Drug-resistant epilepsy

At a glance

• Drug resistance does not mean there are no further treatment options.
• The diagnosis and previous treatment should be reviewed first.
• Surgery may be an option for some people; assessment should be considered early.

“I am already taking a third medicine, but I still have seizures.” This is an important point in treatment. It is a reason to reassess the whole situation and review the strategy, not to assume all options are exhausted.

What is drug-resistant epilepsy?

It is defined as failure of two appropriately chosen, tolerated and properly used antiseizure medication regimens, alone or in combination, to achieve sustained seizure freedom.

First, revisit the diagnosis

• Are all the episodes genuinely epileptic seizures?
• Have the seizure type and epilepsy type been correctly identified?
• Were suitable medicines used at appropriate doses for long enough?
• Did adverse effects limit treatment?
• Does MRI show a possible source of the seizures?

Answering these questions may require prolonged video-EEG monitoring and an epilepsy-protocol MRI.

Medication still matters

Further options may include a different medicine, a carefully chosen combination, or changes to doses and timing. Decisions take account of age, sex, other conditions, other medicines, pregnancy plans and the balance between seizure control and side effects.

Could surgery help?

In some people, seizures repeatedly begin in the same brain region. If it can be precisely located, the possibility of surgery should be assessed.

Assessment is a process rather than a single test: prolonged video-EEG, MRI, neuropsychological assessment, additional imaging and, in selected cases, invasive recording with electrodes placed inside the brain (stereo-EEG). If resective surgery is not possible, neuromodulation such as vagus nerve stimulation or other treatments may be considered.

Looking beyond seizures

Long-standing seizures can affect memory, mood, work, education and independence. Care may involve neuropsychological assessment, psychological or psychiatric support and collaboration between neurologists, clinical neurophysiologists, neuroradiologists, neuropsychologists, geneticists and neurosurgeons.

What to bring

• A list of all previous medicines, doses and reasons for stopping.
• A seizure diary and phone recordings.
• EEG reports and MRI images with reports.
• Hospital discharge summaries.

The consultation may include reviewing treatment, planning further investigations and, when indicated, preparing records for assessment at an epilepsy surgery centre.