Known Limitations

  • For adults with established epilepsy; adolescents, children and epilepsy syndromes need a paediatric or epilepsy specialist
  • Pregnancy or planning pregnancy needs epilepsy specialist and obstetric care; do not stop ASMs abruptly
  • Status epilepticus and acute seizures: separate pathway
  • Doses, titration and interactions: check each ASM's product information

Contraindicated Populations

Status epilepticus or acute seizure: use the status epilepticus pathwayChildren with epilepsy syndromes: paediatric neurologistPregnancy: epilepsy specialist and obstetric care

Applicable Regions

AUUKEUUSglobal

AU: TGA product information and PBS listing govern ASM choice. Driving: Austroads Assessing Fitness to Drive.

EU: ILAE 2017 seizure classification and ILAE 2010 definition of drug-resistant epilepsy apply.

UK: MHRA: do not start valproate before age 55 unless 2 specialists agree; pregnancy prevention programme for valproate and topiramate.

US: AAN/AES 2018 practice guideline updates on newer antiseizure medicines (Kanner et al, Neurology 2018).

Version 2Next review: 2027-09-30

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Frequently Asked Questions

What is the Chronic Epilepsy Management?

The Chronic Epilepsy Management is a management clinical algorithm for Neurology. It provides a structured decision tree to guide clinical decision-making, based on NICE NG217 Epilepsies in children, young people and adults (2022, updated August 2026).

What guideline is the Chronic Epilepsy Management based on?

This algorithm is based on NICE NG217 Epilepsies in children, young people and adults (2022, updated August 2026).

What are the limitations of the Chronic Epilepsy Management?

Known limitations include: For adults with established epilepsy; adolescents, children and epilepsy syndromes need a paediatric or epilepsy specialist; Pregnancy or planning pregnancy needs epilepsy specialist and obstetric care; do not stop ASMs abruptly; Status epilepticus and acute seizures: separate pathway; Doses, titration and interactions: check each ASM's product information. Individual patient factors may require deviation from these recommendations.

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