guidelines for epilepsy nice

The diagnosis and management of the epilepsies in
adults and children in primary and secondary care
November 2013: A footnote has been added to recommendation 81 in this guideline highlighting new advice issued by the
MHRA about oral antiepileptic drugs (AEDs) and switching between different manufacturers’ products of a particular drug.
See the MHRA advice for more information at www.mhra.gov.uk. The corresponding change has been made to
recommendation 1.9.1.4 in the NICE guideline and on the NICE epilepsy pathway.
Final
Health and Clinical Excellence
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Consultant Neurologist, Ninewells Hospital, Dundee
Chairman, SIGN 70 Diagnosis and management of epilepsy in adults (2003)
The inadequacies that have existed in the services, care and treatment for people with epilepsy are
well recognised. Important issues include misdiagnosis, inappropriate or inadequate treatment,
sudden unexpected death that might have been prevented, advice about pregnancy and
contraception and management of status epilepticus. Service provision for people with epilepsy has
been patchy and sometimes poor both in primary and secondary care. This is now changing. The
new General Medical Services (GMS) contract includes targets for epilepsy. The number of
specialists with expertise in epilepsy is increasing. There has been a great increase in the number of
epilepsy specialist nurses, and structured services for epilepsy across primary and secondary care are
emerging. At the same time a number of new antiepileptic drugs have been licensed.
This guideline is published, therefore, at a time when it is likely to have a major impact. The
recommendations on service provision, such as waiting times to see specialists and for investigations,
will be challenging for the service providers, as they have been in Scotland following similar
recommendations (SIGN Guideline 70). The guidance on the use of the newer antiepileptic drugs
confirms their important role in the treatment of epilepsy. Clear guidance is given in various specific
areas such as pregnancy and contraception, learning disability, young people, repeated seizures in
the community and status epilepticus. The importance of the provision of information for people
with epilepsy and their carers is stressed. If there is successful implementation of the
recommendations, there will be a great improvement in the care of people with epilepsy.
Dr Nick Kosky
Community Health Services
Chairman, The epilepsies guideline 2012

Published by the National Clinical Guideline Centre at
The Royal College of Physicians, 11 St Andrews Place, Regents Park, London, NW1 4BT
First published 2004
© National Clinical Guideline Centre – January 2012
Apart from any fair dealing for the purposes of research or private study, criticism or review, as
permitted under the Copyright, Designs and Patents Act, 1988, no part of this publication may be
reproduced, stored or transmitted in any form or by any means, without the prior written permission of
the publisher or, in the case of reprographic reproduction, in accordance with the terms of licences
issued by the Copyright Licensing Agency in the UK. Enquiries concerning reproduction outside the
terms stated here should be sent to the publisher at the UK address printed on this page.
The use of registered names, trademarks, etc. in this publication does not imply, even in the absence of
a specific statement, that such names are exempt from the relevant laws and regulations and therefore
for general use.
The rights of National Clinical Guideline Centre to be identified as Author of this work have been
asserted by them in accordance with the Copyright, Designs and Patents Act, 1988.
Partial Pharmacological Update of Clinical Guideline 20

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The guideline highlighted the inadequacies that existed in the services, care and treatment for
people with epilepsy, and made great progress in addressing relevant important issues
misdiagnosis, inappropriate or inadequate treatment, sudden unexpected death that might have
been prevented, advice about pregnancy and contraception and management of status epilepticus.
Revisiting this guideline is timely. The NHS is facing major financial challenges, and it is vital that a
spotlight is kept on the need to further develop the still variable services for people with epilepsy.
The place of newly licensed drugs for epilepsy also needs careful consideration.
The updated guideline reminds the reader of the need for properly resourced services, offering
appropriate levels of expertise, which allow timely access to assessment and treatment for people
with epilepsy. The primary scope of the guidelines was to consider the role of antiepileptic drugs,
especially given the impact of important, realworld studies such as SANAD. The role of established
and newly licensed drugs has been considered using novel statistical methods allowing comparison
of cost effectiveness – a process that has been much aided, as always, by a robust stakeholder
review process.
People with epilepsy remain at the centre of this guideline, and the need for services to consider the
needs of each individual, to not discriminate in provision and to work in partnership with people with
epilepsy and their carers is underlined.
Attention has been paid to ensure that the recommendations are written in clear language and are
accessible, and, we hope, useful to all. Supporting the written version is an online care pathway, and
quality standards are soon to be published. We remain committed to the care of people with

Foreword
ChairmanElect, Royal College of General Practitioners until 2006
Founding Chairman of the National Collaborating Centre for Primary Care (20012004)
It gives me great pleasure to see the publication of the first major clinical practice guideline from the
National Collaborating Centre for Primary Care, hosted by the Royal College of General Practitioners.
As a practising GP, I am well aware of the challenges faced when dealing with patients with epilepsy.
It is well recognised that the care of patients with epilepsy is suboptimal and more needs to be done
to improve clinical standards. GPs are faced with a complex set of issues on a regular basis including
giving advice to patients about epilepsy and driving, planning a pregnancy and the thorny issue of
withdrawal of anti epileptic medication. In these and other areas, practical recommendations are
essential: It is therefore welcome to have this clear guidance which will support GPs to implement
the Quality and Outcomes Framework of the new General Medical Services contract. In addition the
guideline contains important recommendations about service for patients with epilepsy and the
organisation of care.
The Royal College of General Practitioners exists to promote the highest possible standards of
general medical care and it is committed to increasing support for GPs to enable them to do so. I
commend these guidelines to the health community as a whole and urge commissioners to support
its implementation. I would like to acknowledge the excellent work of the staff of National
Collaborating Centre for Primary Care and colleagues at the University of Leicester in producing this
guideline.
5
Acknowledgements ...................................................................................................................... 20
1.2 Clinical aspects .................................................................................................................... 21
1.5 Health Services for people with epilepsy ............................................................................ 24
1.5.1 Primary care ......................................................................................................... 24
1.5.2 Secondary care .................................................................................................... 25
1.7 Guideline aims ..................................................................................................................... 26
1.9 Who should use this guideline? .......................................................................................... 27
1.11 Guideline limitations ........................................................................................................... 28
2 Methods ................................................................................................................................ 30
2.1 Introduction ........................................................................................................................ 30
2.2.2 The National Clinical Guidelines Centre .............................................................. 30
2.2.3 The methodology team ....................................................................................... 30
2.2.4 The Guideline Development Group ..................................................................... 31
2.3 Developing key clinical questions (KCQs) ............................................................................ 32
2.4.2 Health economics ................................................................................................ 34
2.5.1 Methods for 2004 Guideline ................................................................................ 35
2.5.2 Methods for 2012 Guideline ................................................................................ 36
2.6 Methods of combining studies (2012) ................................................................................ 37
2.7 Protocol for guideline evidence reviews for the partial update (2012) .............................. 37
Types of studies ............................................................................................................................. 37
Types of participants ..................................................................................................................... 38
Types of interventions ................................................................................................................... 39
6
Type of analysis ............................................................................................................................. 41
Inconsistency ................................................................................................................................. 42
Indirectness ................................................................................................................................... 42
Imprecision .................................................................................................................................... 42
2.8.2 Literature review for health economics .............................................................. 45
2.9 Developing recommendations ............................................................................................ 46
2.10 Research Recommendations ............................................................................................... 48
2.10.2 Epilepsy syndromes ............................................................................................. 48
2.10.3 Infantile spasms ................................................................................................... 49
2.10.5 AEDs and pregnancy ............................................................................................ 50
2.10.6 Ketogenic diet in adults ....................................................................................... 50
2.11 Prioritisation of recommendations for implementation .................................................... 51
2.12 The relationship between the guideline and the Technology Appraisals for the newer
antiepileptic drugs (AEDs) ................................................................................................... 51
2.13 The relationship between the guideline and National Service Frameworks ...................... 52
2.14 The relationship between the guideline and the Scottish Intercollegiate Guidelines
Network guidelines on epilepsy .......................................................................................... 52
2.15 External review ................................................................................................................... 53
4 Guidance ............................................................................................................................... 57
5 Audit Criteria ......................................................................................................................... 85
6 Principle of decision making .................................................................................................. 86
6.1 Who should be involved in the decision making process for adults and children with
epilepsy? ............................................................................................................................. 86
7.2 Establishing the diagnosis of epilepsy ................................................................................. 87
7.3 Key features of the history and examination that allow epilepsy to be differentiated
from other diagnoses in adults and children ...................................................................... 88

7
seizure to be differentiated from other causes of attack disorder in adults? .................... 91
7.5 The role of attack/seizure diaries in diagnosis in adults & children ................................... 91
7.6 The role of home video recording in making the diagnosis of epilepsy in adults and
children? .............................................................................................................................. 91
8 Investigations ........................................................................................................................ 93
8.1 Introduction ........................................................................................................................ 93
8.2 The role of EEG in making a diagnosis of epilepsy .............................................................. 93
8.2.1 How good is the standard EEG at differentiating between individuals who
have had an epileptic seizure and those who have had a nonepileptic
seizure? ................................................................................................................ 93
8.2.2 How good is the EEG at differentiating between individuals who have
different epilepsy seizure types and epilepsy syndromes? ................................. 98
8.2.3 How can the diagnostic yield of the standard interictal EEG be improved? ....... 98
8.2.4 What are the roles of longterm videoEEG and ambulatory EEG? ................... 102
8.2.5 What is the role of provocation techniques and induction protocols? ............. 103
8.2.6 Does an abnormal EEG predict seizure recurrence? ......................................... 105
8.3 The role of neuroimaging in the diagnosis of epilepsy ..................................................... 107
8.4 The role of prolactin levels and other blood tests as an aid to diagnosis ......................... 114
8.5 Cardiovascular tests as an aid to diagnosis ....................................................................... 116
8.6 What is the role of neuropsychological assessment in the diagnosis and management
of epilepsy? ....................................................................................................................... 116
9.1 Introduction ...................................................................................................................... 119
9.2 Classification of the epilepsies .......................................................................................... 119
9.3 What is the role of classification in adults and children with epilepsy? ........................... 129
10 Pharmacological treatment of epilepsy ............................................................................... 130
10.1 Introduction ...................................................................................................................... 130
Pharmacological treatment of epilepsy ...................................................................................... 131
10.2 How many times should monotherapy be tried before combination therapy is
considered? ....................................................................................................................... 131
10.2.1 When should AED treatment in adults and children be started?...................... 132
10.2.2 Who should start AED treatment in adults and children? ................................. 136
10.2.3 In adults and children with epilepsy on AEDs does management of
continuing drug therapy by a generalist as opposed to a specialist lead to
different clinical outcomes? .............................................................................. 136
10.2.4 What is the role of monitoring in adults and children with epilepsy? .............. 137
10.2.5 What influences AED treatment concordance in adults and children? ............ 140
10.2.6 When and how should AED treatment be discontinued in adults and
children? ............................................................................................................ 141
10.2.7 In adults/children with epilepsy on AEDs does management of drug

8
10.3.1 Introduction ....................................................................................................... 156
10.3.3 Matrix of the evidence for adults ...................................................................... 156
10.3.4 Monotherapy for adults with newly diagnosed focal seizures .......................... 159
10.3.5 Individual patient data network metaanalysis as monotherapy for focal
epilepsy .............................................................................................................. 199
10.3.6 Health economic evidence of AEDs used as monotherapy for adults with
newly diagnosed focal epilepsy ......................................................................... 200
10.3.7 Monotherapy for children with newly diagnosed focal epilepsy ...................... 206
10.3.8 Health economic evidence of AEDs used as monotherapy for children with
newly diagnosed focal epilepsy ......................................................................... 209
10.3.9 New recommendations and link to evidence .................................................... 211
10.3.10 New research recommendations (for full list see section 2.11) ........................ 221
10.4 Therapy for refractory focal seizures ................................................................................ 222
10.4.1 Introduction ....................................................................................................... 222
10.4.3 Matrix of the evidence....................................................................................... 222
10.4.4 Single AED therapy for refractory focal seizures ............................................... 226
10.4.5 Health Economic Evidence for single AED therapy for refractory focal
seizures .............................................................................................................. 228
10.4.6 Adjunctive therapy in children, young people and adults with refractory
focal seizures ..................................................................................................... 229
10.4.7 Health economic evidence of AEDs used as adjunctive therapy for adults
with refractory focal epilepsy ............................................................................ 268
10.4.8 Health economic evidence of AEDs used as adjunctive therapy for children
with refractory focal epilepsy ............................................................................ 273
10.4.10 Research Recommendations (for full list see section 2.11) .............................. 283
10.5 Generalised TonicClonic Seizures (GTCS) ......................................................................... 284
10.5.1 Introduction ....................................................................................................... 284
10.5.4 Monotherapy for the treatment of generalised tonicclonic seizures in
adults ................................................................................................................. 287
10.5.5 Individual patient data network metaanalysis as monotherapy for
generalised tonicclonic epilepsy ....................................................................... 308
10.5.6 Monotherapy for the treatment of generalised tonicclonic seizures in
children .............................................................................................................. 310
9
10.5.7 Adjunctive therapy for the treatment of generalised tonicclonic seizures ...... 310
10.5.8 Health economic evidence for AEDs used as adjunctive therapy in adults
with refractory generalised tonicclonic seizures .............................................. 315
10.6 Absence Seizures ............................................................................................................... 322
10.7 Myoclonic Seizures ............................................................................................................ 329
10.7.5 Adjunctive therapy for the treatment of myoclonic seizures ........................... 331
10.8 Tonic or atonic seizures ..................................................................................................... 340
10.8.1 Introduction ....................................................................................................... 340
10.9 Infantile Spasms (West syndrome) ................................................................................... 345
10.9.3 Matrix of the evidence for adjunctive therapy .................................................. 345
10.10 Dravet syndrome (SMEI) ................................................................................................... 357
10.11 LennoxGastaut Syndrome ................................................................................................ 363
10.11.1 Introduction ....................................................................................................... 363
10
10.11.4 Adjunctive treatment for LennoxGastaut syndrome ....................................... 364
10.11.5 Health economic evidence of AEDs used as adjunctive therapy for children
with LennoxGastaut syndrome ........................................................................ 369
10.12 Benign epilepsy with centrotemporal spikes, Panayiotopoulos syndrome and late
onset childhood occipital epilepsy (Gastaut type) ............................................................ 376
10.12.1 Introduction ....................................................................................................... 376
10.12.4 Monotherapy for the treatment of adults and children with BECTS,
Panayiotopoulos syndrome and late onset childhood occipital epilepsy
(Gastaut type) .................................................................................................... 377
10.13 Idiopathic Generalised Epilepsy (IGE) ............................................................................... 397
Matrix of the evidence for childhood absence epilepsy, juvenile absence epilepsy and
other absence epilepsy syndromes ................................................................... 400
10.13.4 Monotherapy for the treatment of IGE in newly diagnosed patients ............... 401
10.13.5 Adjunctive therapy in children, young people and adults with IGE .................. 405
10.13.6 Health economic evidence for AEDs used as monotherapy in the treatment
of patients with newly diagnosed IGE ............................................................... 406
10.13.7 Monotherapy for the treatment of childhood absence epilepsy, juvenile
absence epilepsy and other absence epilepsy syndromes ................................ 409
10.13.8 Adjunctive therapy for the treatment of childhood absence epilepsy,
juvenile absence epilepsy and other absence epilepsy syndromes .................. 415
10.13.9 Monotherapy for the treatment of Juvenile Myoclonic Epilepsy (JME) ............ 415
10.13.10 Monotherapy/adjunctive therapy for the treatment of juvenile myoclonic
epilepsy (JME) .................................................................................................... 417
10.13.11 Adjunctive treatment for for the treatment of of Juvenile Myoclonic
Epilepsy (JME) .................................................................................................... 418
10.13.12 AEDs for the treatment of epilepsy with generalised tonic clonic seizures
only .................................................................................................................... 419
10.14 Other epilepsy syndromes ................................................................................................ 443
10.14.1 Introduction ....................................................................................................... 443

11
10.15 Prolonged seizures and convulsive status epilepticus ...................................................... 444
10.15.1 Introduction ....................................................................................................... 444
10.15.4 AEDs for the treatment of prolonged seizures and convulsive status
epilepticus in the community ............................................................................ 448
10.15.5 Treatment of prolonged seizures and convulsive status epilepticus in
children (community) ........................................................................................ 450
10.15.6 Treatment of acute repetitive seizures (children and adults) ........................... 452
10.15.7 Treatment of convulsive status epilepticus in adults in hospitals ..................... 452
10.15.8 Treatment of convulsive status epilepticus in children ..................................... 458
10.15.9 Treatment of refractory status epilepticus ........................................................ 462
10.16 Nonconvulsive status epilepticus .................................................................................... 476
10.16.1 Introduction ....................................................................................................... 476
10.16.3 AEDs for the treatment of nonconvulsive Status Epilepticus (observational
study) ................................................................................................................. 477
10.16.5 Generic prescribing ............................................................................................ 477
10.17 When should an individual with epilepsy be referred for assessment in a tertiary
centre? .............................................................................................................................. 477
10.17.1 Introduction ....................................................................................................... 477
11 The role of nondrug treatments in the management of the epilepsies ................................ 481
11.1 Introduction ...................................................................................................................... 481
11.2 Does the treatment of epilepsy in adults or children with psychological methods lead
to a reduction in seizure frequency and/or a better quality of life? ................................ 481
11.3 Ketogenic Diet ................................................................................................................... 482
11.3.6 Ketogenic diet in adults ..................................................................................... 488
11.4 In people with drug resistant epilepsy, is vagus nerve stimulation (VNS) effective as
an adjunctive treatment?.................................................................................................. 488
12.1 Introduction ...................................................................................................................... 493
12
12.2 Information needs of the individual with epilepsy, the family, the carer, and special
groups ............................................................................................................................... 493
12.3 What information is required at different stages of the care pathway ............................ 496
12.4 What is the risk of SUDEP in individuals with epilepsy ..................................................... 501
13 Women of childbearing age with epilepsy ........................................................................... 504
13.1 Introduction ...................................................................................................................... 504
13.2 What information and counselling should be given and when? ...................................... 504
13.3 What issues should be considered in women who may become pregnant or who are
breast feeding? ................................................................................................................. 507
13.4 Increased risk of seizures during pregnancy or whilst breastfeeding ............................... 508
13.5 Teratogenic effects of AEDs whilst pregnant .................................................................... 511
13.5.1 Introduction ....................................................................................................... 511
13.5.3 Comparison between specific monotherapies on developmental /cognitive
outcomes ........................................................................................................... 516
13.5.4 Any monotherapy exposure versus no exposure in general population .......... 519
13.6 Do AEDs interact with contraceptives? ............................................................................. 533
13.7 Does epilepsy increase the risk of complications in pregnancy? ...................................... 537
13.7.1 Are women with epilepsy at increased risk of complications during the
pregnancy and labour? ...................................................................................... 538
13.7.2 When should screening for structural fetal anomalies be performed in
pregnant women with epilepsy? ....................................................................... 538
13.8 When should folic acid be started? ................................................................................... 539
13.9 What are the dangers of seizures in women who are pregnant or postnatal? ............... 539
13.10 What is the role of drug monitoring in pregnant women with epilepsy? ........................ 541
13.11 Should oral or parenteral vitamin K be used? .................................................................. 542
13.12 What is the risk of of inheriting epilepsy? ........................................................................ 542
13.13 What is the role of joint epilepsy and obstetric clinics in the care of women with
epilepsy who are pregnant? .............................................................................................. 543
14 Children, young people and adults with learning disabilities and epilepsy ........................... 544
14.1 Introduction ...................................................................................................................... 544
14.2 Who should manage and treat epilepsy in children, young people and adults with
learning disabilities? .......................................................................................................... 544
14.2.1 Do people with learning disabilities and epilepsy who receive care from a
specialist in learning disabilities and epilepsy compared with care from a
nonspecialist have differences in processes and outcomes of care? .............. 544

13
learning disabilities? .......................................................................................... 545
14.3.2 What are the practical difficulties in establishing the diagnosis in this group? 545
14.4 Are there difficulties in doing investigations in this group? ............................................. 546
14.4.1 Are there a) difficulties in conducting investigations (EEG; neuroimaging); b)
difficulties in interpreting investigations (EEG; neuroimaging) in people with
learning disability and epilepsy when compared with people with epilepsy
who do not have learning disabilities? .............................................................. 546
14.5 What are the main factors to assess when making a care plan for an individual with
learning disabilities and epilepsy? .................................................................................... 547
14.6.1 Introduction ....................................................................................................... 547
14.6.5 Is epilepsy more difficult to treat in people with learning disabilities? ............ 554
14.6.6 Likelihood of remission of seizures .................................................................... 554
14.7 What are the additional management issues in people with learning disabilities? ......... 555
14.7.1 Is there increased mortality in people with learning disabilities and
epilepsy? ............................................................................................................ 556
14.7.2 What management issues in people with learning disabilities do healthcare
practitioners and carers view as important? ..................................................... 557
15 Young people with epilepsy ................................................................................................. 558
15.1 Introduction ...................................................................................................................... 558
15.2 Is a different approach to management required in adolescence? .................................. 558
15.3 What are the factors that affect adherence to treatment in adolescents with
epilepsy? ........................................................................................................................... 558
15.4 Is there any evidence of effectiveness for any given strategies proposed to improve
outcomes for adolescents? ............................................................................................... 559
15.5 What are the special needs or information requirements of this group? ........................ 559
15.6 Should the diagnosis of epilepsy be revisited in this group? ............................................ 561
16 Older people ....................................................................................................................... 563
16.1.1 Introduction ....................................................................................................... 563
17 People from black and minority ethnic groups ..................................................................... 572
17.1 Introduction ...................................................................................................................... 572
17.2 What are the information and service provision needs of people from black and
minority ethnic groups? .................................................................................................... 572

14
18.1 Introduction ...................................................................................................................... 574
18.2 What features of the care process in primary care/shared care lead to improved
health outcomes for adults and children with epilepsy? .................................................. 574
18.2.1 What evidence is there regarding the quality of care currently provided in
primary care? ..................................................................................................... 575
18.2.2 What process of care has been proposed to improve outcomes for adults
and children with epilepsy in primary care? ..................................................... 576
18.3 What features of the care process in secondary and tertiary care lead to improved
health outcomes for adults and children with epilepsy? .................................................. 577
18.3.1 What evidence is there of the quality of care currently provided in
secondary/tertiary care? ................................................................................... 578
and children with epilepsy in secondary/tertiary care? .................................... 581
18.4 What features of the care process in A&E lead to improved health outcomes for
adults and children with epilepsy? ................................................................................... 583
18.4.1 Quality of care currently provided in and accident and emergency
departments (A&E) ............................................................................................ 583
and children with epilepsy in A&E? ................................................................... 585
18.5 How effective are individual/self management plans in adults and children with
epilepsy? ........................................................................................................................... 585
18.5.1 Introduction ....................................................................................................... 585
18.5.2 Do adults and children with epilepsy who are educated in self management,
when compared with those who do not, have better health outcomes? ......... 586
19 Glossary .............................................................................................................................. 588
15
Ms Kathy Bairstow, nominated by Epilepsy Action (British Epilepsy Association)
Patient Representative, Leeds
Ms Bernie Concannon, nominated by the Royal College of Nursing
Clinical Nurse Specialist (Paediatric Epilepsy), Birmingham Children’s Hospital
Mr Ian Costello, nominated by the Neonatal & Paediatric Pharmacists Group
Chief Pharmacist, Centre for Paediatric Research, School of Pharmacy, London
Dr Helen Cross, nominated by the Royal College of Paediatrics & Child Health
Senior Lecturer & Honorary Consultant in Paediatric Neurology, Institute of Child Health and Great
Ormond Street Hospital for Children, London
Professor John Duncan, nominated by the Royal College of Physicians
Professor of Neurology, The National Hospital for Neurology and Neurosurgery, London
Dr Amanda Freeman, nominated by the Royal College of Paediatrics and Child Health
Consultant Paediatrician, St Mary’s Hospital, Portsmouth
Ms Sally Gomersall, nominated by the National Society for Epilepsy
Patient Representative, Newark
Patient Representative, Wantage
Mr William Harkness, nominated by the Society of British Neurological Surgeons
Consultant Neurological Surgeon, Great Ormond Street Hospital for Children, London
Dr Peter Humphrey, nominated by the Association of British Neurologists
Consultant Neurologist, The Walton Centre for Neurology & Neurosurgery, Liverpool
Dr Tanzeem Raza, nominated by the Royal College of Physicians
Consultant Physician, Royal Bournemouth Hospital
Mr Peter Rogan, nominated by the Joint Epilepsy Council
Patient Representative, Ormskirk
Dr Henry Smithson, nominated by the Royal College of General Practitioners
Guideline Development Group Lead

16
Dr Amanda Freeman
Mrs Diane Flower
Dr Greg Rogers
GP and General Practitioner with a Special Interest in Epilepsy [GPwSI] Eastern and Coastal Kent PCT
Professor Helen Cross
The Prince of Wales's Chair of Childhood Epilepsy, UCLInstitute of Child Health, Great Ormond Street
Hospital for Children & National Centre for Young People with Epilepsy. Head of Neurosciences Unit,
UCLInstitute of Child Health, London.
Professor Ian Chi Kei Wong
Director and Professor of Paediatric Medicines Research, Centre for Paediatric Pharmacy Research,
The School of Pharmacy, The University of London, UCL Institute of Child Health, Great Ormond
Street Hospital NHS Trust for Children (Until August 2011). Department of Pharmacology and
Pharmacy, Li Ka Shing Faculty of Medicine, University of Hong Kong.
Professor John Duncan
Professor of Neurology, Department of Clinical and Experimental Epilepsy, UCL Institute of
Neurology, London. Consultant Neurologist, National Hospital for Neurology and Neurosurgery.
Medical Director, The Epilepsy Society
Dr Margaret Jackson
Mr Michael Harnor
Dr Nick Kosky (chair)
Dorset Community Health Services, NHS Dorset
Dr Richard Appleton
Foundation. Alder Hey Children's NHS Foundation Trust, Liverpool.
Mrs Sally Gomersall
Mr Sean Mackey (until March 2010)
Independent Pharmacist consultant. Dalton
17
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2 0 1 2
Mrs Tracey Truscott
Head of Epilepsy Nursing Service, NHS Eastern and Coastal Kent Community services
Guideline Development Group (GDG) cooptees (2004)
Professor Gus Baker, nominated by the British Psychological Society
Professor of Neuropsychology, University of Liverpool
Professor Frank Besag, nominated by the Royal College of Psychiatrists
Consultant Psychiatrist, Bedfordshire & Luton Community NHS Trust and Visiting Professor of
Neuropsychiatry, University of Luton
Professor Shoumitro Deb, nominated by the Royal College of Psychiatrists
Professor of Neuropsychiatry and Intellectual Disability, University of Birmingham
Dr David Finnigan, nominated by PRODIGY
General Practitioner, Sowerby Centre for Health Informatics, University of Newcastle
Mr Andrew Green, nominated by the College of Occupational Therapists
Occupational Therapist, Frenchay Hospital, Bristol
Dr Jo Jarosz, nominated by the Royal College of Radiologists
Consultant Neuroradiologist, King’s College Hospital, London
Dr Andrew Lloyd Evans, nominated by the Royal College of Paediatrics and Child Health
Consultant Paediatrician, Royal Free Hospital, London
Dr David McCormick, nominated by the International League Against Epilepsy (ILAE)
Consultant Paediatrician, East Kent Hospitals NHS Trust, Kent
Mr James Oates, nominated by the Royal College of Nursing
Epilepsy Liaison Nurse (Adult), Hull Royal Infirmary
Dr Gillian Penney, nominated by the Royal College of Obstetricians and Gynaecologists
Senior Lecturer, Scottish Programme for Clinical Effectiveness in Reproductive Health, University of
Aberdeen
Ms Linda Perry, nominated by the National Centre for Young People with Epilepsy (NCYPE)
Director of Medical Services, NCYPE, St Piers Lane, Lingfield
Mr Martin Shalley, nominated by the British Association for Accident & Emergency Medicine
Consultant in A&E Medicine, Birmingham Heartlands Hospital
Professor Raymond Tallis, nominated by the British Geriatrics Society
Professor of Geriatric Medicine, University of Manchester
Guideline Development Group (GDG) cooptees (2012)
Professor Frank Besag
18
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0 1 2
Centre, Bedford.
Dr Aza JJ Abdulla
NHS Trust. Princess Royal University Hospital. Kent
Professor Tony Marson (External Peer Reviewer)
Professor of Neurology. University of Liverpool and Coordinating Editor Cochrane Epilepsy Group
Dr Catrin TudurSmith (External Peer Reviewer)
Senior Lecturer in Biostatistics. University of Liverpool and Statistical Editor Cochrane Epilepsy Group
Dr GP Sinha (External Peer Reviewer)
Consultant Paediatrician. Walsall Healthcare NHS Trust, Manor Hospital
National Collaborating Centre for Primary Care (NCCPC) Project Team (2004)
Professor Richard Baker, Director, NCCPC
Director, Department of Health Sciences, University of Leicester
Ms Janette CamossoStefinovic, Information Librarian, NCCPC
Information Librarian, Department of Health Sciences, University of Leicester
Ms Nicola Costin, Systematic Reviewer, NCCPC (January 2004 onwards)
Research Associate, Department of Health Sciences, University of Leicester
Ms Ariadna JuarezGarcia, Health Economist, NCCPC (May 2003 to July 2004)
Research Associate, Department of Health Sciences, University of Leicester
Ms Elizabeth Shaw, Senior Systematic Reviewer, NCCPC
Research Fellow, Department of Health Sciences, University of Leicester
Dr Tim Stokes, Deputy Director, National Collaborating Centre for Primary Care, Leicester (NCCPC)
Project Lead
Senior Lecturer in General Practice, Department of Health Sciences, University of Leicester
Dr Allan Wailoo, Health Economist, NCCPC (until May 2003)
Lecturer in Health Economics, School of Health and Related Research, University of Sheffield
National Clinical Guideline Centre Project team (2012)
Dr Jennifer Hill (until March 2011)
Guidelines Operations Director

19
Ms Julie Neilson
Senior Research Fellow
Ms Laura Sawyer
Senior Health Economist
Dr Grammati Sarri
Senior Research Fellow
Mr Carlos Sharpin

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Acknowledgements
2004
The Guideline Development Group would like to thank Nancy Turnbull and Charmaine Larment of the
National Collaborating Centre for Primary Care, Royal College of General Practitioners for all their
hard work in arranging GDG meetings and supporting the guideline development process.
The Project Team would like to thank Ms Vicki Cluley, University of Leicester, for secretarial support
and Dr Ali AlGhorr and Dr Moray Nairn, Scottish Intercollegiate Guidelines Network, Edinburgh for
their help in sharing relevant searches and evidence reviews on the epilepsies in adults and children.
The team would also like to thank Dr Allan Wailloo, University of Sheffield for his initial health
economic input and Ms Nicola Costin for her help with the second draft.
2012
The Guideline Development Group and project team would like to thank Dr LeeYee Chong, Ms
Katrina Sparrow, Mrs Fulvia Ronchi, Ms Abigail Jones, Mr David Wonderling, Mr Tim Reason, Ms
Elisabetta Fenu, Mrs Liz Avital, Ms Hati Zorba and Dr Norma O’Flynn for all their help and support
throughout the guideline development process. The project team would also like to thank Professor
Tony Marson and Dr Catrin Tudur Smith for providing further data for the evidence analyses and for
acting as expert peerreviewers to the guideline update.

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2004
An epilepsy is defined as a neurological condition characterised by recurrent epileptic seizures
unprovoked by any immediately identifiable cause. An epileptic seizure is the clinical manifestation
of an abnormal and excessive discharge of a set of neurons in the brain 1.
Epilepsy should be viewed as a symptom of an underlying neurological disorder and not as a single
disease entity. The term ‘epilepsies’ is used in the title of the guideline to reflect this.
1.2 Clinical aspects
2004
The clinical presentation depends on a number of factors, chiefly: the parts of the brain affected, the
pattern of spread of epileptic discharges through the brain, the cause of the epilepsy and the age of
the individual.2 The classification of the epilepsies is controversial and has tended to focus on both
the clinical presentation (type of epileptic seizure) and on the underlying neurological disorder
(epilepsies and epilepsy syndromes).3
Epilepsy is primarily a clinical diagnosis based on a detailed description of the events before, during
and after a seizure given by the person and/or witness. Electroencephalogram (EEG), magnetic
resonance imaging (MRI) and computed tomography (CT) are used to investigate individuals with
known and suspected epilepsy. The diagnosis of epilepsy requires that seizure type, epilepsy
syndrome and any underlying cause are determined.4 It can be difficult to make a diagnosis of
epilepsy and misdiagnosis is common.5
The UK National General Practice Study of Epilepsy found that 60% of people with epilepsy have
convulsive seizures, of which two thirds have focal epilepsies and secondarily generalised seizures
and the other third will have generalised tonicclonic seizures.1,6,7 About onethird of cases have less
than one seizure a year, onethird have between one and 12 seizures per year and the remainder
have more than one seizure per month.8
In adults and children with epilepsy, most (70%) will enter remission (being seizure free for five years
on or off treatment) but 30% develop chronic epilepsy.9 The number of seizures in the 6 months
after first presentation is an important predictive factor for both early and longterm remission of
seizures.10
The UK National General Practice Study of Epilepsy found that the majority (60%) of people with
newly diagnosed or suspected epileptic seizures had epilepsy with no identifiable aetiology. Vascular
disease was the aetiology in 15% and tumour in 6%. Among older subjects the proportion with an
identifiable cause was much higher: 49% were due to vascular disease and 11% to tumours.6
The mainstay of treatment for epilepsy is antiepileptic drugs (AEDs) taken daily to prevent the
recurrence of epileptic seizures. Since the development of MRI there has been an increase in the
number of people identified with epilepsy who could benefit from surgery. There is also a need to

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2012
Since 2004, discussion with regard to the classification of the epilepsies has continued. With
advances in technology, particularly imaging and genetics, some of the older termininology eg
idiopathic/symptomatic/cryptogenic, has become redundant in general use. Furthermore, although
seizures may be focal or generalised in onset, such terminology cannot be applied to syndromes. The
terms partial, complex and simple are also replaced simply by focal.
Ensuring an accurate diagnosis is important for planning management. Although the primary aim is
to diagnose a recognisable electroclinical syndrome, it is recognised this may not be possible in a not
insignificant number of individuals. The exact syndrome diagnosis may not be readily apparent at
presentation. Moreover, in some, the cause may be of equal importance. A more descriptive
approach has been recommended, retaining the electroclinical syndromes where possible but where
underlying aetiology is taken into account 12. This has implications for treatment in an increasing
number of situations.
2004
The epilepsies comprise the most common serious neurological disorders in the UK. It affects
between 260,000 and 416,000 people in England and Wales (Appendix G).13
The incidence of epilepsy is about 50 per 100,000 per annum.14 The incidence is high in childhood,
decreases in adulthood and rises again in older people.6 The usual prevalence figure given for active
epilepsy in the UK is 510 cases per 1,000.11
Epidemiological studies consistently report a standardised mortality rate (SMR) of 24 for
epilepsy.15,16 In newly diagnosed epilepsy, death is largely attributable to the underlying disease (for
example, vascular disease, tumour). In chronic epilepsy, however, the main cause of excess mortality
is death during a seizure: sudden unexpected death in epilepsy (SUDEP).17 SUDEP is estimated to
account for 500 deaths a year in the UK and has been the subject of a recent National Sentinel
Clinical Audit.18
Epilepsy is not always associated with significant morbidity. Many people with epilepsy continue to
have highly productive and fruitful lives, in which the epilepsy does not interfere to a great extent.
However, there is an associated morbidity which may be significant in some individuals, and may be
due to the effects of seizures, their underlying cause and/or treatment. Epilepsy may sometimes
result in significant disability, social exclusion and stigmatisation. People with epilepsy commonly
encounter problems in the following areas: education; employment; driving; personal development;
psychiatric and psychological aspects and social and personal relationships.11 In addition, it is
important to recognise that people with epilepsy may have comorbidities. For example, children
with epilepsy may have attentional difficulties or learning difficulties. 19
2012
Analysis of data from the Quality and Outcomes Framework (QOF) epilepsy diagnostic codes suggest
a prevalence of diagnosed epilepsy in people aged 18 and over of 1.15%. The use of data from
administrative databases such as the QOF, however, which incorporate nonvalidated epilepsy
diagnostic codes for the estimation of prevalence rates is fraught with difficulty and there is a
tendency for such databases to overestimate prevalence. There are no direct estimates&nb

guidelines for epilepsy nice

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