Medical treatment of newly diagnosed epilepsy

The first step in the treatment of epilepsy is the confirmation of the diagnosis. A correct diagnosis not only includes the epileptic origin of the event, but also the diagnosis of the seizure type and the epileptic syndrome. The second step is to try to find the aetiology of the seizures. Some papers have shown that the prognosis of epilepsy is better if the seizures are treated earlier, but other papers did not find any difference in the long-term prognosis between patients treated after the first seizure or after several seizures. Therefore, one of the most difficult points, after confirmation of the diagnosis, with a first or few seizures will be to identify the risks of relapse in some patients and to immediately treat them and to avoid treating the others who will have only one or rare seizures during their lives without any damage. In most cases, the first treatment will be the prescription of an antiepileptic drug (AED) in monotherapy. If the cause is treatable, it will be treated concomitantly. In generalised epilepsies, especially in idiopathic syndromes, valproate will be the first choice, most of the classic AEDs may worsen some seizure types in these syndromes. In partial epilepsies, there are no statistically significant differences in efficacy between the 4 classic major AEDs (carbamazepine, phenytoin, phenobarbitone and valproate) in pooled data. The choice of the drug should be more influenced by considerations of safety profile, dosing frequency, and costs for equivalent advantages. Accordingly, valproate is a good first choice in patients in whom the epilepsy syndrome is not clearly defined. Efficacy of newer AEDs is similar to old AEDs but most are better tolerated. However, some studies including seizure control, side effects, medical consultation, inpatient, accidental injuries, and laboratory investigations showed that newer AEDs are more expensive in newly diagnosed patients, compared to classic major AEDs and this notion should be taken into account for the prescription.