Editing Epilepsy (section)

===Medications===
[[File:Anticonvulsants.jpg|thumb|upright=1.4|Anticonvulsant]]
The primary treatment for epilepsy involves the use of [[Anticonvulsant|antiseizure medications]] (ASMs), which aim to control seizures while minimizing side effects. Treatment plans should be individualized, taking into account the seizure type, epilepsy syndrome, patient age, sex, comorbidities, lifestyle factors, and the potential for drug interactions.<ref name="NICE2022" />

First-line treatment for most individuals with epilepsy is monotherapy with a single ASM. For many people with epilepsy, seizure control is achieved with a single medication, but some may require combination therapy if seizures are not well-controlled with monotherapy.<ref name="NICE2022" />

<!-- Medication by type -->
There are a number of medications available including phenytoin, [[carbamazepine]] and [[valproate]]. Evidence suggests that these drugs are similarly effective for both focal and generalized seizures, although their side-effect profiles vary.<ref>{{cite journal |vauthors=Nevitt SJ, Marson AG, Tudur Smith C |title=Carbamazepine versus phenytoin monotherapy for epilepsy: an individual participant data review |journal=The Cochrane Database of Systematic Reviews |volume=2019 |issue=7 |pages=CD001911 |date=July 2019 |pmid=31318037 |pmc=6637502 |doi=10.1002/14651858.CD001911.pub4}}</ref><ref>{{cite journal |vauthors=Nevitt SJ, Marson AG, Weston J, Tudur Smith C |title=Sodium valproate versus phenytoin monotherapy for epilepsy: an individual participant data review |journal=The Cochrane Database of Systematic Reviews |volume=2018 |issue=8 |pages=CD001769 |date=August 2018 |pmid=30091458 |pmc=6513104 |doi=10.1002/14651858.CD001769.pub4}}</ref> [[Controlled release]] carbamazepine appears to work as well as immediate release carbamazepine, and may have fewer [[side effect]]s.<ref>{{cite journal |last1=Powell |first1=Graham |last2=Saunders |first2=Matthew |last3=Rigby |first3=Alexandra |last4=Marson |first4=Anthony G |title=Immediate-release versus controlled-release carbamazepine in the treatment of epilepsy |journal=Cochrane Database of Systematic Reviews |date=9 December 2016 |volume=2017 |issue=4 |pages=CD007124 |doi=10.1002/14651858.CD007124.pub5 |pmid=27933615 |pmc=6463840 }}</ref> In the UK, carbamazepine or [[lamotrigine]] are recommended as first-line treatments for focal seizures, with [[levetiracetam]] and valproate used as second-line treatments due to concerns about cost and side effects. Valproate is the first-line choice for generalized seizures, while lamotrigine is used as second-line. For absence seizures, [[ethosuximide]] or valproate are recommended, with valproate also being effective for myoclonic and tonic–clonic seizures.<ref name="NICE2022" /><ref>{{cite journal |vauthors=Nevitt SJ, Sudell M, Cividini S, Marson AG, Tudur Smith C |date=April 2022 |title=Antiepileptic drug monotherapy for epilepsy: a network meta-analysis of individual participant data |journal=The Cochrane Database of Systematic Reviews |volume=2022 |issue=4 |pages=CD011412 |doi=10.1002/14651858.CD011412.pub4 |pmc=8974892 |pmid=35363878}}</ref>

Controlled-release formulations of carbamazepine may be preferred in some cases, as they appear to be equally effective as immediate-release carbamazepine but may have fewer side effects. Once a person’s seizures are well-controlled on a specific treatment, it is generally not necessary to routinely check medication blood levels, unless there are concerns about side effects or toxicity.<ref name="NICE2022" />

<!--Developing world  -->
In [[low- and middle-income countries]] (LMICs), the management of epilepsy is often hindered by limited access to medications, diagnostic tools, and specialized care.<ref name="Poor2012" /> While phenytoin and carbamazepine are commonly used as first-line treatments due to their availability and low cost, newer drugs like levetiracetam and lamotrigine may not be accessible. Additionally, surgical options and advanced therapies, such as vagus nerve stimulation or resective surgery, are typically inaccessible due to high costs and lack of infrastructure. 

The least expensive anticonvulsant is [[phenobarbital]] at around US$5 a year.<ref name="Poor2012" /> The [[World Health Organization]] gives it a first-line recommendation in LMICs and it is commonly used in these countries.<ref>{{cite journal | vauthors = Ilangaratne NB, Mannakkara NN, Bell GS, Sander JW | title = Phenobarbital: missing in action | journal = Bulletin of the World Health Organization | volume = 90 | issue = 12 | pages = 871–871A | date = December 2012 | pmid = 23284189 | pmc = 3524964 | doi = 10.2471/BLT.12.113183 }}</ref><ref>{{cite book | veditors = Shorvon S, Perucca E, Engel Jr J |title=The treatment of epilepsy|year=2009|publisher=Wiley-Blackwell|location=Chichester, UK|isbn=978-1-4443-1667-4|page=587|url=https://books.google.com/books?id=rFFzFzZJtasC&pg=PA587|edition=3rd|url-status=live|archive-url=https://web.archive.org/web/20160521102931/https://books.google.com/books?id=rFFzFzZJtasC&pg=PA587|archive-date=21 May 2016}}</ref> Access, however, may be difficult as some countries label it as a [[controlled drug]].<ref name="Poor2012" />

<!--Side effects  -->
Adverse effects from medications are reported in 10% to 90% of people, depending on how and from whom the data is collected.<ref name="Per2012" /> Most adverse effects are dose-related and mild.<ref name="Per2012" /> Some examples include mood changes, sleepiness, or an unsteadiness in gait.<ref name="Per2012" /> Certain medications have side effects that are not related to dose such as rashes, liver toxicity, or [[aplastic anemia|suppression of the bone marrow]].<ref name="Per2012" /> Up to a quarter of people stop treatment due to adverse effects.<ref name="Per2012" /> Some medications are associated with [[birth defect]]s when used in pregnancy.<ref name="National Clinical Guideline 57_83">{{cite book |author=National Clinical Guideline Centre |url=http://www.nice.org.uk/nicemedia/live/13635/57784/57784.pdf |title=The Epilepsies: The diagnosis and management of the epilepsies in adults and children in primary and secondary care |date=January 2012 |publisher=National Institute for Health and Clinical Excellence |pages=57–83 |archive-url=https://web.archive.org/web/20131216151008/http://www.nice.org.uk/nicemedia/live/13635/57784/57784.pdf |archive-date=16 December 2013 |url-status=live}}</ref> Many of the common used medications, such as valproate, phenytoin, carbamazepine, phenobarbital, and gabapentin have been reported to cause increased risk of birth defects,<ref name="Bromley_2023">{{cite journal | vauthors = Bromley R, Adab N, Bluett-Duncan M, Clayton-Smith J, Christensen J, Edwards K, Greenhalgh J, Hill RA, Jackson CF, Khanom S, McGinty RN, Tudur Smith C, Pulman J, Marson AG | title = Monotherapy treatment of epilepsy in pregnancy: congenital malformation outcomes in the child | journal = The Cochrane Database of Systematic Reviews | volume = 2023 | issue = 8 | pages = CD010224 | date = August 2023 | pmid = 37647086 | pmc = 10463554 | doi = 10.1002/14651858.CD010224.pub3 }}</ref> especially when used during the [[first trimester]].<ref name="Kam2013" /> Despite this, treatment is often continued once effective, because the risk of untreated epilepsy is believed to be greater than the risk of the medications.<ref name="Kam2013">{{cite journal | vauthors = Kamyar M, Varner M | title = Epilepsy in pregnancy | journal = Clinical Obstetrics and Gynecology | volume = 56 | issue = 2 | pages = 330–341 | date = June 2013 | pmid = 23563876 | doi = 10.1097/GRF.0b013e31828f2436 }}</ref> Among the antiepileptic medications, levetiracetam and lamotrigine seem to carry the lowest risk of causing birth defects.<ref name="Bromley_2023" />

<!--Tapering  -->
Slowly stopping medications may be reasonable in some people who do not have a seizure for two to four years; however, around a third of people have a recurrence, most often during the first six months.<ref name="National Clinical Guideline 57_83" /><ref>{{cite book|title=Adolescent health care: a practical guide|year=2008|publisher=Lippincott Williams & Wilkins|location=Philadelphia|isbn=978-0-7817-9256-1|page=335|url=https://books.google.com/books?id=er8dQPxgcz0C&pg=PA335|edition=5th|editor=Lawrence S. Neinstein}}</ref> Stopping is possible in about 70% of children and 60% of adults.<ref name=WHO2012/> Measuring medication levels is not generally needed in those whose seizures are well controlled.<ref name=Wise2018>{{cite web |title=American Epilepsy Society Choosing Wisely |url=http://www.choosingwisely.org/societies/american-epilepsy-society/ |website=www.choosingwisely.org |date=14 August 2018 |access-date=30 August 2018}}</ref>