[Refractory epilepsy]

DRUG-RESISTANCE: Partial epilepsies are more often drug-resistant than generalized epilepsies, excepting severe syndromes which often begin in childhood. There is no need to try all anti-epileptic drugs before concluding as to the drug-resistant nature of the seizures. Refractory epilepsy can be diagnosed if well-conducted therapy (two alternative single-drug regimens with classical anti-seizure drugs and 1 or 2 trials with a two-drug regimen using new-generation compounds) is unsuccessful. MECHANISMS OF DRUG-RESISTANCE: The clinician should revisit the entire clinical history in patients with apparently refractory epilepsy, evaluating the treatments and the specific manifestations of the seizures. Conducted in a specialized center, this reassessment can recognize false cases of drug resistance such as non-epilepsy-related malaise or syncopes, inadequate regimens, or psychogenic "pseudo-seizures" which can be observed in patients with authentic epilepsy. Video-coupled EEG and ambulatory EEG may offer very useful information. SEVERAL EFFECTIVE THERAPEUTIC OPTIONS: Prognosis depends on effective and early control of seizures. This implies entertaining surgical excision of the epileptogenic focus early in the disease course. With several promising anti-epilepsy drugs, either recently marketed or under development, therapeutic indications in epilepsy should progress to more evidence-based prescriptions adapted to the type of epilepsy and the underlying cause.