Epilepsy treatment over time: The chess game analogy for choosing, adjusting, and adding antiseizure medications

Recurrent seizures have such a negative impact upon the lives of persons with epilepsy that their prevention is a constant preoccupation of neurologists. Despite the large number of antiseizure medications (ASMs) currently available and of publications on their putative efficacy, adverse effects, and order of preference to start treatment, there is very little information on how to manage treatment over time. Here, we propose the analogy of a chess game to encourage neurologists to develop strategic decisions at each point in time to correctly manage ASMs toward the best possible degree of seizure control. We leverage that the strategy of the chess player must be adapted to each move of the opponent, to emphasize the need to individualize the treatment of epileptic seizures according to variations in response to ASMs that occur over time. The chess player calculates the best move at each point in the chess game just as the neurologist draws upon their knowledge and experience to select the best ASM regimen for a given patient and adjust it based on their "gestalt" of the patient's response to each treatment change. This gestalt, however, is firmly grounded in rational, flexible adaptations to ASM treatment protocols. Strategic decision-making in several epilepsy scenarios is given to illustrate the utility of the chess analogy.