Overview of Diagnosing, Managing, and Treating Epilepsy As Per NICE Guideline NG217

Overview of Diagnosing, Managing, and Treating Epilepsy As Per NICE Guideline NG217

On Thursday 30 January 2025, NICE released an update of NG217. While specialists in epilepsy will likely know the guideline thoroughly, the following summary is provided for non-specialists who may be involved in the care of patients with epilepsy. As an alternative to reading this, you may want to subscribe to our Podcast and listen to a summary while walking, jogging, driving or doing other activities. Just search for the GP Pharmacy Club Pod podcast on Apple Podcasts, Amazon, Spotify or YouTube.

The NICE guidelines provide a structured approach to diagnosing, managing, and treating epilepsy in primary, secondary, and tertiary care. The goal is to improve diagnosis, enhance treatment for different seizure types and epilepsy syndromes, and reduce risks for people with epilepsy.


1. Diagnosis and Management in Primary and Secondary Care

A. Referral and Initial Assessment

  • Urgent referral (within two weeks) is recommended for children, young people, and adults after a first suspected seizure​.
  • Diagnosis should include:
    • Detailed history-taking, including eyewitness accounts and video evidence​.
    • Electroencephalography (EEG) to support but not exclude epilepsy​.
    • Neuroimaging (MRI preferred) to identify structural causes​.
    • Genetic testing in cases of early-onset epilepsy or suspected genetic syndromes​.

B. Treatment Principles

  • Antiseizure medications (ASMs) should be chosen based on seizure type and epilepsy syndrome​.
  • Medication withdrawal can be considered after two seizure-free years​.
  • Drug-resistant epilepsy should be evaluated for ketogenic diet, surgery, or vagus nerve stimulation (VNS)​.

C. Referral to Tertiary Services

Referral is recommended when:

  1. Diagnosis remains uncertain (e.g., distinguishing between seizure types).
  2. Seizures remain drug-resistant despite first- and second-line treatments.
  3. Specialized interventions (e.g., epilepsy surgery, ketogenic diet, VNS) are needed.
  4. Participation in clinical trials is possible​.

Urgent Pediatric Referrals (Within 2 Weeks)

  • Children under three years old.
  • Children under four years with myoclonic seizures.
  • Children with unilateral structural lesions.
  • Children showing developmental regression​.

2. Types of Epilepsy and Their Treatment Options

A. Generalized Epilepsies

Seizures begin in both hemispheres of the brain simultaneously.

1. Generalized Tonic-Clonic Seizures (GTCS)

🔹 First-line: Sodium valproate (avoid in females of childbearing age unless necessary).
🔹 Alternative: Lamotrigine, levetiracetam​.
🔹 Second-line: Perampanel, topiramate​.

2. Absence Seizures

🔹 First-line: Ethosuximide, sodium valproate.
🔹 Alternative: Lamotrigine, levetiracetam​.
⚠ Avoid: Carbamazepine, gabapentin, oxcarbazepine, phenytoin, vigabatrin (can worsen absence seizures)​.

3. Myoclonic Seizures (Juvenile Myoclonic Epilepsy)

🔹 First-line: Levetiracetam, sodium valproate​.
🔹 Second-line: Brivaracetam, clobazam, clonazepam, lamotrigine​.
⚠ Avoid: Carbamazepine, oxcarbazepine, gabapentin, phenytoin​.

4. Tonic or Atonic Seizures (Lennox-Gastaut Syndrome)

🔹 First-line: Sodium valproate​.
🔹 Second-line: Lamotrigine, topiramate, rufinamide.
🔹 Third-line: Cannabidiol, ketogenic diet, vagus nerve stimulation, surgery​.


B. Focal (Partial) Epilepsies

Seizures originate in one hemisphere of the brain.

1. Focal Seizures

🔹 First-line: Carbamazepine, lamotrigine, levetiracetam, oxcarbazepine​.
🔹 Second-line: Brivaracetam, cenobamate, eslicarbazepine, perampanel.
🔹 Third-line: Phenobarbital, phenytoin, sodium valproate​.


C. Childhood-Onset Epilepsy Syndromes

1. Dravet Syndrome

🔹 First-line: Sodium valproate, stiripentol (with clobazam)​.
🔹 Second-line: Topiramate, cannabidiol, ketogenic diet.
⚠ Avoid: Carbamazepine, lamotrigine, phenytoin (worsens seizures).

2. Infantile Spasms (West Syndrome)

🔹 First-line: Prednisolone, tetracosactide, vigabatrin​.
🔹 Second-line: Ketogenic diet, cannabidiol, surgery if focal lesion is present.

3. Self-Limited Epilepsy with Centrotemporal Spikes (Rolandic Epilepsy)

🔹 First-line: Carbamazepine, oxcarbazepine​.
🔹 Second-line: Zonisamide, sulthiame.

4. Epilepsy with Myoclonic-Atonic Seizures (Doose Syndrome)

🔹 First-line: Sodium valproate​.
🔹 Second-line: Lamotrigine, topiramate, ketogenic diet.


3. Reducing Risks for People with Epilepsy

A. Preventing Epilepsy-Related Deaths (Including SUDEP)

  • Identifying high-risk individuals (e.g., uncontrolled seizures, sleeping alone, non-adherence to medication)​.
  • Encouraging adherence to medication and considering night-time supervision​.

B. Transition of Care

  • Ensuring smooth transitions from paediatric to adult epilepsy services​.

C. Psychological and Cognitive Support

  • Addressing mental health comorbidities (e.g., depression, anxiety, ADHD).
  • Providing epilepsy specialist nurses for continuous care​.

4. Non-Pharmacological Treatments for Drug-Resistant Epilepsy

🔹 Ketogenic Diet – Effective in Dravet syndrome, Lennox-Gastaut syndrome, Doose syndrome​.
🔹 Epilepsy Surgery – Considered for focal epilepsy unresponsive to drugs​.
🔹 Vagus Nerve Stimulation (VNS) – Adjunctive therapy for drug-resistant epilepsy​.


Conclusion

  • The NICE guidelines ensure personalized, evidence-based treatment for all seizure types.
  • Early referral to specialists and access to modern treatments improves outcomes.
  • Avoiding medications that exacerbate seizures enhances patient safety.
  • Integrating non-drug therapies (ketogenic diet, surgery, VNS) provides options for drug-resistant cases.

Discover more from The GP Pharmacy Club

Subscribe to get the latest posts sent to your email.

M Moyo

Founder of GP Pharmacy Club. Clinical Pharmacist working in GP Primary Care. Experienced community pharmacist. Independent Prescriber.

Leave a Reply

This site uses Akismet to reduce spam. Learn how your comment data is processed.

Discover more from The GP Pharmacy Club

Subscribe now to keep reading and get access to the full archive.

Continue reading