Clinical use of anticonvulsants: a neurologist's perspective

Seizures may have an acute, reversible cause; antiepileptic drugs (AEDs) are not needed for every patient who presents with a seizure. The neurologist's decision concerning whether to initiate drug therapy depends on verifying that one or more seizures has occurred, on determining the likelihood of recurrence, and on balancing the risks of future seizures against the risks of treatment. Choice of AED is guided by classification of the seizure type and epilepsy syndrome, and by assessment of the likelihood of successful use based on patient characteristics such as age, childbearing potential, and comorbidities, balanced against drug characteristics such as pharmacokinetic profile and common side effects. Dose adjustment depends on communication between the physician and patient regarding seizure control and adverse drug effects. Patients who do not respond adequately to the first two or three appropriate AEDs should be referred for a comprehensive evaluation to verify the diagnosis and determine suitability for alternative treatments such as epilepsy surgery.