Summary of Guidelines Updates

Download a PDF of the summary sheet at the links below:

Defining Epilepsy

Epilepsy is a disease of the brain defined by any of the following conditions:
  • At least two unprovoked (or reflex) seizures occurring >24 h apart
  • One unprovoked (or reflex) seizure and a probability of further seizures similar to the general recurrence risk (at least 60%) after two unprovoked seizures, occurring over the next 10 years
  • Diagnosis of an epilepsy syndrome

Types of Epilepsy Depending on Underlying Etiology

  • Structural – There is a structural abnormality or disease associated with an increased risk of developing epilepsy, e.g. stroke, trauma
  • Genetic – Epilepsy results from a known or presumed genetic mutation, e.g. Dravet syndrome (>80% of patients have a mutation in the SCNA1 gene)
  • Metabolic – Epilepsy results from a known or presumed metabolic disorder. Most metabolic epilepsies have a genetic basis, but others are acquired, e.g. cerebral folate deficiency
  • Infectious – Epilepsy results from an infection, e.g. tuberculosis, HIV, cerebral malaria, neurocysticercosis and Zika virus
  • Immune – Epilepsy results from an immune disorder, e.g. anti-NMDA (N-methyl-D-aspartate) receptor encephalitis
  • Unknown Cause – The nature of the underlying cause is unknown; it may have a fundamental genetic defect as its core or it may be the consequence of a separate yet unrecognized disorder


Drug Treatment

See Section 6.2 (pages 22-24) of the Management Guidelines for an updated list of first-line and adjunctive anti-seizure drugs (ASDs).

Effects of ASDs on Hepatic Enzymes:
  • Physicians should exercise caution when withdrawing an enzyme-inducing drug from a polytherapeutic regimen
  • Interactions should be especially considered for drugs with narrow therapeutic indices (e.g. carbamazepine, lamotrigine, phenobarbital, phenytoin, and valproic acid)
Women with Epilepsy
  • Avoid enzyme-inducing ASDs in women with epilepsy using oral contraceptives, transdermal patches, or levonorgestrel implants
  • Whenever possible, valproic acid should be avoided in women of childbearing potential due to the risks to the fetus, including teratogenicity and neurodevelopmental delays
  • Folic acid supplements (0.4 – 4mg/day) are recommended before and during pregnancy
Sudden Unexpected Death in Epilepsy (SUDEP)
  • The incidence of sudden death is estimated to be approximately 11.2 cases per 1000 individuals with epilepsy per year
  • Seizure freedom, particularly freedom from generalized tonic-clonic seizures, is strongly associated with decreased SUDEP risk
    • The risk may be reduced by lowering seizure frequency and by adherence to ASD treatment
  • Depression and anxiety are common in people with epilepsy
  • Patients should be regularly screened for depression and offered supportive therapy
  • Antidepressant use is generally safe in people with epilepsy when used at therapeutic doses
  • Stigma is experienced by people with epilepsy in two main ways:
    • Felt (or internalized) stigma – the shame of having seizures and the fear of encountering epilepsy-linked enacted stigma
    • Enacted (or institutionalized) stigma – reflects actions or discrimination that people with epilepsy face in their communities
  • Stigma is associated with higher seizure frequency and linked to poor psychosocial outcomes (e.g. depression, anxiety, social isolation)
  • Targeted educational programs, counseling, and self-help groups can be empowering for people with epilepsy
Psychogenic Non-Epileptic Seizures (PNES)
  • PNES look like epileptic seizures but are not caused by abnormal brain electrical discharges
  • Between 53 and 100% of PNES patients have at least one comorbid psychiatric disorder, most commonly depression, anxiety, or posttraumatic stress disorder
  • A PNES diagnosis is made by an epileptologist who monitors a patient until a seizure occurs and then interprets a video-EEG
  • Cognitive behavioural therapy may be a first-line psychological treatment