Epilepsy Treatments: Finding the Right Medication

Last Editorial Review: 6/28/2005

Could your treatment for epilepsy be better? A guide to medications to help you and your doctor decide.

By R. Morgan Griffin
WebMD Feature

Reviewed By Charlotte Grayson

Epilepsy treatment has come a long way in the last 15 years. Today, many new and effective anti-epileptic drugs (AEDs) are on the market. Though there's no cure, the prognosis for most of the 2 million people with epilepsy in the U.S. is quite good. Up to 80% of people can control their condition with medicine.

But dozens of epilepsy drugs can make things confusing. How do you know if you're getting the right one? Are there better epilepsy treatment options out there that you don't know about?

"The number of choices can seem almost staggering to people," says John M. Pellock, MD, spokesperson for the American Epilepsy Society and chairman of Child Neurology at Virginia Commonwealth University.

Experts say that many people with epilepsy do settle for treatment that could be better. They stick with the medicine -- or medicines -- they're familiar with, even if they're not working that well.

"A lot of people with epilepsy are using medications that aren't right for them," says Orrin Devinsky, MD, director of the New York University Epilepsy Center. "They're having side effects and medical problems that they don't need to have."

The new goal for epilepsy treatment is simple: No seizures and no side effects. Are you getting the best treatment possible? Or could you be doing better, too?

Is Your Epilepsy Treatment Right for You?

Good epilepsy treatment with medication is a tricky balancing act. You need enough of a medicine to stop the seizures. But if you have too much of it, you can have a lot of side effects. The key is to find a happy medium.

So there's a bit of trial and error when it comes to finding the right medication at the right dose. You may need to try a few different drugs. According to Pellock, the process of fine-tuning your medicine can take a few months.

The good news is that for most people with epilepsy, a lot of different drugs will help. "Up to two-thirds of people control their epilepsy with the first or second drug they try," Pellock tells WebMD.

But that's not always a good thing. People may quickly settle for a drug that works well enough, even though they could do better. The goal is not to find a medicine that works for you, it's to find the medicine that works best for you.

"People will wind up staying on a drug for years, even though they're having all sorts of side effects," says Pellock. "They think that their treatment is as good as it gets."

Also, the longer you're on a drug, the more used you become to the side effects.

"I see people who have been on the same medication for 10, 15, or 20 years, and they don't realize that they're having side effects anymore," Devinsky tells WebMD. "They think that sleeping 12 hours a day and always being exhausted is normal. They don't remember what it was like before they went on the medication."

1 Drug or More for Epilepsy Treatment?

For most people with epilepsy, monotherapy -- treatment with just one drug -- is the goal. Why is one drug better than two or three? The main issues are side effects.

"If you're on more than one drug, it's not just like the side effects are being added together," says Pellock. "They're multiplied."

The side effects of epilepsy drugs vary widely, but they include fatigue, nausea, vomiting, and long-term problems like osteoporosis (brittle bones.) Also, the more drugs you have, the more possible drug interactions you face.

Monotherapy simplifies things. You only have to remember to take one medicine. It's often cheaper than taking multiple drugs, too.

So when it's possible, epilepsy experts try to get patients on more than one drug down to one. The effects can be dramatic. "Sometimes, I'll have a patient who goes from two drugs to one," says Pellock, "and his memory will suddenly get better. He'll say, 'Wow, I can think clearly again.'"

However, monotherapy isn't always possible. Some people with tough cases of epilepsy just can't be controlled by one medicine.

"Monotherapy should always be the goal," says Devinsky. "But there really are some people out there who need to be on more than one drug."

Old vs. New Drugs: What's the Difference?

Beginning in the 1990s, a number of new drugs for epilepsy came on the market. Pellock says that many of the new medicines cause fewer side effects that the older ones. The American Academy of Neurology and the American Epilepsy Society generally advise that people who are newly diagnosed start on one of the newer medicines.

But Pellock stresses that new drugs aren't always preferable to old drugs. It depends on your individual case. Some older drugs have also been improved. They're now being sold in different forms -- like extended release caplets -- that cause fewer side effects.

Older drugs have their own advantages. Some old generic drugs cost a lot less than newer brand name drugs. Doctors also know more about their effects and how to minimize any negative effects.

"The older a drug is, the more we know about its long-term side effects," says Pellock. "With some of the newer drugs, we only know about their effects over a couple of years."

How Does Your Doctor Choose?

Experts stress that when it comes to epilepsy, there's no one-size-fits-all treatment. Each person's therapy is individually tailored.

The following are some of the things your health care provider will consider when prescribing a medicine for epilepsy.

  • The type of seizures you have. The right medicine depends on this factor. Not all drugs will help. In fact, some AEDs can increase the risk of having certain types of seizures. For instance, Tegretol -- used for partial and generalized tonic-clonic seizures -- can raise the risk of absence or myoclonic seizures.
  • Your treatment track record. Before prescribing a medicine, your doctor will want to know all of the medicines you've used for epilepsy in the past. If certain drugs didn't help, it's less likely that your doctor will try them again.
  • Other medical conditions. Your health care provider will consider any health conditions that you have when prescribing a medicine. Sometimes, side effects can be beneficial. Devinsky tells WebMD that if he has a patient who is obese or who has diabetes, he might consider an AED that can cause weight loss, like Zonegran or Topamax. People who suffer from epilepsy and chronic migraines may benefit from Depakote or Topamax, he says.
  • Other medications you use. Many AEDs can interact with common over-the-counter and prescription medications.
  • Your time of life. The best treatment depends on what fits right now. If you're a woman thinking about getting pregnant, talk to your doctor first. Some medications for epilepsy, like Depakote, Depakene, and phenobarbital, may increase the risk of birth defects. The safety of some other medicines in pregnant women hasn't been proven. However, Gregory L. Barkley, MD, chairman of the Epilepsy Foundation's Professional Advisory Board and a doctor at the Henry Ford Hospital in Detroit, stresses that pregnant women should realize that the risks of having a seizure can be even more dangerous than side effects. "Seizures, especially convulsive seizures, in a pregnant woman can kill the baby or cause brain damage," he says.  "Abruptly stopping your medication during pregnancy is a very bad idea." An older man might be more focused on treatment that won't interact with his other medications. Children need medications that are easy for them to take.
  • Practical issues. Different drugs have different dosing schedules and prices. So what's more important to you: convenience or cost? "Taking a dose twice a day instead of three times a day is definitely easier," says Barkley. "But if you can remember to take three doses a day, you could go with an older generic drug and save a lot of money."

Changing Your Epilepsy Treatment

If you take medication and are still having side effects or seizures -- or if you're on more than one medicine -- you should definitely see your health care provider. You should also consider finding an epilepsy expert, such as a neurologist, to talk about other treatment options.

Changing your medication is a delicate process. You must never stop taking your medicine or change your dose without your health care provider's approval. It could be dangerous and result in more seizures. Your doctor will probably shift you onto a new medicine gradually while tapering you off the old one. You may need regular blood tests to check the levels of the medicine in your body.

Even when it's done slowly and carefully, you can face risks to changing medicines. A new medicine might not work as well as the old one. Seizures are a small but real danger.

"It's a period of risk," says Pellock. "I tell patients that when they're changing from one drug to another, they might feel worse before they feel better."

That risk can be scary for many people.

"The consequences of having a seizure can be serious," Barkley tells WebMD. "You could lose your license and not be able to drive for six months or more. That can be devastating if you need to drive for your job. This fear can paralyze people into sticking with their old medication and not taking a chance on one that might be better."

But Pellock encourages people not to lose sight of the long-term potential benefits.

"Losing your license is a big deal," says Pellock. "But on the other hand, might not driving for a few months be worth it if you could be on a medicine that made you feel so much better?"

Obviously, making the decision isn't easy. Talk over the pros and cons with your health care provider.

Working With Your Doctor

Experts stress that people with epilepsy have a lot of hope. More drugs are being developed. Pellock believes that up to four new drugs may be approved in the next few years. Barkley is also excited about the number of brand-name drugs, such as Neurontin, that are now available as much cheaper generic medicines.

And while epilepsy treatment can be frustrating and confusing, Pellock urges you to look at the positives.

"Even though your options may seem bewildering," says Pellock, "we have many new drugs and new techniques that work."

Devinsky agrees. "When people with epilepsy switch to a better medication, they often feel brighter and me energetic than they have in years," he tells WebMD. "They're so happy and grateful." Learn some helpful tips to get the most out of your treatment.

Medications for Treating Epilepsy

Here's a rundown of some of the most common medications used for epilepsy. Some medicines are approved for initial treatment. Others are approved as "add-on" drugs, used in addition to initial treatments. However, your doctor may not strictly follow these recommendations; he or she may use add-on drugs as your main treatment.

Newer drugs include:

The older drugs include:

  • DILANTIN and PHENYTEK (phenytoin)
    Use: Partial and generalized tonic-clonic seizures.
    Side effects: Dizziness, fatigue, slurred speech, acne, rash, increased hair. Long-term risk of bone thinning.

  • DEPAKOTE, DEPAKENE (valproate, valproic acid)
    Use: Partial, absence, generalized tonic-clonic, and myoclonic seizures.
    Side effects: Dizziness, nausea, vomiting, tremor, hair loss, weight gain, depression or irritability, attention problems, slowed thinking. Long-term use can cause bone thinning and menstrual problems. This medicine increases the risk of birth defects. Less common effects are hearing loss, liver, pancreas, and blood problems.

  • MYSOLINE (primidone)
    Use: Usually an add-on treatment for partial and generalized tonic-clonic seizures.
    Side effects: Fatigue, nausea, dizziness, and mental changes.

  • phenobarbital
    Use: Partial and generalized tonic-clonic seizures. Now considered an add-on drug.
    Side effects: Dizziness, fatigue, difficulty thinking, hyperactivity, and rash. This medicine increases the risk of birth defects.

  • TEGRETOL and CARBATROL (carbamazepine)
    Use: Partial, generalized tonic-clonic, and mixed seizures.
    Side effects: Fatigue, vision problems, nausea, dizziness, and rash.

    Use: These are tranquilizers for short-term treatment for all seizures. Often used to stop a seizure.
    Side effects: Fatigue, dizziness, nausea, depression, and loss of appetite. If taken regularly, these drugs become less effective.

Published June 2005.

SOURCES: Gregory L. Barkley, MD, chairman, Epilepsy Foundation's Professional Advisory Board; Henry Ford Hospital, Detroit. Orrin Devinsky, MD, director, New York University Epilepsy Center; professor of neurology, NYU School of Medicine. John M. Pellock, MD, spokesman, American Epilepsy Society; chairman of child neurology, Virginia Commonwealth University. French, J.A. Neurology, April 2004; vol 62: pp 1252-1260. French, J.A. Neurology, April 2004; vol 62: pp 1261-1273. Wheless, J.W. ACP Medicine, Chapter XII: Neurology, Epilepsy, 2003. The Epilepsy Foundation. Epilepsy.com. The National Institute of Neurological Disorders.

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