Medicines, surgery, devices, diet and specialist care

Epilepsy treatment is individual. The best plan depends on seizure type, epilepsy syndrome, cause, age, other health conditions, pregnancy considerations, medicine interactions, side effects and the person’s own priorities.

Antiseizure medicines are the main treatment

Before taking something new: over-the-counter medicines, cough and cold remedies, supplements and herbal products can interact with epilepsy treatment. Check medication side effects and interactions →

NICE recommends starting an antiseizure medicine once epilepsy is confirmed. Treatment may also be considered after a first unprovoked seizure when recurrence risk is high — for example when EEG shows unequivocal epileptic activity, imaging shows a structural abnormality or examination identifies a neurological deficit.

Medicine choice should be matched to the seizure type and epilepsy syndrome. Some medicines that help one seizure type can worsen another, so accurate classification matters.

Monotherapy is preferred where possible

NICE recommends using a single antiseizure medicine whenever possible. The aim is to control seizures with the fewest medicines needed while keeping side effects acceptable.

Starting doses are usually increased gradually. Older people, people with multiple health conditions and people taking several other medicines may need slower titration because of interactions and tolerability.

If the first medicine does not work

NICE says the diagnosis should be reviewed if seizures continue despite an optimal dose of a first-line medicine. If epilepsy remains confirmed, another appropriate monotherapy can be tried, usually by introducing the new medicine gradually before tapering the first.

If monotherapy remains unsuccessful, add-on treatment may be considered. The best regimen is not simply the one with the most drugs: it is the one that gives the best balance between seizure control and side effects.

The exact medicine depends on seizure type

There is no universal “best epilepsy drug”. NICE has separate recommendations for focal seizures, generalised tonic-clonic seizures, absence seizures, myoclonic seizures, tonic or atonic seizures and specific epilepsy syndromes.

For example, first-line options for focal seizures differ from those used for absence or myoclonic seizures. Current UK guidance also includes newer options such as cenobamate in selected adults with focal-onset seizures when earlier treatment has not worked.

Side effects are part of the treatment decision

Antiseizure medicines can cause tiredness, dizziness, slowed thinking, mood changes, coordination problems, weight change or other effects depending on the drug. Treatment review should consider quality of life as well as seizure count.

NICE recommends frequent review when add-on treatment is started, including monitoring for adverse effects such as sedation.

Medicine levels are not routinely needed for everyone

Blood levels can be useful in selected situations, including uncontrolled seizures, suspected side effects, pregnancy, renal failure or concerns about adherence. For many people, treatment is guided mainly by seizure control, side effects and clinical response rather than a target blood level.

Pregnancy and reproductive safety can change the choice

Some antiseizure medicines carry important reproductive risks. In the UK, current MHRA safety rules for valproate and topiramate must be followed.

Anyone who could become pregnant, is planning pregnancy, becomes pregnant unexpectedly or is changing contraception should have medicine-specific advice rather than stopping treatment suddenly.

Read Hormones, Contraception & Pregnancy →

Drug-resistant epilepsy is a treatment turning point

The ILAE defines drug-resistant epilepsy as failure of adequate trials of two tolerated, appropriately chosen and used antiseizure medication schedules to achieve sustained seizure freedom.

That does not mean “nothing can be done”. It means the person should not simply remain on an endless cycle of medicine changes without specialist reassessment.

Read Drug-Resistant Epilepsy →

Referral to a tertiary epilepsy service

Specialist centres can review whether the diagnosis and seizure classification are correct, whether previous medicines were truly adequate trials, whether MRI and EEG have been fully interpreted, and whether surgery or another advanced treatment should be considered.

This can include video EEG, specialist MRI review, neuropsychological testing, functional imaging and multidisciplinary discussion.

Epilepsy surgery

Surgery can be one of the most effective treatments for selected people with drug-resistant focal epilepsy. The aim is to remove, disconnect or ablate the brain tissue responsible for seizures while protecting essential functions such as language, memory, movement and vision.

NICE recommends referral for surgical assessment in drug-resistant epilepsy when surgery may be appropriate. A visible lesion on MRI is not always required before referral.

The ILAE also recommends early referral once drug resistance is established rather than treating surgery only as a last resort after many years of uncontrolled seizures.

What surgical assessment can involve

Presurgical assessment may include prolonged video EEG, high-resolution MRI, neuropsychology, PET or SPECT, language and memory mapping, and sometimes invasive EEG using intracranial electrodes.

Referral does not mean someone has agreed to surgery. It means a specialist team assesses whether surgery is possible, what the likely benefit is and what risks may be involved.

Types of surgery

The operation depends on where seizures start and which brain functions are nearby. Options can include focal resection, temporal lobe surgery, lesionectomy, laser ablation in selected centres, hemisphere surgery in severe childhood cases, and disconnection procedures such as corpus callosotomy.

The goal is not always complete seizure freedom; in some operations the aim is to reduce the most dangerous seizure types.

Vagus nerve stimulation

Vagus nerve stimulation, or VNS, uses a pulse generator implanted under the skin of the chest with a lead connected to the vagus nerve in the neck. It delivers regular electrical stimulation intended to reduce seizure frequency and severity.

NICE recommends considering VNS as an add-on treatment in drug-resistant epilepsy when resective surgery is unsuitable or has not worked.

VNS is usually a seizure-reduction treatment rather than a guaranteed route to complete seizure freedom.

Deep brain stimulation and other neuromodulation

Deep brain stimulation, or DBS, delivers electrical stimulation through electrodes placed in specific deep brain targets. NICE has separate interventional-procedure guidance for DBS in selected adults with refractory epilepsy.

Other countries also use responsive neurostimulation, or RNS, which detects abnormal electrical activity and delivers targeted stimulation. Availability varies by country and health system, and RNS is not a routine NHS treatment pathway in the same way as VNS.

Ketogenic and related dietary therapies

Ketogenic dietary therapy changes the body’s main fuel source by using a high-fat, low-carbohydrate diet under specialist supervision. NICE recommends considering ketogenic diet therapy for certain childhood-onset epilepsies and for selected people with drug-resistant epilepsy through a specialist ketogenic-diet team.

Modified Atkins and related approaches are also used in some specialist services. These are medical therapies, not ordinary weight-loss diets, and they require monitoring because of possible nutritional, gastrointestinal, lipid, kidney-stone and bone-health effects.

Read Atkins, Modified Atkins & Ketogenic Therapy →

Rescue medication is part of treatment for some people

People who have prolonged seizures or seizure clusters may be prescribed rescue medication such as buccal midazolam or rectal diazepam, together with an individual emergency plan.

Rescue medication does not replace daily antiseizure treatment. It is used to stop a prolonged or repeated seizure emergency according to a person-specific plan.

Read Status Epilepticus & Rescue Medication →

Treatment can include mental-health and cognitive care

Epilepsy treatment is not complete if seizures are discussed but depression, anxiety, memory problems, sleep, medication side effects or postictal difficulties are ignored.

NICE recommends reviewing psychological, cognitive, neurobehavioural and developmental comorbidities and treating them appropriately alongside seizure management.

Lifestyle does not replace medical treatment, but it can matter

Regular medication, adequate sleep, avoiding known personal triggers, managing alcohol carefully, keeping hydrated and treating illness promptly can all support seizure control.

These measures should not be presented as a “cure”. They work alongside medical treatment rather than replacing it.

When can medication be reduced or stopped?

NICE recommends an individualised review after someone has been seizure-free for 2 years to discuss the risk of recurrence if medication is withdrawn. That does not mean everyone should stop treatment at 2 years.

If withdrawal is agreed, most antiseizure medicines are reduced gradually over at least 3 months, with benzodiazepines and barbiturates usually tapered more slowly. Multiple medicines are withdrawn one at a time.

After epilepsy surgery, any medicine reduction should be guided by the epilepsy surgery centre.

Treatment goals are broader than seizure freedom

Seizure freedom is the ideal outcome, but treatment also aims to reduce injury, emergency admissions, seizure severity, treatment burden and epilepsy-related mortality while preserving cognition, mood, independence and quality of life.

For someone whose seizures cannot yet be eliminated, a meaningful improvement may still be fewer tonic-clonic seizures, shorter recovery, fewer injuries or less medication toxicity.

Questions worth asking at a treatment review

• Is my seizure classification still considered correct?
• Is this medicine appropriate for my seizure type?
• Could the medicine itself be worsening another seizure type?
• Are my side effects acceptable for the benefit I am getting?
• Have two appropriate medicines already failed?
• Should I be referred to a tertiary epilepsy centre?
• Should surgery, VNS, DBS or dietary therapy be discussed?
• Do I need a rescue-medicine plan?
• Do pregnancy, contraception or other medicines change the safest option?
• What is the goal of my treatment now: seizure freedom, reduction, safety or quality of life?

Related specialist pages

Epilepsy Surgery and Presurgical Assessment · Vagus Nerve Stimulation · DBS, RNS and Other Neurostimulation · Remission, Seizure Freedom and Resolved Epilepsy

Antiseizure medicine selection and monitoring

Rescue Medicines for Seizures Worldwide →

Antiseizure Medicine Blood Levels →
Drug Interactions Between Antiseizure Medicines →
Generic and Brand Antiseizure Medicines →
How Antiseizure Medicines Are Chosen by Seizure Type →

Sources and guidance

NICE NG217 — Principles of treatment, safety, monitoring and withdrawal

NICE NG217 — Treating epileptic seizures

NICE NG217 — Non-pharmacological treatments

NHS — Epilepsy treatment

International League Against Epilepsy — Epilepsy surgery

ILAE Surgical Therapies Commission — Surgery and neurostimulation reports

Medical note: Treatment choices must be individualised. Do not start, stop, switch or alter antiseizure medication without advice from the clinician responsible for epilepsy care.

Related researched deep dives

• Kidney Disease, Dialysis and Antiseizure Medicines
• Liver Disease and Antiseizure Medicines
• Weight, Obesity and Metabolic Health in Epilepsy
• Fasting, Dehydration, Illness and Epilepsy
• Vaccination, Fever and Epilepsy

Evidence checked: September 2026.