Treatment

Seizure control is most effectively achieved through the appropriate use of anticonvulsant drugs. The use of behavioural techniques to inhibit seizure activity holds promise, but is still in its infancy. Surgical treatment is increasingly available, but should only be considered for those patients who have failed repeatedly to respond to drug therapy and who have resectable lesions. Drug treatment should aim to achieve seizure control through the use of a single anticonvulsant drug, thus minimizing unwanted side-effects. This should be possible in the great majority of patients. If a first-choice drug fails, a second-choice drug should be substituted. Polytherapy may be necessary, notably in the management of partial seizures, but should be avoided wherever possible. Most first-line drugs, except phenytoin, are described in Chapter.6.2.6. Phenytoin, although relatively toxic, especially to the cerebellum, is an effective anticonvulsant and still widely prescribed. Serum monitoring is particularly important. Other anticonvulsant drugs include vigabatrin and phenobarbitone. There is little place for the latter; it is unduly sedative, and may cause depression and behavioural disturbance especially in children and adolescents. However, it is still often prescribed. Vigabatrin may cause aggressive behaviour and psychotic reactions, particularly at high dosage. Recently it has been shown to cause visual field constriction. The need for continuing anticonvulsant therapy should be reviewed by a specialist neurologist once the patient has been free of seizures for 2 years. For a more detailed account of the management of epilepsy and of status epilepticus the reader is referred to Shorvon et al. (21>

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