Although convulsive seizueres appear frightening and painful, the affected person is unaware of what is

happening. Those who witness a tonic-clonic seizure should remain calm and help the person lie down in
a safe place. Roliing the patient on his side helps prevent aspiration of vomitus or saliva , but restraints
may result in injury to the patient or the witness. Tight clothing should be loosened and necklaces and
eyeglasses removed. ​Nothing ​(including fingers) should be inserted in the person’s mouth; it might be
bitten off and choked on.

The tonic-clonic seizure may be followed by confusion, and physical restraint may provoke an
aggressive response. Nothing should be given by mouth until yhe patient is fully alert. Before the
patient is left alone, the witness should determine id full recovery has taken place by asking questions
the require more than a “ yess” or “ no “ answer. Medical attention is usually needed only for a first
convulsive seizure’ a convulsion that lasts more than 5 to 10 minutes ‘ or a postseizure fever (>102 F)
that persists longer than 4 hours or develops 6 to 12 hours after seizure.

When person has a complex partia seizure . and thus retains some level of consciousness, first
aid is simple: the patient should be kept in a safe environment and restrained only for safety ( for
example , to prevent him from walking into traffic) automatism during complex prtial seizures may be
embrassing but are not dangerous . if possible, the person should be led to a quiet and private location.
An unexpated seizure is most dangerous when it occurs while the patient is driving a car or operating
potentially dangerous equipment. Most patients with seizures that impair consciousness or motor
control should avoid these activities.

Treatment plan

Once the diagnosis of a seizure or epilepsy is made, the question of wheter or not to treatatises.
Recurrence rates after a single tonic-clonic seizure vary from 61%. After two tonic-clonic seizures, the
risk of having third seizure rises to about 85%. The major risk factors for recurrence after a single
tonic-clonic seiazure include prior brain injury,abnormalities on neurogenic examination and
epileptiform abnormalities on EEG. Other risk factor include todd paralysis, status epilepticus,family
history, of seizures and acute symptomatic seizures caused by head trauma. Treatment after a single
seizure reduces the risk of recurrence only while the patient is taking medications.

Treatment decisions must be individualized because the consequences and recurrence rates of
seizures vary considerably. A 10-years old girl wuth a single, afebrile, nocturnal tonic-clonic seizure and
normal findings on MRI and EEG would probably not be treated. However treatment would be strongly
advised for a 25-years-old saleswoman with a single daytime tonic-clonic seizure who drives long
distances and had asymptometric deep tendon reflexs, an area of encephalomalacia on MRI, and focal
spikes on the EEG.

Driving and work related issues are often of paramount importance in managing adults with
epilepsy. In children, the physician must consider the effect of the treatment on physical, educational,
and social development. The choices are not easy. The physician and patient must decide if if it is better
not to take medications and have an occasional mild seizure or to endure some adverse effects from
moderate doses od antiepileptic drug but experience no seizures.
Treatment decisions are also influenced by the diagnosis. Therapy is deffered for children with a single
febrile seizure. However if the seizure recurs, rectal diazepam may be given prophylactically only when
the chid develops a fever. In children with benign rolandic epilepsy, antiepileptic drug can be
discontinued by age 16, but treatment is often continued. Indefinitely in patients with juvenile
myoclonic epilepsy.

Simple or complex partial, absence, and myoclonic seizure are rarely isolated events. When one
occurs , others are likely to have occurred or to occur soon. However even these seizures do not always
require therapy. Since these relatively mild seizures occur infrequently , therapy may be postponed.

Antiepileptic drug

Drugs are the mainstay or epilepsy therapy and monotherapy with first-line (primary) agents is
preferred for most patient. The advantages of monotheraphy include (1) equal or superior efficacy to
many two-drug and three-drug regimens; (2) reduced frequency of adverse effects ; (3) absence of
interactions between antiepileptic drugs; (4) lower cost ; (5) enhanced ability to correlate response,
adverse effects, and abnormal laboratory values to specific drug ; (6) reduced risk of birth defects; and
(7) in some case improves compliance (noncompliance is the most common cause of drug failure and
breakthrough seizures). A small number of patients. However require two or rarely three antiepileptic
drugs.

Altought the same drugs are used to threat both children and adults. The pharmacokinetics and
side effect profiles of the drugs can differ. Absorption and metabolism of antiepileptic agents are often
different in-young children than in older children and adults, and for many drugs, such as phenytoin,
proportionally higher doses are needed to achieve therapeutic levels in young children. Also, drugs that
cause ine type of side effect in adults sedation) may cause the opposite effect (hyperactivity) in children.

Mechanisms if action. The numerous mechanisms of action of antiepileptic drug have not been
precisely defined. Carbamazepine and phenytoin act mainly to damp down the activity of
sodium-dependent action potentials (reducing sustained high-frequency neuronal firing) and to reduce
calcium uptake and neurotransmitter release. Drug that facilitate the activity of gamma –amino butyric
acid (GABA) an inhibitory amino acid, include benzodiazepine ,Phenobarbital, and valproate.
Ethosuximide reduces slow rhitmic firing of thalamic neurons , and felbamate and lamotrigine may block
the actions or release of excitatory amino acids.

Drug selection . the goal of antiepileptic drug therapy is to establish a balance between seizure
control and adverse effect. The choice of antiepileptic drug is based on the seizure type ( table 1)
epilepsy syndrome, and patient variables.

Therapy must be individualized. Just as epilepsy affects people differently . there are enormous
differences in efficacy and toxicity of antiepileptic drugs among patients, even among patient with the
same type of seizure or epilepsy syndrome . since first line agents are similar in efficacy and side effects ,
features such a specific adverse reactions, cost, and ease and timing of administration also influence the
treatment decisions. Patient should be include in the decisions process and should understand why one
drug is recommended over others (its low cost or less frequent dosing) adverse effects are especially
important factors to consider.

The effective dose of antiepileptic drugs varies from patient to patient. Low doses given once a
day may be adequate for some patients with mild epilepsy; other patients with the same diagnosis but
more rapid hepatic metabolism require higher doses given at more frequent interval.

Antiepileptic drugs are usually introduced gradually. Although gabaoentin , Phenobarbital, and
phenytoin can be started at or near their daily maintenance dose , the initial doses of carbamazepine,
clonazepam, ethosuximide, felbamate, lamotrigine, pirimidone, and valproate should be low and the
doses increased slowly. If seide effect occur with a drug given at low doses. The drug may be
reintroduced at very low doses and the dose increased in small increments when side effect have
abated.

A drug that is ineffective or that causes troublesome side effect is tapered gradually, while an
akternative primary or secondary drug is simultaneously introduced slowly. The occurrence of side
effect or seizures may necessitate changes in the speed of drug introduction or withdrawal.
Benzodiazepines and barbiturates should always be withdrawn slowly because rapid discontinuation
often precipitates with drawal seizure. Othe antiepileptic drug can be withdrawn more rapidly ; however
, abrupt discontinuation is not recommended unless clinically indicated by toxic effects. For example if a
quickly or stopped immediately.

When seizure have remained well controlled with drug therapy for 2 to 4 years, many patients
can safely discontinue medication. The relapse rate after medication withdrawal is 20% to 35% in
children and 30% ti 65% in adults. Recurrence during or after medication withdrawal is more common in
patient with (1) abnormalities on EEG , especially epileptiform discharge (2) progressive EEG
abnormalities documentes while medication is being discontinued; (3) abnormalities on neurologic
examination (4) mental retardation ; or (5) frequent seizure before adequate control. Social
considerations such as driving needs and employment, should be included in the decision to discontinue
antiepileptic medications.