How do you decide which medicine to try first?

Some of the same factors that are considered when deciding if medicine should be started are also important when deciding which medicine to try first. Your health care provider will recommend one or more possible medicines based on:  

  • What type of seizure occurred and what type of epilepsy is suspected.
    • If the event(s) are thought to be partial (focal) seizures, then most currently available seizure medications may be appropriate.
    • If the event(s) are thought to be generalized seizures (involving both sides of the brain from the beginning), then the doctor may suggest medicines that can help many different seizure types. These medicines are called broad spectrum anti-seizure medicines. (The term seizure medicines and anti-seizure medicines or AEDs are used to mean the same thing.)
    • Broad spectrum anti-seizure medicines include: valproic acid and divalproex sodium, lamotrigine, levetiracetam, topiramate, zonisamide, felbamate, and benzodiazepines. Some of the newest anti-seizure medicines also may have a broad spectrum of activity and work against different seizure types. 
    • If the seizure type is not known, then usually a broad spectrum seizure medicine is recommended first.
  • The risk of seizure recurrence (having more seizures) predicted by history, examination, and test results as well as the person's willingness to take or not take medicines and their lifestyle are also important to consider.
    • Some medicines can be started more quickly while others need to be started at low doses and slowly increased over days, weeks or sometimes months.
    • Starting a medicine quickly may be preferred if the risk for more seizures is high or if the person's lifestyle requires it. Yet, side effects are more likely to occur when a medicine is started at a large dose or the full dose right away or if the dose is increased quickly.
    • Thus, a person with a lower risk for more seizures or someone with a flexible lifestyle may want to start a medicine more slowly, even if it takes longer to get to the best dose.

The challenge of choosing a seizure medicine is that the best choice for one person may not be the best choice for another person. Some seizure medicines have unique advantages and disadvantges that may be a more important for some people. For example, some anti-seizure medicines:

  • Can also help migraines.
  • May help with depression or anxiety while others may make these problems worse.
  • May increase the risk of birth defects and should be avoided in women during their reproductive years.
  • May cause weight gain or loss.
  • Require periodic blood tests.
  • Are more likely to interact with other medicines the person may be taking.
  • May be more expensive than others or not covered fully by a person's insurance plan. If cost is an issue, ask your health care team about medication assistance programs and how to work with your insurance company to get the medicine you need.
Authored by: Robert T. Wechsler MD, PhD | Medication Editor on 2/2015