Overview of evaluation and treatment guidelines for epilepsy.

Choosing the most appropriate treatment for a patient with epilepsy depends on complicated and critical decisions. The number of treatment options has become large, and evidence of effectiveness for each treatment continues to expand. To address this problem, numerous guidelines have been produced by several societies and organizations. However, the guidelines do not always agree in their recommendations, mostly because of differing methods reflecting distinct purposes, but these differences are useful because they highlight both what is incontrovertible and what is unknown. Overall, the evidence needed to choose an antiepileptic drug (AED) wisely is incomplete, and no individual AED or group of AEDs is universally preferred as first-line therapy. Initial treatment should be based in part on the seizure-type diagnosis because the AEDs differ in their efficacy for various seizure types. The AEDs also differ in their safety, tolerability, and potential for pharmacologic interactions. These issues and the patient's general medical history are additional factors to be used when selecting an AED. The failure of AEDs to completely control seizures should lead to consideration of epilepsy surgery, especially for patients with mesial temporal lobe epilepsy. However, there is no consensus regarding how many AEDs should be tried before the condition is deemed pharmacoresistant. Vagus nerve stimulation and the ketogenic diet are alternative treatments for patients with pharmacoresistant epilepsy who do not have epilepsy surgery or who have unsuccessful surgery.