Guidelines Summary – Nurse Practitioner

Background

There are approximately 90,000 Ontarians with epilepsy, and around 6,500 will develop epilepsy each year. Beginning in 2014, The Epilepsy Implementation Task Force (EITF), supported by Critical Care Services Ontario, released a series of evidence-based recommendations to standardize epilepsy care and improve access to treatment.

Clinical Diagnosis

A diagnosis of epilepsy is based on a combination of the description of the event, associated symptoms and ancillary information. A detailed history should be taken from the patient and an eyewitness if possible. A careful history and neurologic examination may allow a diagnosis without extensive further evaluation.

Conditions such as syncope, migraine, drug reaction or intoxication, transient ischemic attacks or mental disorders may confound diagnosis. If a clear diagnosis cannot be established, referral to an appropriate specialist should be made. If psychogenic non-epileptic seizures are suspected, suitable referral should be made to psychological or psychiatric services for further investigation and treatment.

Brain imaging and electroencephalography (EEG) should be considered as part of the neurodiagnostic evaluation of patients presenting with an apparent unprovoked first seizure.

Anti-Epileptic Drug Therapy

AED treatment should aim to provide the best quality of life with seizure freedom and the fewest adverse effects. The shared decision to initiate AED treatment should be based on the type of seizures/epilepsy, risk of seizure recurrence, adverse effects of treatment, cost and duration of treatment, and goals of treatment. Patients should be treated with a single AED when possible.

Patient Education and Counselling

Ensuring patients are knowledgeable about their condition can help to alleviate stigma and negative attitudes about epilepsy and provide additional support for co-existing conditions. Patients should be given contact information for their local Community Epilepsy Agency. A list of agencies can be found by calling 1-866-EPILEPSY or visiting http://epilepsyontario.org/agency.

When Should Patients Be Referred?
  • After the first unprovoked epileptic seizure, patients should be referred for an EEG, and if necessary a brain MRI. Patients with abnormalities on MRI should be referred to a neurologist or neurosurgeon (when appropriate). AED treatment may be initiated by a primary care provider or specialist once a diagnosis is established.
  • Patients who are not seizure-free (duration ≥ 12 months) after an adequate trial of the first AED should be referred to a neurologist. AEDs must be tolerated, appropriate for the type of seizures and taken at the proper dose.
  • Patients who are not seizure-free after two adequate trials of AEDs should be referred to an epileptologist at a specialized epilepsy centre for further testing. Treatment options for drug-resistant epilepsy include surgery, diet therapy, immune therapy or neurostimulation.