Seizure Disorders in Adults: Principles of Treatment of Epilepsy

Management of epilepsy requires an individualized, longitudinal approach that incorporates seizure type, recurrence risk, comorbidities, lifestyle, reproductive planning, and safety implications of recurrent seizures. Family physicians play a central role in early counseling, initial medication discussions, monitoring for adverse effects, and recognizing when referral for advanced therapies is warranted. Evidence shows that early initiation of maintenance antiseizure medication after a first unprovoked seizure lowers short-term recurrence but does not change long-term remission or mortality, underscoring the need for shared decision-making grounded in patient preferences and psychosocial or occupational needs. Because epilepsy is increasingly viewed as a heterogeneous group of disorders rather than a single entity, treatment must integrate mechanism-based medication selection, titration principles, therapeutic monitoring, and nonpharmacologic options such as dietary therapy, neuromodulation, and surgery. This section provides a primary care–focused overview of medication strategy, emphasizing when to start medication, how to choose and adjust therapy, and how to manage breakthrough seizures, drug resistance, and pregnancy-related issues.