Uncontrolled epilepsy

Approximately one-third of patients with epilepsy do not achieve complete seizure control. Reasons include:

• poor concordance with antiepileptic drug therapy or lifestyle advice
• wrong diagnosis of epilepsy (eg psychogenic nonepileptic events, convulsive syncope)
• wrong diagnosis of epilepsy syndrome (focal seizures mistaken for generalised seizures, or vice versa)
• suboptimal choice or use of antiepileptic drug
• drug-resistant epilepsy.

If the patient does not respond to first-line therapy, refer to an expert. Treatment may include a trial of two or three more antiepileptic drugs, individually or in combination. If these drugs fail to control seizures completely, the patient should be referred to a specialist epilepsy centre for further evaluation.

Of patients who have video-electroencephalogram monitoring in a specialist epilepsy centre:

• up to 30% are diagnosed with psychogenic nonepileptic seizures (pseudoseizures)
• more than 50% have the diagnosis of epilepsy or the type of epilepsy syndrome changed.

Patients referred to an epilepsy centre who have drug-resistant epilepsy may be considered for surgery. If surgery is not suitable, a vagus nerve stimulator may be implanted.

For a child with refractory epilepsy, a ketogenic diet should be considered, under the guidance of a specialist dietitian.